Wednesday, June 1, 2011

HIT Lessons Learned from Scotland

My trip to Scotland provided a remarkable opportunity to exchange ideas and experiences.

Scotland has nearly 100% adoption of electronic health records among general practioners and is making good progress in hospitals with innovative built/bought inpatient systems.   As in most countries, health information exchange is still evolving, but novel databases supporting disease management at the community level and an emergency care summary exchange are already live.

Here's what I learned while in Scotland

1.  Scotland has 5 million people - about the same size as Massachusetts.    There's a real "can do" attitude that makes significant change at the national and regional level possible.

2.  General Practictioners are passionate about IT.   There are 2 major electronic health records (Vision and EMIS) used in ambulatory settings in Scotland.  I was able to test them with demonstration patients and they seem to be a bit more focused on creating a journal of patient health events as compared to EHRs in the US which follow the Meaningful Use paradigm of structured problem lists,  e-prescribed medications, allergies, notes/reports, and coded diagnostic results.

3.  Healthcare information exchange between EHRs and hospitals is document centric.   My limited experience suggests that clinical encounter summaries in Scotland are shared via episode of care documents rather than structured data element exchange.

4.  There is a national healthcare identifier which enables records to be coordinated and aggregated in a national emergency care database, registries, and for continuity among caregivers.

5.  The National Health Service provides comprehensive care across all settings and therefore can drive innovation and adoption across the country.

Scotland has many of the same healthcare challenges as the US - increasing obesity, earlier onset and increased numbers of diabetics, and the worldwide issues of tobacco and alcohol use.  

Through the use of careplans/guidelines, registries, electronic health records, and care coordination across the community, Scotland is hard at work improving public health and population health.   I think of Scotland as an extraordinary testbed for healthcare IT implementation.  With its high adoption of EHRs among community clinicians, its bottom up approach to creating automation to meet the need of hospital stakeholders at a local level, and its population size that makes implementation doable, I highly recommend that vendors partner with Scottish healthcare provider organizations to test innovative solutions which can then be spread throughout the world after successful pilots.

Thanks for Andrew Morris and the University of Dundee for hosting me.  I look forward to our further work together.


Donald Green MD said...

It seems the paramount focus in Scottish medical IT is the history and physical exam rather than the tearing apart approach adopted with this country's present agenda.

By documenting and presenting a more complete record for review(visits rather than discreet data) more information stands with its creators. This allows more accurate corroboration for population studies.

Those who generate the data should carry the primary responsibility for its verification. By melding together pieces of data from different sources this invites incorporation of errors that will be difficult to discover or track.

Attempts to prevent this from happening will only make producing such records even more expensive and probably less expansive. Before going too far down the road, even after such herculean work to produce Meaningful Use, it should be reexamined. As I have stated previously the users must have products that satisfy their professional needs first before any massive hook up.

This caveat is not to delay implementation but a call for some introspection on what best serves medical practitioners and their patients. With more than half the medical visits in this country performed by small practices the present plans may spell unwanted outcomes in the future.

mickmaguire said...

John, did you get any sense of how different Scotland may be from the rest of the UK? I'm sure there must be strong ties with the NHS?

Ian McNicoll said...

As a former Scottish GP turned informatician, I attended and thoroughly enjoyed John's presentation in Dundee. Scottish NHS e-Health has developed rather differently to efforts in England, particularly that we use a home-grown messaging standard called SCI-XML that has proven a lot easier to use than HL7v3 that has been used in England. We have also been a little resistant to SNOMED adoption but it is only a matter of time!!

One of the major strengths of UK e-Health has been the independent development of high-quality GP systems, highly encoded using the READ codes.
This is often overlooked in discussion of the 'failing' English national program, and indeed, one of the original aims of that program was to rip-and-replace these systems which were seen as legacy.

The different approaches of each of the 4 countries to 'emergency summary' records is an interesting study of how subtle social and policy differences which can easily derail widespread public support.


James M said...


Your comments are spot on, having been involved in both Scotland and England there are both significant differences and similarities.

Similarities include the fact that penetration of systems is highest in primary care, although Scotland is moving away from its own system GPASS to commercial systems. This introduces another similarity which is the systems supplier market, the same suppliers operate on both sides of the boarder. We also face the same challenge that of sharing information across different care settings. I feel the key challenge here is not technical standards, but ensuring all the users appreciate the benefits of sharing information.

Differences include the technical standards, Ian has mentioned messaging, but other differences include the strategy. Although England started out with a 'rip and replace' strategy it is moving towards a 'connect all' strategy which builds on pre-existing systems and connects them together. The other significant difference is geography, Scotland has a sparse population compared to England and this impacts how far users have to travel for services.