HIStalk Interviews Shaun O’Hanlon MD, UK Physician

Hi, this is Inga. Shaun O’Hanlon, MD works for EMIS, the largest supplier of EHR products to primary care docs in the UK. Mr. H and I were intrigued by his note: “I really enjoy reading your website. There are stunning similarities and differences between the EHR functionality in the US and that in the UK. There is undoubtedly room to learn as, underneath it all, we are all caring for patients.”

Thanks, Shaun, for providing some great insights. “Whilst” I had a bit of a struggle understanding the accent and the British-isms, it was a fun conversation that got me thinking about what we could learn from the UK model and what aspects we independent-minded Yanks would never embrace.

Give me some background information about you. 

I am a physician by background. I qualified from Cambridge in 1986 and I pursued a career in hospital medicine in cardiology. Then I decided to be a General Practitioner (GP), which is the UK equivalent of family practice. I spent 13 years being a GP in Guildford, just south of London, which I loved. My interest in healthcare informatics products started after working on a smart card project in 2000. Since then, I have been working for EMIS in healthcare informatics.

The company I work with today provides the GP EMR for 60% of patients in the UK, so it is a fairly prevalent system. Largely, it will do everything for EMR, management recall, appointment scheduling, and orders, all done through a single application. Billing is included, but in the UK it's not that important. The economy is such that the government pays for healthcare through the National Health Service (NHS) and there is very little pay for services aside from some hospital ones. 99% of it is free. Well, not free – it’s paid for by taxes. [laughs] There is a secondary insurance market, used mostly for second opinions.

There is little competition for patients in General Practice because there is a match between doctors available and the number of patients. The government is generally reluctant to set up new practices. Since 1947, GPs have set up partnerships of five to 10 clinicians. That practice has a contract with the government to provide all General Practice services to their patients.

Can you give me UK Healthcare 101?

The practices are largely where they have been for many, many years. GPs have a geographic catchment area for patients. Although there may be several practices in one area, the competition is not widespread, as the government tries to match the number of doctors available to the number of patients. To set up a new practice, you have to have a pretty strong case and show local need. It is therefore fairly uncommon. The number of GP physicians is fairly stagnant.

We are now seeing some attempts to try to bring in private providers to improve patient access to healthcare. The number of doctors is relatively low and you have some big companies trying to provide an alternative model of providing care. Some of the bigger healthcare providers are trying to set up private clinics, as there is a perception that the GPs are stuck in their ways and innovation is needed.

Most GPs offer office hours from 8 to 6. Outside those normal office hours, service is provided predominantly by “out of hours” or emergency facilities. This is a problem for patients who are in employment, especially those who commute, and need to see their doctor early or late in the day. This has triggered a desire to find more innovative ways to provide care.

Patients are registered at a particular practice, which usually contains five to 10 physicians, equating to 6,000 to 12,000 patients per practice. Everyone who lives in the UK has one GP. The practice will provide all their primary care, including managing all their prescriptions, tests, and referrals. If you are on holiday, you can see someone temporarily, but your records will remain with your GP where you live.

So if I live in the country and commute to the city and need to see a doctor, I can’t see one in the city?

Right. Not very easily. A bit rubbish, isn’t it? They are considering creating a concept of dual registration to enable commuters to have a city doctor. The model now is one of a monolithic cradle-to-grave record. That has many advantages for continuity of care, cost containment, and quality care delivery. You begin to worry if you fragment a patient’s record, then you fragment care and may have dual care, redundant tests, and increased cost. In order to offer dual registration, you have to be able to share records around as well.

What is overall state of technology?

If you are a GP, every practice will have an electronic record on one of three or four available systems. That information will be held in a largely codified, structured manner. It will include a full medical history and all consults. It will include problems or diagnoses, all results, tests, prescriptions, and letters, resulting in a full, rich record that is fairly advanced in its structure.

The information is now transferable electronically between GPs in a structured format. If you move to a different location, then your record will follow you. What happens at the moment is that the record is held in a server in a practice or an enterprise with central service. When you move, your record transfers. There is a national standard that allows you to transfer the record around. We have a national messaging service that relays the messages from the practice database service to the receiving service. You request the records and you receive them the next day. A copy is extracted to the new practice. The patient's complete medical record is sent and then imported in a coded format.

You indicated that there are stunning similarities and differences between EMR functionality in the US and UK.

A lot of my experience from that side of the pond comes from Canada. I find it quite difficult to talk about specifics because I haven’t been on the hospital side in US. But there are a lot of similarities around the need to share information. There is this conception that the GP performs one role and the hospital performs another role. The result is that information silos exist with pieces of paper -- referral letters, outpatient letters, etc. -- connecting them.

The other similarity, very macro, is that we are seeing increased focus on what patients want to know about themselves. Up until recently, this has been resticted due to technical issues. There also exists a kind of a high-handed attitude that patients can’t have their records by some clinicians.

We have brought the patient into the loop and now offer them access to their records, appointments, and electronic ordering of prescriptions. We have hundreds of thousands of patients using EMIS Access for just this every month. Projects like Healthvault will further enable this citizen involvement across the globe.

Suppliers are realizing that the real benefit of their data is sharing with other providers. People are sharing data between different systems. You need your applications to work together. Now that there is increased requirement to look at the lab system and radiology, interoperability has been become the core business that companies are beginning to focus on. We work hardest at determining how to share data and what data should look like. By sharing information everything works better. Everyone’s data is much richer when it is shared. Interoperability is the key to future EMRs.

To interoperate, you have to have standards. Unless you come up with agreed standards, you can’t have interoperability. Standards for coding data, messaging data, and viewing data.

EMIS has adopted SNOMED-CT as it does appear to be becoming the universal standard for record coding. We are working quite hard to understand SNOMED-CT because, whilst it is very advanced and offers granularity and breadth not found elsewhere, it is not a straightforward taxonomy, either for data entry or for reporting. So, new and innovative ways of entering data will need to be designed.

Message standards are now generally focused around HL-7. In the UK, we have adopted V3 XML, but our Canadian teams are now using V2 as well

Data display standards are equally important. Microsoft has been working with NHS and some suppliers like EMIS in defining a Common User Interface for healthcare applications. Their approach is to help establish a set of evidence-based standards for display and entry of healthcare data which is platform and location independent. The program is in its early days, but they are beginning to look at some of the challenges that SNOMED-CT and citizen records have on the healthcare user interface

Is the UK ahead of the US in terms of technology?

In certain areas, we appear to be in a luxurious position of having a national approach of how medical record and information should be used in the National Health Service and in Connecting for Health. We are mandating the use of HL-7 and are required to adopt these technologies and standard so we can share information between systems. It is putting us in good stead in some respects, but central control can be slow and laborious and does not always follow business drivers. If you don’t have an economy with that central control, the supplier sets standards based on business drivers, which can be more adaptive to the changing market.

Anyone would be well to learn from the issues that the UK has in providing a national EMR solution. There are a lot of lessons learned about standards and where they do and don’t work and how to go about implementing them

What is the state of adoption for EMRs in the UK?

Hospitals primarily use PAS, patient administration systems, PACS, and order systems. All have back-end billing systems to make sure they get paid by NHS. A lot of them rely on paper records for the medical record piece, although some use components of EMRs.

It’s a very mixed bag in terms of hospital adoption of EMR. Cerner is a big player and being employed, though it is going slower than they would have hoped due to implementation issues. Localizing the product has taken time and effort, as the requirements in a UK hospital are different than an American hospital. They are also going into sites with mixed technology and systems. That isn’t my area of specialty, so I can’t really comment further. iSoft also has a product called Lorenzo which is a single system for GP and hospital, but the full release has been delayed for several years.

How are EMRs funded?

It is all paid for by the government. In General Practice, they are provided through an NHS agency. The clinicians have a choice of systems, which was assured after a lot of pressure from the clinicians as the government didn’t want initially to offer that. The current situation is that the GP can pick the EMR solution they wish, so long as it fulfills a set of basic and interoperability requirements.

There is a also a big move to central hosting and enhanced data sharing across regions, if you like, so you can share between hospitals and physicians. What you call RHIOs -- it is exactly like that, driven by the government. Some physicians think it’s a good idea, whilst some are concerned with losing control of their data. Others might argue it’s the patient's data and that it is up to them who sees what information. The legal status is somewhere in between, that the doctors are the guardian of patient data.

Personally, I think the citizens have different expectations about their records. Most patients would be startled if they knew the hospitals couldn’t see the information that GP has, that historically it couldn’t be shared for technical and non-technical reasons. The non-technical reasons revolve around clinicians and administrators not wanting to mobilize data, sometimes for legitimate security reasons, whilst at other times, they are scared of someone seeing “their” data.

Some concerns are rational and some not rational. There is a need for putting solutions in place to encourage the sharing of data on terms they feel acceptable with. A patient can say, "I don’t want this one piece of information shared" and control who can see what. At the end of the day, the patient has to be able to see that. If you put in technology controls, then the clinician is the guardian and the patient controls who has the access. That has to be the way going forward. We need more control with the citizen and less with the clinicians whilst respecting that the clinician needs some controls because he is a stakeholder in the information, too.

Are physicians receptive to technology?

How you get clinicians to adopt EMR is a really interesting question. Before I went on the industry, side I tried to evangelize GPs about importance of coding data. I suspect 25 to 30% understood that and took it as a trigger for change. It has to be easy to do and have a business case behind it for it to be a success.

Prescriptions and repeat medications – the computer is very good for that. Appointment scheduling - no doubt that the computer helps. But what the government did over here was put part of the remuneration for the doctors based on how they are providing for the patients. Twenty percent of GP income is now around achieving targets for quality of care. For example, patients with heart disease have a certain level of cholesterol and blood pressure that the clinician should achieve to trigger the quality care payments.

The key is that if you see 10,000 patients, then there is no way you can collect the information required by the government on an ongoing basis without an effective EMR. All GPs now know it will pay to use an EMR package and, at the end of the day, it helps with quality of care. Once they realize how easy it is to enter data for disease management, they use it more.

The emphasis on chronic disease management was the big driver for adoption. Now that we are beginning to share the records, that will become the next business driver, I am sure. Some doctors complain it is check box medicine, but most recognize the improvements in care and data quality that have resulted. One very positive effect has been that there is now much more quality data on EMRs, something we gave been able to take advantage of and have used this data for some very high quality research. That has been an incredible falling out from all this.

Are citizens interested in having access to their medical history?

Very much so. I was recently looking at some stats. We have had 250,000 hits on our patient-facing service that is based on the EMR. Sending messages to doctors and ordering prescriptions online is now very popular. There are some issues that we have overcome around that, including privacy, but it is beginning to take off here in the UK. Our health portal is restricted to one part of the UK. You can log in and see your records provided you and your doctor are happy for that to happen.

How did you come across HIStalk?

[Laugh]s I got an e-mail from a person in our Canadian install. I read and found it an interesting mix of suppliers and users essentially talking to each other. In the UK, there isn’t a forum like HIStalk where you have senior suppliers and physicians sharing their knowledge. I think I learn a lot reading the e-mail that comes through. I don’t feel I can contribute much because I come from a different space.

Do you have anything else to share?

Our problems are complex and some need addressing on a national or international level. We have to have something to shoot for. The approach we’ve had involves citizen and doctor groups, as we have found there are a lot of concerns. Frequently they are unfounded, but we don’t realize they are unfounded until we analyze them in detail. If you told me 10 years ago I could log into my bank account online, I would have been horrified, but now I do it all the time. Suppliers and clinicians need a citizen view as well as a self-interest view.