The complexities of NHS information systems; a lack of interconnection with front line doctor communication; and the absence of an effective bug reporting system are combining to cause case mismanagement and even patient deaths, according to one doctor and software developer.
Carl Reynolds is founder and chief executive of Open Health Care UK, a start-up developing open source software tools for doctors and health service managers whose board members include the doctor, campaigner and writer Ben Goldacre, author of "Bad Science".
A self-styled "doctor and geek", Reynolds was addressing an audience at Electromagnetic Field, a festival of hackers, makers, coders and other techie types drawing in about 1,000 people to a remote Buckinghamshire field in unusually connected circumstances. These included power and internet to the tent, radio networks and high speed Wi-Fi, not to mention laser cutting facilities, vintage computer games, a robot production line mixing cocktails, quadcopter building, a giant moving eyeball and a blacksmith's forge.
The festival's wide-ranging agenda included NHS IT, and Reynolds told campers that doctors such as himself had to navigate a system which still holds many relevant bits of information in different places such as scan images or details of past procedures. Added to that are disparate communications systems, some outdated - such as pagers and faxes - and others not joined up.
"We are not properly capturing communications information - sometimes we initiate requests for tests that are lost in system", he said. "This is seemingly intractable - in my four years as doctor in the NHS, I do not have a feeling it is getting better."
In the worst cases, patients can die because of ICT issues, Reynolds said. In his own experience this has happened at least once, when an X-ray image went missing that would have shown a patient's feeding tube was in the wrong place. The woman suffered a perforated lung.
"Surely someone files a bug report and gets fixed? There isn't a proper reporting system", he said. There is supposed to be: the National Reporting and Learning System (NRLS), a mechanism for reporting and tackling patient safety issues that is now housed in the new NHS Commissioning Board Special Health Authority. This is supposed to collate issues and feed back information so people can fix the system, Reynolds said. However in practice, it fails to work well for a number of reasons, as he found out for himself when he was seconded to the agency that used to run the system.
"I picked a sub-set of information systems and software incidents to look at, and I found more than 1,700 incidents. But there is not a lot of granularity. The sort of detail is 'it didn't do what I wanted it to do', so it is hard to replicate and know the cause.
"There is also massive under-reporting, because there are lots of ongoing issues and not adequate mechanisms to fix them with regards to software within the NHS."
There are many causes to the health service's ICT problems, including a lack of digital nous among leadership; a lack of influence by the end user ("there is no way to vote with your feet, like with a supermarket"), software commissioned at the wrong level in the system, too high up; and a cohort of procurement manager who have been brought up in relationships with larger vendors and so look at issues like governance rather than focusing on usability, Reynolds said.
His start-up Open Health Care UK was attempting to tackle some of these issues by developing systems openly, allowing greater influence to come from the front line.
These include Open Prescribing, a interactive data exploration tool that allows clinicians, researchers, journalists, and the public to analyse drug prescription patterns; and OPAL, a simple framework for looking after lists of patients, tracking in-patients and out-patients and managing wards, that can be customised for any hospital setting - UCLH is using a version. The software is open source and Open Health Care charges for work on customisation, deployment and support, Reynolds said.
Asked what the "big players" think about his efforts - the technology giants who perennially win the major ICT contracts let out by the NHS - Reynolds said his start-up was not yet winning large enough contracts to hurt them. "There is now in NHS England an open source programme, possibly partly to do with our efforts, but on the whole they just pay lip service to open source and open standards". But ultimately, becoming a larger commercial player was the way to expand the open approach, he said.
"The way is to make OPAL represent the best value for money for hospitals - then using it will become commercially strategic for them."
Another delegate asked Reynolds whether the creation of a "Government Digital Service" style central digital agency within the NHS might help, in the same way as the government has set up a single digital unit for its departments and agencies sitting in the Cabinet Office.
"Something like that would be difficult because of the way hospitals are set up, but there could be some means of doing it, and I would fully support that - I would love to be doing what am doing with my start-up within the NHS", he said.
Open Health Care UK already runs a series of "NHS Hack Days" where anyone can come along and try to create prototype software solutions for a range of problems that are pitched to them, Reynolds said. The next NHS Hack Day runs in Leeds on 27-28 September.
Pictured: Signs made by artists and volunteers at technology festival Electromagnetic Field.
Open Health Care UK: www.openhealthcare.org.uk
NHS Hack Day: http://nhshackday.com
NHS National Reporting and Learning System: www.nrls.npsa.nhs.uk
Electromagnetic Field: www.emfcamp.org