There is a wide and occasionally bewildering array of software used by patients and clinicians in the NHS. This is a short, introductory reference guide to illustrate the range. It is by no means comprehensive so any critique or additions are well received. I hope it’s useful to some.
Clinical system: If you are new to healthcare, one of the immediate things you encounter is the primacy of the clinician and the concept of clinical safety. A clinician is someone with a medical qualification who treats people i.e. a doctor, nurse, paramedic, dentist, pharmacist, or midwife. ‘Clinical system’ is a broad term that is used to refer to the software that supports clinical activity i.e. the act of treating patients in a healthcare setting. When software is considered to be clinical it means it is subject to legislation such as clinical safety standards (as defined under the Health and Social Care Act 2012) or the Medical Device Regulations. This means clinical systems must be able to evidence their safety through testing and by explaining their approach to clinical risk management.
Clinical systems are the bread and butter of healthcare and this is where most of the health IT money goes. They can range from specific standalone systems for a specific purpose like a Radiology Information System/Picture Archiving and Communication System, to care pathway-specific dealing with, say, cancer. A care provider chooses these based on its needs then often integrates them into a core enterprise system, more on which below. There could be over 100 in a given hospital.
Patient administration system (PAS): used in hospitals, this describes the software that manages administration of patient interactions. This includes things like: the hospital’s patient index with patient demographic details, appointment booking functionality, checking patients in and out, scheduling and workflow type stuff, referral management, payments. Notably, PAS’s are distinct from being clinical i.e. they do not typically store or process clinical information about patients. Pretty much every care setting has something akin to a PAS, it’s just that the term is synonymous with hospitals. Because of the way PAS’s in acute settings have evolved to meet very specific NHS-y needs such as national data returns or payment processing, it makes it a niche market with higher barriers to entry.
Electronic Patient Record (EPR): self-explanatory in some respects, as this refers to the digital manifestation of the patient’s healthcare record. EPRs are everywhere, although the term itself is most closely associated with hospitals. This is mainly because in hospitals there is a historic distinction between the care record and the PAS, and because other care settings have EPRs that are already called other things. These days EPR systems often do heavy lifting for both the patient record and various jobs previously undertaken by the PAS, as part of the trend to enterprise approach. EPRs can also go by the name EHR, or EMR. The market leaders in the UK are Cerner and Epic. It is apparently not cheap to install an EPR. Leeds Teaching Hospitals built their own, starting in 2003. Many sensible people on all sides of the political divide think that the patient data layer should be separated from the enterprise applications, and more who suggest it should be nationally owned. This is not going to be easy.
GP IT Systems: these are the main software systems used by GPs, and are really an EPR for the GP setting. They have a whole range of features from appointment booking and management, prescription management, to generation of letters and storage of data. Crucially, they store your GP medical record, allowing GPs to code entries and enter free text information regarding your consultations, conditions or medications. The GP record is particularly important in NHS terms because the way the NHS is structured means it is de facto the main record for your healthcare. It stores correspondence between your GP and hospital or other provider. The systems also automatically pump data to NHS Digital for aggregate, statistical use. There are 4 GP system suppliers in England which are TPP, EMIS, Vision and Microtest.
Clinical decision support system: commonly abbreviated to CDSS, this is a tool that is often embedded as a feature within types of clinical systems. It typically forms a series of questions that can be asked of a patient in order to help a healthcare professional (either clinically trained or not) assess the patient’s condition. You can see a CDSS in action on 111.nhs.uk in which patients themselves access the NHS Pathways CDSS. Pathways’ underlying clinical information makes a risk assessment based on the combination of answers provided. It’s essentially a corpus of medical knowledge with the “one thing per page” design principle applied. CDSS’s can be either for diagnostics or triage. Diagnostics is where the tool is actively trying to suggest possible illnesses whereas triage simply assigns a level of risk to direct a patient to the appropriate clinician or care setting. The former is governed by stricter regulations, but this is a bit of a false distinction in my view as a triage system is still making some guess at what the problem might be, in order to assign a risk score. As well as online, CDSS is used by phone operators e.g. on 111, or at the front door of emergency departments. Very specific CDSS can also exist to support clinicians in highly specialist settings e.g. to help doctors select the right chemo dosage in cancer treatment.
Online consultation systems: these are relatively new on the scene, and are systems in primary care to enable GP-patient interaction to happen remotely. They comprise a number of features that support this. Online consultation is often conflated with video consultation. While the former does encompass video consultation, the terms are not wholly interchangeable because online consultation also encompasses things like form-based triage (i.e. the patient fills in a questionnaire about their symptoms and this is sent to the practice); 2-way messaging between the practice and patient; and symptom checking using a CDSS. Examples are eConsult, Ask my GP, Engage Consult.
Personal healthcare record (PHR): PHR is an umbrella term for a digital healthcare record that is owned and administered by the patient themselves. It’s not clear to me yet how much this term is understood beyond a core group of wonkish types like me who work in digital healthcare delivery and policy. A PHR may combine clinical information from various sources, but crucially they also allow the patient to submit information themselves either through manual data entry or via wearables. NHS Digital maintain a working definition of a PHR on their website. Some examples are Tiny Medical Apps, Patient Knows Best or Apple Health.
Computer Aided Dispatch (CAD): This is the system that supports 999 control centres in the management of telephone calls into the service and the coordination of staff and vehicles in support of the calls. It also supports CDSS modules to help triage calls. Ambulance services will also often have a separate EPR for their patients. As the urgent and emergency care sector evolved as its own sector through the advent of the 111 service, so too did the case management tooling. So now equivalent products are available in 111 to queue and manage calls, undertake referrals, update records and perform triage. And some are used across both 999 and 111. In NHSD we have broadly referred to these as Encounter Management Systems but this is not a widely used term. Examples are Cleric, Adastra.
Internet pharmacies: also known as ‘distance selling’ pharmacies in commissioner language. These are pharmacy services that fulfil prescriptions by delivering them to your house as opposed to requiring you to go to the pharmacist. They tend to have web or native apps that enable you to manage prescriptions accordingly. Examples are Echo, Pharmacy2U.
Patient portals: as much as it pains me to write this heading, this is nonetheless still a term that is oft used in the NHS. It refers to any application either browser-based progressive web app or native app that enables a patient to interact with an underlying clinical system. Usually this is so the patient can see their records, book and manage appointments, and manage their medication. There are a ton of these for both primary and secondary care.
Wellbeing: there is a massive market for wellbeing apps which support everything from diet, mental wellbeing, sleep. For a browse of some examples it’s worth a look at the NHS Apps library. I’ve not really given them the full treatment here because I know little about them and they aren’t typically transactional in the same way the other examples are.
Having set all of this out, a few thoughts on healthcare products.
- The boundaries around the different types of products are very fuzzy. e.g you will get PHRs that have some features of online consultation tools; or EPRs that do the work of a PAS. This sometimes makes it hard to know what to buy, and exacerbates the challenge of ensuring interoperability between systems. i.e. it’s a bit confused, in a similar manner to the organisation of our health institutions as I have blogged before.
- Somewhat unlike central government departments (in my experience at least) the NHS and its staff are entirely comfortable with the concept of ‘services’. The clue is in the name I suppose. But there is very little discussion of services in the context of digital delivery, except at the national level with things like PDS and e-RS. You rarely hear the term ‘product’ compared to say ‘system’ or ‘tool’, and the closest you get to service is probably ‘digital care pathway’ which is kind of getting there but can miss the real fundamentals.
- This proliferation of product types means there are lots of places that patient data can be held, hence the massive focus on interoperability in the NHS, and the importance of point 6 in the Future of Healthcare.
Hopefully this is helpful to digital healthcare workers new and existing. As above, I welcome any additions or comments.
The views expressed here are all mine and not those of my employer. Thanks to Kate Gill for her fact checking and examples. This was originally published on Medium on 1 May 2020.
