Sunday, September 20, 2009

Socialized PACS

I've commented in an earlier post about the Britain's difficult experiences with EMR. As part of their massive IT initiative, there has been an attempt to introduce PACS as well throughout the system. You can have a look at the NHS PACS site here, with numerous links to history and other information. From what I can gather, the project has been largely successful, although there have been some problems.

The "Stakeholders' Brochure" discusses the British PACS experience:

Prior to the advent of the National Programme for IT (NPfIT) it had taken 50 trusts some 14 years to implement PACS. But in the last three years, the national PACS programme – a key element within NPfIT – saw the pace accelerated massively and all hospital trusts now have experience of the technology.
The NHS National Programme for IT (NPfIT) is actually the umbrella under which national EMR and the various PACS are deployed, and the whole thing is itself under "a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. CfH absorbed both staff and workstreams from the abolished NHS Information Authority, the organisation it replaced."

This very ambitious program includes the following particulars:

*The NHS Care Records Service (NHS CRS)

*Choose and Book, an electronic booking service

*A system for the Electronic Transmission of Prescriptions (ETP)

*A new national broadband IT network for the NHS (N3) (see also external link to BT N3 website)

*Picture Archiving and Communications Systems (PACS) *IT supporting GPs including the Quality Management and Analysis System (QMAS) and a system for GP to GP record transfer.

*Contact รข€" a central email and directory service for the NHS.

The Spine

The creation of a core data storage and messaging system, known as the Spine, is key to providing electronic NHS Care Records for every patient.The Spine will:

*Store personal characteristics of patients, such as demographic information

*Store summarised clinical information which may be important for the patient's future treatment and care

*Provide the security systems required to restrict access to the national and local systems

*Provide a secondary uses service, using anonymized data to provide business reports and statistics for research, planning and public health delivery

*Bind together all the local IT systems within the programme.

Clusters and Local Service Providers

The programme divides England into five areas known as "clusters": Southern, London, Eastern, North West and West Midlands, and North East. For each cluster, a different Local Service Provider (LSP) was contracted to be responsible for delivering services at a local level. This structure was intended to avoid the risk of committing to one supplier which might not then deliver; by having a number of different suppliers implementing similar systems in parallel, a degree of competition would be present which would not be if a single national contract had been tendered.

As of October 2005, four different industry consortia are LSPs:

*CSC Alliance - North West and West Midlands Cluster

*Accenture - North East and Eastern Clusters

*The Fujitsu Alliance - Southern Cluster

*Capital Care Alliance - London

National Application Service Providers

In addition to these LSPs the programme has appointed National Service Providers (NASPs) who are responsible for services that are common to all users e.g. Choose and Book and the national elements of the NHS Care Records Service that support the summary patient record and ensure patient confidentiality and information security. As of October 2005, the NASPs are:

*BT - NHS Care Records Service and N3

*Atos Origin and Cerner - Choose & Book

*Cable and Wireless - Contact

Obviously, this is an incredibly ambitious project, one that should be considered successful if it works at all, and indeed it does, as near as I can tell, anyway. But that's the good news.

A humongous project like this is going to have some cost issues, and apparently NPfIT does. From the Wiki:

Originally expected to cost £2.3 billion (bn) over three years, in June 2006 the total cost was estimated by the National Audit Office to be £12.4bn over 10 years, and the NAO also noted that " was not demonstrated that the financial value of the benefits exceeds the cost of the Programme"[14]. Similarly, the the British Computer Society (2006) concluded that "...the central costs incurred by NHS are such that, so far, the value for money from services deployed is poor"[15]. Officials involved in the programme have been quoted in the media estimating the final cost to be as high as £20bn, indicating a cost overrun of 440% to 770%[16].

In April 2007, the Public Accounts Committee of the House of Commons issued a damning 175-page report on the programme. The Committee chairman, Edward Leigh, claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite a probable expenditure of 20 billion pounds "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."[2]

The costs of the venture should have been lessened by the contracts signed by the IT providers making them liable for huge sums of money if they withdrew from the project; however, when Accenture withdrew in September 2006, then Director-General for NPfIT Richard Granger charged them not £1bn, as the contract permitted, but just £63m[17]. Granger's first job was with Andersen Consulting[18], which later became Accenture.

Oooops.... Sounds rather like having certain members of a larGE company having much to do with CCHIT, but I digress.

The Southern Cluster had a bit of a problem. Initially,

GE Healthcare, a division of General Electric (NYSE:GE), today announced that it has signed a contract with Fujitsu Services Ltd., the designated Local Service Provider for the southern region of the National Health Service's (NHS's) National Programme for IT. Under the agreement, GE Healthcare will provide its Picture Archiving and Communication System (PACS) technology that will enable the conversion of hospitals and clinics to a new digitised system for storing, retrieving and displaying patients' medical images.

The UK government announced in May that the NHS in England will install nationwide digital imaging systems that allow medical images of a patient to be transmitted on demand around hospitals and to remote sites for expert medical scrutiny and diagnosis. The National Programme for IT is being implemented into five regional clusters, the southern cluster (covering the South East and South West) being the largest with approximately a third of the country's PACS.

GE Healthcare will supply PACS technology for the new digitised records system to its partner Fujitsu. PACS allows images such as x-rays and other medical scans to be digitized, stored and transmitted electronically, avoiding the need for cumbersome film development processes and delivery by post or by hand. Eventually, PACS, together with other components of the new IT system, will enable the electronic storage, display and retrieval of a patient's records at the touch of a button from anywhere in the country. (Business Wire, 11/22/04)

But something then went haywire:

Fujitsu may not have its contract renewed to provide Picture Archiving and Communications Systems (PACS) services to NHS trusts in the south of England.

The development comes two weeks after Fujitsu had its £1.1bn contract as local service provider (LSP) for the region terminated on 28 May, following its withdrawal from contract re-negotiations. Fujitsu had previously been expected to get the lucrative PACS deal renewed.

When the LSP contract was terminated, the linked PACS contract was also ended, leaving NHS trusts across the south with systems that were not covered by formal support contracts. (eHealthEurope, 6/16/2008)

What happened to Fujitsu? There was of course finger-pointing:

Fujitsu was working with medical imaging specialist GE Medical Systems on the project and was to provide support until 2013.

Negotiations had broken down due to what Fujitsu claimed were too-strict conditions on payment and deliverables, according to media reports that day. The Connecting for Health programme – which started in 2002 and was scheduled for completion 2010 – is already four years late, they said. ( 5/30/2008)

From eHealthEurope:

The development comes two weeks after Fujitsu had its £1.1bn contract as local service provider (LSP) for the region terminated on 28 May, following its withdrawal from contract re-negotiations. Fujitsu had previously been expected to get the lucrative PACS deal renewed.
When the LSP contract was terminated, the linked PACS contract was also ended, leaving NHS trusts across the south with systems that were not covered by formal support contracts.

E-Health Insider has been told that as a result, key clinical systems in the region – including PACS, Radiology Information Systems (RIS), child health, Map of Medicine and Cerner Millennium – are only covered by a “promise” of support from the ex-LSP. . .

This would have followed the pattern set in September 2006, when Accenture walked as LSP in the North and North East of England, but still retained its PACS contracts.
In a 28 May letter to NHS chief executives in the south about the ending of Fujitsu’s LSP contract, Gordon Hextall, head of NHS CfH said: “However, the PACS and RIS contracts are not expected to be affected by this outcome.”
The agency now appears to have reversed its position and to be proceeding on the assumption the terminated PACS contract will not be renewed.

Uhhh. . . Two of the cluster providers walked? This doesn't sound good. . . But Fujitsu apparently is continuing to support its RIS/PACS:

Fujitsu has delivered PACS in full and it is generally working well. Although there was a single contract covering both the Care Records Service and PACS and the termination of the contract therefore covers both items, the intention of both Fujitsu and the Department is that Fujitsu will continue to deliver PACS’ and RIS’ services in the South, subject to contract, at least in the short term prior to a general transition to an alternative supplier subject to the agreement of terms. Without prejudice to Fujitsu’s legal rights, Fujitsu continues to provide these services pending confirmation by the Department of commercial cover. (Parliament document, The National Programme for IT in the NHS: Progress since 2006)
For much more on the Fujitsu situation, have a look at pages 45 and on.

The reprecussions of the Fujitsu withdrawl are multitude, and Parliament wan't really pleased with how things had been going:

Recent progress in deploying the new care records systems has been very disappointing, with just six deployments in total during the first five months of 2008–09. The completion date of 2014–15, four years later than originally planned, was forecast before the termination of Fujitsu’s contract and must now be in doubt. The arrangements for the South have still not been resolved.

However, this aspect was indeed recently solved:

NHS Connecting for Health has confirmed that responsibility for Picture Archiving and Communication Systems (PACS) and Radiology Information Systems (RIS) in the south of England will be transferring from Fujitsu to the CSC Alliance (CSCA).

Fujitsu, following the termination of its contract in May 2008, has been continuing to support PACS and RIS in most of the trusts encompassed by three strategic health authorities (SHAs): South East Coast, South Central and the South West. It also supports a further three trusts outside of these areas.

The SHAs and NHS Connecting for Health have been working to put in place new arrangements to ensure continuity of service provision for PACS and RIS. A contract has now been signed with CSCA which will see it steadily assume responsibility for PACS and RIS in the trusts previously supported by Fujitsu. The contract period with CSCA is effective from 20th July 2009 through to June 2013.
Fujitsu will continue to support trusts until November 2009 and support service transition activities until the end of March 2010.

OK, problem solved, at least for now. But this betrays the problem with the philosophy. To have one monolithic vendor covering an area could work very well, or very poorly. And one more thing. Particular regions of Great Britain decided which vendors to utilize. Let me rephrase that. The bureaucrats of the NHS of the particular quasi-independent clusters decided which vendors to foist on the hospitals in their area. One more time. THE GOVERNMENT CHOSE THE PACS FOR THE DOCS. How does that sound? I've had the joy of an IT department dictating the decision for me, and I didn't like it one bit. But having the government choose, likely by lowest bidder, is absolutely asinine.

From all I can gather, the system does work, and the NHS took on a monumental job in trying to make it work for an entire nation, albeit a smaller nation than ours. Would we in America be willing to take on the sacrifices and limitations entailed by this approach? Well? Anyone?

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