Open-source electronic patient records in the NHS

Malcolm Senior, director of informatics at Taunton and Somerset NHS Foundation Trust, says that the opportunity for trusts to use the technology that is right for their requirements is here and needs to be seized to maximise clinical benefits and enhance patient safety and experience

"Any customer can have a car painted any colour that he wants, so long as it is black". So said Henry Ford, one of the first to master the principles of mass production. Over a century later, you can buy a car in nearly any colour you want, complete with a range of mod cons, through a financial package tailored to your budget.

From purchasing cars, to deciding when and what programmes to watch on TV, the modern world is full of choice. The healthcare sector is no exception, with patients able to choose their GP, which hospital to visit and the type of treatment they want. Even the way the NHS spends money on patients is more individually controlled through schemes like personal health budgets.

The freedom of choice, however, has not always been exercised across NHS IT. For eight years, we were very limited in our options of IT systems; so limited in fact that in many instances trusts did not have a choice about the supplier they partnered with. However, following the end of the National Programme for IT (NPfIT) and the emergence of Local Service Provider exit strategies, choice is finally coming back to the sector.

The new open market
The approach taken by NHS England in launching the Integrated Digital Technology Fund (better known as "tech fund two") is a positive step in that it gives trusts the freedom to be different and make technology work for them. This provides greater opportunities for clinicians to make the IT work for them, rather than change clinical processes in a way defined by an IT supplier.

At Taunton and Somerset NHS Foundation Trust, we are taking advantage of the open source approach, strongly advocated in tech fund two. This is essentially around deploying an electronic patient record (EPR) - a system that the industry has talked about for many years but implementations across the NHS have been slow in terms of delivering the highly anticipated clinical benefits in addition to nearing a paper-lite or paperless environment.

Lessons learnt from NPfIT suggest that a one-size-fits-all approach for EPRs has its limitations, as every trust made the case, rightly or wrongly, that it was somehow different. This is why we believe that open source provides another way of delivering those clinical benefits; trusts can take ownership of the code and develop it alongside clinicians to their requirements.

But open source is not for everyone. Each healthcare provider has varying degrees of IT maturity; some may be close to becoming paperless or have systems in place that just need to be built on, some may decide that a new approach is right for their organisation.

For our trust, the timing and opportunity of open source just came together and made it the logical choice. Open source fits with our culture and our approach, clinicians liked the IMS Maxims software, and it was particularly affordable for us, giving us the ability to manage change from our current system - it lets us control our own IT requirements.

Time for responsibility
And the ability to drive those IT requirements is good for the industry, as software suppliers cannot transform the NHS alone - there needs to be a partnership approach in which trusts take their share of responsibility. Trusts have the choice to bid for tech fund two support, with the freedom to implement software in their own way. But with freedom comes responsibility and trusts must have a renewed focus to fully implement a paper-lite NHS by 2018. Am I alone in remembering the "Information for Health" ambition to have EPR level 6 organisations by 2005?

From an IT perspective, we have a responsibility to work closer with clinicians, to understand their processes, but also to challenge their thinking. At Musgrove Park Hospital (part of Taunton and Somerset NHS Foundation Trust), we have clinicians driving this change, rather than IT - an approach we have been committed to from the start of our EPR procurement. We made sure clinicians were involved in the procurement and we now have a real momentum going, with the frontline staff playing a significant part.

You can see this works well using open source for smaller, niche systems because developers visit hospitals to sit beside doctors and nurses, listen to what they are saying and they can define the software and its best elements as they observe. Apply this approach to an EPR project, and by working closely with IMS Maxims the opportunities for change are considerable.

Relationships
Much has been made about vendor lock-in on big contracts; many trusts are frustrated that the smallest change request can take months and be of considerable expense, this is something that open source can help us to avoid. Trusts will not mind being locked into a solution if it is working for them but if the relationship with the IT supplier breaks down, through not meeting expectations or delivering on agreed deliverables, it can become a real issue.

Open source has the ability drive up service quality with the IT supplier as trusts have the option to either find another support service provider or take ownership and responsibility of the code in-house, in turn keeping suppliers on their toes. There seems to be a concern that not all organisations will have the skills and resources needed to support an open source solution once implemented, but again, trusts have the ability to control this situation - for example, in the short term trusts can choose to have a traditional support role from a supplier as they adapt to the new approach.

Just because a trust has taken an open source approach does not mean you have to take all that work, control, ownership immediately - you can take as much time as you want to develop those abilities. Also, with a community interest company in place to support the management of the code, there will be a structure in place for clinicians to really input into the way the system is developed, whilst maintaining the integrity of the code for better patient experience and outcomes.

Malcolm Senior is director of informatics at Taunton and Somerset NHS Foundation Trust