Guidelines for Computerised Information Systems in the UK NHS Physiotherapy Services: An Historical Perspective

Background

This paper (below) was published in the Chartered Society of Physiotherapy Journal “Physiotherapy” in April 1994.  At that time, there were very few computerised information systems specifically designed for physiotherapy services and Allied Health in the UK but computerised information systems were gradually becoming more widely used in the NHS generally although physiotherapy was often added into the system as an afterthought.  In view of widespread moves within the NHS to include physiotherapy and Allied Health Services more widely in very generalist, often inappropriate systems which were not developed to include the specific needs of our services, I was concerned and strongly believed that user involvement in systems design was essential to ensure that computerised support was relevant to the services we provided, our practice  and modes  of working. Central to my thinking was the conviction that all computerised data should, as far as possible,  emanate from clinical activity.

I have been led to believe that by the time I retired from the NHS  from leading and managing a wide range of Allied Health services the physiotherapy service for which I was responsible was the first in the UK to make PC access fully available to all physiotherapy staff; all of my out-patient staff had their own work stations complete with PCs.  The system incorporated a wide range of clinical data as well as extensive, relevant data needed for management and leadership purposes and, of course, most importantly, patient care.

Having led a team of physiotherapy colleagues in making extensive input to the specification and design of an appropriate computerised information system for physiotherapy services it was my aim to create a set of guidelines which I hoped might be useful to others setting out along this often difficult road. My 1994 “Guidelines” paper was the result of this. The work was further developed over many years and further publications eventually followed. For example, the book “Managing Money, Measurement and Marketing in the Allied Health Professions” edited; Robert Jones and Fiona Jenkins in which several chapters further developed this and related topics.

Reference:  “Managing Money, Measurement and Marketing for the Allied Health Professions” Radcliffe Publishing, Oxford, New York.   2010

Introduction

For many years computerised information systems have been developed so that organisations might be more aware of their own state, and the state of the environment in which they operate.  The growth of this concept continues to take place in the National Health Service (NHS), in common with other organisations.  During the 1970s and 1980s the environment for the provision of health care within the United Kingdom has undergone wide-ranging and radical changes and the process of developing information systems and technology has gathered momentum throughout this period.  This process continues as further changes take place both within and alongside the service.

The need to provide more detailed and relevant information than ever before is fundamental to the many changes being brought about by national and local priorities.   There are many possible approaches to the development and use of computerised systems for physiotherapy.   It is the purpose of this article to focus on some of the important issues and provide guidelines on some of the aspects to be considered. This is not a ‘prescription’, nor is it claimed that the approaches outlined are the only or ‘best’ way forward.

Using the information

Detailed, timely, accurate and relevant information is essential for and central to the quality management of healthcare in physiotherapy and throughout the NHS as a whole.  Data and information are important to underpin all aspects of management quality and clinical practice, to demonstrate achievement of performance indicators of all types and facilitate and enable management and leadership processes to be pro-active.  It is difficult to comprehend how services could be managed effectively, without good quality data and information which must be part of the culture; relevant data and information are the ‘life blood’ of management – if you can’t measure it, you can’t manage it!

Physiotherapy and other Allied Health Professions now participate in the service specification process and agreement of service contracts and in conjunction with this it is necessary to develop methods and approaches to many demanding systems such as quality assurance, audit and the determination of outcome measures, service costing and pricing, case mix and resource management initiatives.  In order to be able to achieve all this; to be able to show what we are doing and how much of it, how effective and efficient we are and how much it all costs, therapists need powerful information systems capable of bringing together clinical and managerial information. Information is power.

The Development of IM&T for Physiotherapy and Allied Health Professions

The primary function of physiotherapy is the provision of clinical services.  However, over recent years information systems have become increasingly more important in the NHS and consequently, also in our services.

Computers were first used in the early days of the NHS in medical records departments for the Hospital Activity Analysis, which summarised selected basic information held in medical records on, for example, admission and discharge, but no physiotherapy or other allied health profession (AHP) information.

For nearly forty years, statistics about AHP activity were collected on a form known as SH3 which asked only for data on new patients and attendances by in and out-patients. The returns were often based on estimates rather than accurate data.  There was no feedback to managers, leaders or their staff on local or national activity trends which resulted in very little commitment to the quality of statistical data collection and submission, which was a widespread problem throughout many disciplines.

The initial impetus for the development of information in the AHPs was provided by the NHS/Department of Health and Social Security Steering Group on Health Services Information   which reported during 1982-1985¹.  The steering group was chaired by Mrs. Edith Kőrner, who was vice-chair of the South West Regional Health Authority in England. The data collection requirements set out in the Kőrner Reports for England and Wales gave rise to a variety of paper-based and computerised systems to capture and process information.

A few systems were designed by AHPs to suit national requirements and local needs, while others were the result of modification to existing systems used by other disciplines and adapted for AHP use.

Kőrner noted that much ‘lip-service’ was paid to the crucial and central importance of high quality statistics and that few health authorities, management teams or heads of departments analysed data expertly or used them intelligently in the performance of their management tasks.²

Around the same time as Kőrner, other far reaching management initiatives were being introduced with information systems; many of these had information implications for AHPs.

The early 1990s saw the development of costing mechanisms, development of pricing for contract purposes, of care profiles for clinical and managerial audit purposes, introduction of case mix systems and computers, improved coding systems, balancing organisational development and clinical information systems – the basis for much of current information systems work.

The main themes were:

1. Development of specialty and consultant costing systems in detail
2. Development of case mix measures for planning and management purposes
3. Development of advanced nursing dependency and management systems
4. Financial and staff activity systems linked together
5. Future budget setting based on planned activity levels and case mix costs
6. Regular report generation and on-going monitoring against budgets and planned activity
7. The development of costing systems
8. Comparison of actual and predicted use of resources to allow monitoring of clinical performance and deployment of resources.

The basis of case mix systems was intended to be the bringing about of implementation of a comprehensive record of every patient with data about every event occurring during a complete episode of hospital and community care.  The record was to include:  the patient’s personal details, diagnosis and operative procedures together with diagnostic events and therapeutic interventions.  All of these events had resource use implications in manpower, materials and facilities.  Therefore, costing was to be an important element of the case mix equation.

For the first time in NHS history a strategy for IM&T was initiated requiring active participation and implementation by the entire service³.

Computerised Systems for Physiotherapy Services

The author would argue that physiotherapy  managers faced with  the clinical requirements and demands of preparing service specifications, business plans, service level agreements (SLAs), tendering documentation, pricing and costing mechanisms, capacity management including supply and demand, activity, outcomes, caseloads, case mix, skill mix must be proactive in the development and/or choice of relevant information systems as well as clinical records and linking mechanisms with the wider demands of healthcare.

Not only is this important in its own right, but it is crucial in the wider context of AHP managerial responsibility and clinical autonomy which could be undermined if these services were treated as an ‘add-on’ to other services such as nursing.   The physiotherapy contribution to patient care is unique, wide-ranging and complex and differs from other services, therefore, physiotherapy managers must be involved in contributing their specific expertise, clinical and managerial requirements and management and business needs.

IM&T is crucial in an ever-increasing business-minded NHS in which clinical requirements for data and information systems support are paramount. When considering which computerised systems might be suitable for physiotherapy services or contributing to service development and specification, it is hoped that the principles which are in the guidelines below form a useful checklist.

During the mid-1980s the author and his team specified, tested, piloted and used computerised information systems for a wide range of clinical and managerial purposes.  Working closely with physiotherapy colleagues in adjacent health districts data recording, methods of collection and systems specification were designed using methods appropriate to clinical practice.  Throughout this period the author and his team worked on the entire computerised information system development process with a number of computer companies which enabled us to gain valuable experience in this field.

During the past few years there have been scores of inquiries from physiotherapists and people from a wide range of other Allied Health disciplines within the NHS and these guidelines emanated from this work.  The guidelines are not intended as “standards” which must be adhered to, but rather highlight major areas for consideration to help those working on further development of existing computer systems and those new to IM&T.

Guidelines for Computerised Information Systems for AHP Services

By Robert J Jones

1.  Information use: All information collected should be for identified and agreed use Computerised information systems should provide:

• information required for clinical, managerial and business purposes within AHP services locally
• information required nationally or regionally
• information required for the employing organisation
• information required by commissioners and all other service purchasers

2. Local ownership: The computerised information system should be specific to the clinical and managerial needs of AHP services locally

• systems should be ‘owned’ by the AHP services using them locally, and part of the wider computer system within the organisation
• information contained within the system is ‘owned’ by the AHP services and the organisation
• AHPs should be involved in the choice and/or design of appropriate information systems for their own services.

3. Computer ‘hardware’: AHP services should have appropriate ‘hardware’ to support their information systems, the ‘hardware’ must:

• have the capacity to handle the quantity of data required at present and be capable of expansion to meet future needs
• be capable of supporting a wide variety of applications
• be capable of supporting a variety of input devices and terminals including adaptive equipment for sensory impaired users
• be compatible with ‘hardware’ used by other services and departments locally
• be capable of supporting a variety of data collection modes such as data collection in ‘real’ time, bar coding, Personal Digital Assistants (PDAs), optical character recognition (OCR), paper systems, retrospective input
• operate at the highest speed commensurate with the size of the information system locally
• be capable of processing data in ‘real’ time and batch modes

4. Computer software: Computer software for AHP information systems should be appropriate to clinical and managerial practice, the software must:

• be specific to AHP managerial and clinical requirements
• be compatible with other programmes used locally to facilitate interfacing
• enable archiving and retrieval of archived data
• interface easily with other programmes such as Microsoft packages, programmes for clinical purposes and other databases
• interface with specialist software for sensory impaired users
• be capable of updating in line with changing requirements
• be designed to accommodate SNOMED, ICD and other coding systems

5. System security: AHP systems must be secure to protect the confidentiality of patients, staff and all others about whom data are held.

• data must be collected, processed and stored within the requirements of data protection legislation
• entry to the AHP system must be governed by a system of passwords
• staff must ‘log off’ of computer equipment when not using it
• there must be full backup of data on at least a daily basis

6. Data collection: All data collected by AHPs should – wherever possible – be a by-product of clinical practice

• all patient intervention data items are collected once only if possible
• the data system must facilitate the collection, processing and reporting of locally agreed clinical and managerial information as well as that required regionally and nationally – it must be possible to report on all parameters input to the system
• the system should facilitate the collection, processing and reporting of information about the use of AHP resources in: patient activity and non-patient related activity
• data input to systems may be undertaken by clerical, clinical or managerial staff

7. Reporting: The computer system must be capable of producing standard and ad hoc reports for AHP clinical, managerial, research and business purposes, as well as meeting the agreed requirements of others.

• The system must be able to produce reports to support a wide range of business processes, such as service line reporting, costing and pricing, referral to treatment time (RTT) reporting, external contract requirements, practice-based commissioning, staff activity and throughput, capacity and demand.
• The system must be able to produce reports to support a wide range of clinical processes, such as: audit, research requirements, clinical case loads, case mix, outcome measurement
• computer reports must be available to AHP managers and clinicians as and when required
• reports are easily accessible from the system in a variety of modes; tabular, bar charts, pie charts, spreadsheets and so on
• the system should facilitate the design and generation of ad hoc reports as well as standard reports by AHP managers and clinicians as well as others within the organisation

8. Service agreements: There must be service agreements with computer companies supplying the AHP system:

• there must be service agreements for the computer software with agreed ‘call-out’ and support response times
• agreements should include – for example, systems failure, maintenance, support, trouble shooting, further developments
• it is helpful if there is a user group attended by the software company that the AHP manager and clinical leads can participate in

9. Computer system documentation: There must be full documentation for the software:

• comprehensive manual on the computerised information system software use
• user manuals (paper and electronic)
• coding manuals
• report templates

10. Staff training: Training at all levels on use of the system must be provided:

• training must be provided for clerical and reception staff
• training must be provided for all AHP staff

In Summary

Information management is an essential aspect of AHP clinical services, management and leadership.     IM&T offers many benefits to AHP managers, clinicians and service users including:

• Better management of patient care and facilitation of high quality clinical practice
• Support to strategic and operational management
• Support to good business and staff management
• Identification of trends
• Warning of potential adverse events
• More effective and efficient record keeping
• Development of and access to the evidence base
• Audit, research, and development

Whether the service is in primary or secondary care, the private or other sectors, information management of the service directly impacts on the quality of care provided.   Information management and technology is an essential ‘tool’ to support all elements of quality management to enable service effectiveness and efficiency, management of change and service re-design.   The effective use of data to manage services enables managers to contribute fully to business processes, performance management and governance.

In order to thrive – or even survive – it is imperative that we have robust information management systems to ensure the evidence for our management, clinical practice and patient care.

 

References

1. Kőrner E. In: Jones, R. 1991. Management in Physiotherapy. Oxford: Radcliffe Publishing Ltd; 1985.
2. Kőrner E. Report on the collection and use of information about hospital clinical activity in the NHS (first Report) DHSS Steering Group on Health Services Information. London: HMSO; 1982.
3. IMG, NHSME. Information Management and Technology Strategy. London: HMSO; 1993.