Specification for a directed enhanced service in England: Information management and technology

Introduction
1. This Directed Enhanced Service (DES) is designed to facilitate information management and technology (IM&T) adoption to support the delivery of the National Programme for IT. It requires primary care trusts (PCTs) to pay practices specified, non-recurring payments following successful preparation for and adoption of IT systems and processes. There will be variations in the timing of roll out of these systems across the country. Therefore timing of payments in respect of this DES will also vary across the country. In some cases, the implementation of an area of work might not take place until 2007 or later and PCTs will need to ensure, for budgetary purposes, that they plan for the likely local timescales of implementation.

Background
2. NHS Connecting for Health (CfH) is the agency delivering key Department of Health priorities in the National Programme for IT. It is tasked with providing new information technology (IT) facilities for the NHS to improve patient care in all parts of the health service, by reducing risks, increasing efficiency and enabling more effective ways of working.

3. Among these new IT facilities are a number which will initially have significant impact on the delivery of high quality patient services by GPs and their practice teams including:
(i) Electronic Prescription Service (EPS)
(ii) Electronic transfer of GP records (GP2GP)
(iii) Choose and Book
(iv) The NHS Care Record Service.

4. Introducing these systems and services to GP practices will result in benefits and increased efficiencies within practice workflows and business processes. New processes and procedures will support the requirements of data quality, data protection and patient confidentiality, system failure recovery, and systems management. With time, as practices move to paper-light status (footnote 1 - go there now), these processes and procedures will become increasingly vital to the security, stability and safety of clinical care. These changes will result in improved patient care and improved practice efficiency and will enable practices to communicate electronic patient information with other parts of the NHS for the direct benefit of their patients and their practice organisation.

Aims
5. This DES will support practices to become properly equipped for the innovative new IT approaches to patient service delivery. This will include:
(i) active implementation of the key national initiatives outlined above
(ii) ensuring that all practice staff, clinical and non-clinical, receive adequate training to equip them to adopt new methods and systems; and that staff receive sufficient skills development to ensure that the practice can function effectively in the new IT-intensive environment that will prevail in primary care
(iii) recognition of and resources for the successful installation and implementation of new technologies. Practices will benefit from increased efficiency once these programmes are embedded in the practice, but it is recognised that the initial installation and training has workload implications
(iv) provision of adequate support to ensure smooth service delivery during installation of new systems and the practice’s adaptation to new ways of working
(v) accreditation of the quality of the electronic record keeping of practices which record their consultations in the surgery setting contemporaneously through their computer systems, otherwise termed paper-light.

Requirements
6. The timing of deployments of programmes across the country will vary depending on the state of readiness of practices and the development of the programmes in those localities. DES payments will reflect these variations and be made available when the deployment takes place.

7. The elements below are key to successful implementation of the overall programme and the DES provides practices with a contribution to supporting the costs of them:
(i) protected time for team members to attend training tailored to their needs and ensure that the practice meets Information Governance, data quality and system operation standards. This does not include the direct costs of the facilitator staff provided by the PCT whose training is provided free by the NHS CFH contract Primis +
(ii) protected time for new team members, especially clinical, to be inducted to meet the practice’s information standards
(iii) time for practice staff to undertake necessary additional work in order to ensure safe and effective implementation
(iv) provision of additional clinical and non-clinical support to ensure efficient service when practices are learning how to use each new technology to best effect
(v) recognition of any adjustments to skill mix that may be required due to the higher technology environment.

Component one
8. Practices will be required to prepare a plan that demonstrates their commitment to the DES which should include:
(i) nomination of a practice lead who will liaise with Connecting for Health
(ii) nomination of a Caldicott Guardian
(iii) a training needs assessment and linked training plan for each member of the practice team involved with the operation of IT systems
(iv) evidence of compliance with good information governance practice including clauses on confidentiality in contracts of employment, training, compliance with the Data Protection Act, Computer Misuse Act and Caldicott guardianship.

9. In addition practices should:
(i) maintain a log of training undertaken by each member of the practice team linked to his or her training needs assessment and personal development plan
(ii) maintain a log of in-house training events undertaken including induction of new staff, including locums and relief staff and a signing-off process
(iii) undertake appropriate training and demonstrate proficiency in information governance standards.

10. All practices are expected to be connected to the N3 network by the end of this DES. Practices are expected to enable the upgrade of the hardware estate to a nationally specified standard as set by Connecting for Health in consultation with the Joint General Practitioners Committee (GPC)/Royal College fo General Practitioners (RCGP) IT Committee.

11. Every staff member who is to have access to the computer system must be authenticated and registered with a Smart card and know how to use it. The practice must have a process in place for staff changeover with regard to the smart cards. This process will be supported by the PCT.

Component two – Preparation of data for accreditation
12. Practices will be expected to work towards data accreditation in readiness to upload electronic patient summaries to the spine when appropriate. This includes electronic note summarisation. This accreditation will be for paper-light practices and will require a process of reviewable accreditation. The data standards required for this accreditation can be found in Annex A - go to this section. It is not envisaged that practices will be finally uploading data to the spine in 2006/7 other than in pilot practices. It is not intended that detailed discussions with patients about their spine data would occur under this DES.

Component three
13. Maintenance of patients addresses with opportunistic regular validation with patients. The practice is the sensible location within the health service for the patients’ addresses to be maintained and validated for accuracy. This will require administrative effort and new workflows to ensure that address changes are processed accurately. It would be expected that practices will validate a patient’s address and other relevant details at the point of referral and/or when a practice has received information about a patient that contains a conflicting address.

14. Electronic Prescription Service (EPS). Practices will prepare for the EPS programme, including accessing training, and identify changes in working practice and amend standard operating procedures. Practices will be required to utilise EPS Release 1 software. Patient information (via practice leaflets etc) on any local changes for prescription collection arrangements should be available. When available and permissible, EPS Release 2 Software should be utilised.

Payment Schedule
15. Component one: In order to receive an upfront, first component payment, practices will need to agree a practice plan with the PCT. This payment acknowledges the commitment and planning the practice will need to invest ahead of programme deployments, and the work required to fulfil all the elements in paragraphs 8 to 11 above.

16. Component two: Practices will receive a further payment following data accreditation, as set out in the standards at Annex A - go to this section.

17. Component three: Practices will receive a further payment for successful completion of the requirements set out in paragraphs 13 and 14 above.

18. Component four: Practices will receive a further payment following migration to a CfH accredited hosted system.

19. PCTs will make prompt payments to practices upon completion of each component. If a practice has not made reasonable efforts to complete the elements of a component it agreed with the PCT to do, the PCT may seek repayment of a proportion of the specific component payment relative to the amount of work done by the practice. If a practice has not been able to fully implement a component of this DES due to circumstances beyond its control (eg due to national or regional difficulties), the practice should receive a pro-rata payment for the work that they have completed.

Validation
20. Connecting for Health will provide PCTs on a regular basis with electronic evidence of those practices that have successfully deployed each of the programmes. This will enable PCTs to make the specified payments to practices upon receipt of individual claims and supporting evidence from practices.

Annex A - Data standards for accreditation process
The accreditation of practices is required by NHS Connecting for Health before patients electronic summaries are uploaded to the spine - go there now.

The demonstration of a workable and regularly updated summary of patients records is required in order that another clinician can rapidly comprehend the clinical issues that are pertinent to the patients clinical care. The summary should include repeat medications that are linked to the significant diagnoses/problems that are identified. Allergies and adverse reactions should be included.

Uploads will be taking place during the year 2007/8 of patients who are registered with accredited practices. This document outlines the accreditation standards and process.

The standards that are expected of practices are those already signed up to by the profession and outlined in detail within the Good Practice Guidelines - go there now.

Practices will be expected to be part of the PRIMIS+ facilitated network or equivalent. PRIMIS+ facilitators will support practices with their education and training on data quality issues and information governance. This will help them in providing the evidence of audits required for the accreditation process.

Practices will be expected to demonstrate compliance with Good Practice Guidelines and the process that has been designed is to enable practices to demonstrate their abilities in the following ways:

Organisational

# Standard   e-audit Submission visit
1 Practice is using the computer contemporaneously in consultation for all clinicians consulting regularly at the practice; or entries are made expeditiously- partial note keeping on the computer is not an acceptable standard     x x
2 There is a process in place to update patients addresses opportunistically (in line with the DES) on the computer system     x x
3 Locums and people who are unused to the system have a system to support their consultation and data entry     x x
4 Evidence of recording of telephone consultations in the electronic record at an appropriate rate   x    
5 Evidence of recording of visits in the electronic record at an appropriate rate   x    
6 Referrals are coded and recorded at an appropriate rate, including to secondary care and to other agencies who are not part of the extended practice team, such as counsellors, physiotherapists, community psychiatric nurses   x    

Information Governance

# Standard   e-audit Submission visit
7 The practice is registered under the Data Protection Act     x x
8 The practice complies with laws on data access including role based access for all terminals, ensuring that no terminals are used by a staff member on another staff member's card     x x
9 The practice has effective, validated data recovery processes     x x
10 The practice has a nominated and trained Caldicott Guardian who performs the role appropriately     x x
11 Alleged breaches of data security are investigated promptly and efficiently     x x

Clinical Data Entry

# Standard   e-audit Submission visit
12 Prevalence of specified significant, common disease diagnoses, relevant to the practice demographics, within 2 standard deviations of the mean or evidence to explain the variation   x    
13 Prescriptions indicative of a major chronic diagnosis not present without an appropriate diagnostic code in the summary record   x    
14 Problems/diagnoses classified as "significant" or "important so that an accurate and complete summary can be created   x    
15 The rate of recording of drug and other important allergies and adverse reactions, is within 2 standard deviations or a valid explanation given   x    
16 Major diagnoses made by secondary care and other health care professional are recorded and prioritised if appropriate in the summary   x    

Measurement of standards
There will be a three part process of accreditation:
1. When a practice applies for accreditation it will submit a plan that includes the suggested letter in appendix 5 of good practice guidelines. It will submit evidence of protocols and audits in support of the standards described above.
2. A quantitative analysis of practice data will look at the following suggested areas Searches to be defined with PRIMIS+ to help identify practices whose recording is substandard.
3. A visit will be arranged by a team from the PCT to accredit the practice. The visit will do qualitative checks of a cross section of notes from every clinician who consults on a regular basis. The team will also explore areas it has identified in the evidence submitted by the practice in its application.

Accreditation will normally last for three years but the team will be able to give a shorter time of approval if they feel that it is more appropriate due to the special circumstances within the practice.

Footnote 1 - Paper-light infers a practice that uses its computer system as the main place it records its patient records. Practices will not be dually recording that information on paper. They will be using the computer system contemporaneously in the consultation and recording their findings according to the standards set out in the Good Practice Guidelines and will be coding their data systematically against standards to be published.