English electronic medical records plan hits some snags

The benefits of the Summary Care Record (SCR) scheme, introduced as part of the National Programme for IT (NPfIT), appear more modest than anticipated, according to a study published on bmj.com June 17.

The findings are based on an independent evaluation by researchers at University College London and come as the new coalition government in the U.K. announces a review of the scheme.

The Summary Care Record is an electronic summary of patient medical records, comparable to an electronic medical record (EMR) in the U.S., that is accessible over a secure Internet connection to authorized National Health Service (NHS) staff. The plan was adopted nationally with the aim of improving the quality, safety, and efficiency of care, especially in emergency situations. The English government began to roll it out in 2008.

But the scheme has proved controversial. Alleged benefits and drawbacks range from better clinical care and fewer medical errors to high costs and threats to confidentiality.

Researchers analyzed data across three sites over a three-year period (2007-2010). They collected information on more than 400,000 encounters in participating primary care out-of-hours and walk-in-centers and conducted 140 interviews with policymakers, managers, clinicians, and software suppliers involved in the scheme.

By early 2010, 1.5 million SCRs had been created. But creating SCRs and supporting their adoption and use, the investigators found, is a complex, technically challenging, and labor-intensive process that has occurred much more slowly than originally planned.

In participating primary care out-of-hours and walk-in centers, they found that an SCR was accessed in 21% of encounters when one was available. The figure was rising in some, but not all, sites.

Individual clinicians accessed available SCRs between 0% and 84% of the time. This varied depending on setting, type of clinician, and clinician level of experience.

When accessed, SCRs seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a positive impact on preventing medication errors.

The research team found that SCRs sometimes contained incomplete or inaccurate data, but they did not see any cases where this led to harm; clinicians used their judgment when interpreting such data and took account of other sources of information. SCR use was not associated with shorter appointments nor did it appear to reduce hospital admission, benefits that had been anticipated by policymakers.

The evaluation also showed that successful introduction of SCRs required collaboration between stakeholders from different worlds with different values, priorities, and ways of working. The authors say these differences may have accounted for many of the misunderstandings and frictions that occurred at the operational level. And they suggest that the program’s fortunes will depend on an ability to bridge the worlds of different stakeholders and align their conflicting logics, and to mobilize implementation efforts.

“This evaluation has shown that some progress has been made in introducing shared electronic summary records in England and that some benefits have occurred. However, significant social and technical barriers to the widespread adoption and use of such records remain, and their benefits to date appear more subtle and contingent than early policy documents predicted,” they wrote.

In two accompanying papers, also published on bmj.com June 17, experts debate whether summary care records have the potential to do more harm than good. Mark Walport, director of the Wellcome Trust, believes that the national electronic database of patient records will make valuable contributions to better care, but Ross Anderson, a professor of security engineering at the University of Cambridge, argues that it is both unnecessary and unlawful.