eHealth Strategy 2011-2017 (Revised July 2012 to include a Sixth Strategic Aim)

5. How We Are Responding To The Challenges - Our Strategic Aims For Ehealth

Our drive for quality must be the priority within tight resourcing. Nonetheless we have the opportunity to mainstream eHealth through delivering significant benefits. The Quality Strategy provides the policy context, and our response to budgetary constraints and the NHSS efficiency Framework has been to focus on how eHealth initiatives can deliver both quality services and efficiency savings. In doing this we have developed six new strategic eHealth aims for 2011-17 and positioned these aims and our eHealth Strategy to meet the future challenges. The relationship between these policies is depicted in the figure below.

The six strategic eHealth aims have been developed in consultation with stakeholders. Our new strategic eHealth aims contribute to the realisation of the three Quality Ambitions to varying amounts (see below).

They are to use information and technology in a coordinated way to:

• maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money
• support people to communicate with the NHSS, manage their own health and wellbeing, and to become more active participants in the care and services they receive
• contribute to care integration and to support people with long term conditions
• improve the availability of appropriate information for healthcare workers^[12] and the tools to use and communicate that information effectively to improve quality
• improve the safety of people taking medicines and their effective use
• provide clinical and other local managers across the health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery

Additionally, we will:

• continue to promote, encourage and facilitate collaboration between Boards, and to drive the convergence and standardisation of IT systems
• build evaluation into eHealth developments and share the evidence from these experiences
• ensure that Equality Impact Assessments are undertaken prior to the introduction of new eHealth systems and processes
• capitalise on our existing eHealth investments and
• support innovative applications of eHealth which enable the delivery of the NHSS's three Quality Ambitions

The benefits of this strategic approach are represented in the table below.

		The 3 Quality Ambitions
		Person Centred	Safe	Effective
Strategic eHealth Aims 2011-17	Maximising efficient working practices
	Supporting people to communicate with NHSS and manage their own health and wellbeing
	Contributing to care integration and supporting people with long term conditions
	Enhancing the availability of appropriate information for healthcare workers
	Improving the safety of people taking medicines and their effective use
	Providing clinical and other local managers with the management information they need to inform their decisions

Other important activities and national systems that we will continue to support and promote include: CHI, and capitalising on the new PMS and GP IT systems, the ePharmacy Programme and progress on technology support for reducing healthcare acquired infection control. Effective themes from the previous strategy will be continued and strengthened. They are:

• supporting the transformation of NHSS services
• making patient care safer and more effective by making available the right information at the right place and at the right time
• information is a key asset and its management is an integral part of good corporate governance
• an incremental and pragmatic approach
• implementing the benefit from existing assets that have been acquired
• supporting innovation and
• understanding the needs of different communities

Further detail on each strategic aim can now be provided:

1 To Maximise Efficient Working Practices, Minimise Wasteful Variation, Bring About Measurable Savings And Ensure Value For Money.

Making use of information and technology effectively can bring about quality improvements in healthcare services and efficiency savings in healthcare across NHSS. It also crucially frees up staff time for patient care and reduces waiting times.

A 'paper-light' NHSS offers fast, local and reliable access to services through appropriate technologies. Achieving this across NHSS, and particularly at the interface between primary and secondary care, will require focused activity and systematic change in the way services are delivered and how people work. Examples show that services can be delivered more efficiently, effectively and become more person-centred.

Making it real - reducing document distribution times at the Golden Jubilee As one of 2 distinct parts that make up the NHSS National Waiting Times Centre, the Golden Jubilee is able to take referrals from any NHS Board to provide additional support for a wide range of procedures, helping make sure that waiting times targets are met. By introducing digital dictation, speech recognition and clinicians reviewing documents electronically, document turnaround times have been reduced and the need for numerous different paper copies removed. All letters are now being sent out in under 12 hours, ensuring that patients and GPs receive correspondence as efficiently and quickly as possible, thereby reducing waiting times.

There is tremendous potential to re-shape the way in which NHS Boards deliver services and run their business. Exploiting technology can help bring about significant reductions in waiting times and administration costs. A number of Boards are piloting technologies (digital dictation, voice recognition, scanning and video conferencing) aimed at reducing waiting times, business overheads and travel. The challenge for Boards is to move from these discrete projects into mainstream service delivery and ultimately eliminate paper based exchanges between care providers.

Our vision for 2017 includes a 'paper light' NHSS, where digital dictation, voice recognition, scanning and video conferencing are common place.

By 2014 NHS Boards will have well established programmes to replace paper with digital equivalents, along with digital dictation, voice recognition, scanning and video conferencing.

Making it real - Digital Dictation in NHS Dumfries and Galloway In 2009 digital dictation was introduced across all specialities at the Royal Infirmary in Dumfries. A combination of digital dictation, the auto-population of letter templates from the patient administration system and online checking and verification of letters by clinicians has reduced the overall time between patients attending clinics and their letters being posted. In June 2009 there were 1,300 letters taking longer than 14 days to be posted after dictation, in November 2009 that had reduced to 31. This reduction was achieved without an increase in medical secretary resource.

Making it real - Delivering more for less in NHS Lothian A speech recognition project was undertaken across 4 sites. Benefits included: significant efficiency gains in time savings (e.g. discharge summary production fell from 9 to 5 days in gastroenterology); reduction in telephone calls and case notes having to be pulled; improved prioritisation of urgent letters (e.g. 23 minutes from dictation to sign-off); and bar coding reduced the risk of patient identification errors. Quicker throughput of letters directly benefited patient care and led to less staff being required to type clinical correspondence and letters. As a result of the evidence obtained, an efficiency gain of 33% has been incorporated into the business case.

In NHS Lothian that transition is well underway. Video conferencing technology was initially procured for staff use and was rolled out across its locations onto staff desktop PCs. Following its successful implementation, and in response to staff feedback, work is now underway to expend its use into clinical settings e.g. pulmonary clinics, breast feeding support and smoking cessation clinics.

2 To Support People To Communicate With The NHSS, Manage Their Own Health And Wellbeing, And To Become More Active Participants In The Care And Services They Receive.

Technological change is leading to new ways of delivering and improving public services. It allows greater opportunity for people to contribute their views, access information and interact with others. Improved broadband coverage across Scotland is allowing greater and faster internet access from home and smartphones. For young people in particular, the internet and mobile phones are fast becoming the primary means by which they can be communicated with and through which they expect to access services.

Society is increasingly comfortable with self-service models of interaction and although face-to-face services have not disappeared, their dominance has been replaced by a much more diverse mix. Although NHS24 delivers telephone based and online services, NHSS relies heavily on face-to-face consultations and the way people receive healthcare remains largely unchanged despite the radical transformation in the way in which other public services are delivered.

eHealth can enable NHSS to take advantage of the everyday technologies already used by most people in their daily lives. It can also enable people to become more active participants in the healthcare and services they receive. What's more, effective engagement with people is fundamental to quality improvement. High quality care is not just about meeting the needs of people who present themselves but is also about reaching out to those who need care but may not seek it. eHealth has considerable potential to make healthcare more person-centred and responsive. For NHSScotland, this means that failing to develop ways to reach out electronically has serious implications for the long-term health of a large section of society.

eHealth could contribute to a radical transformation in the delivery of health and social care services in Scotland through enabling people to access and interact with their health records electronically, and through a greater emphasis on the delivery of services through different communication channels, e.g. online by patient portals or electronic windows to information, via email, websites, digital channels and social media.

Over the course of this strategy we will hold a public debate on how eHealth should enable people in Scotland greater participation in the healthcare and services they receive from NHSS.

The delivery of services online can provide services that are easier, quicker and more convenient for people to use. It can also do so at a lower price than other more conventional methods allow^[13]. For both these reasons, the public sector, including the Scottish Government, is committed to delivering an increasing proportion of its services online.

Making it real - the Scottish Care Information - Diabetes Collaboration Using the NHSS My Diabetes My Way patient information website, the pilot, involving over 100 patients, will allow users access to relevant parts of their electronic diabetes record, such as biochemistry tests, blood pressure, body mass index, foot risk scores, eye screening results and prescribing. Alongside the clinical data, "patient friendly" information helps to explain what their record means. This will give patients better understanding of diabetes and greater involvement, empowerment and control of their care. Secure user account provisioning and authentication is carried out in partnership with the Improvement Service "Citizen‟s Account" programme. Primarily established to enable citizens to gain secure access to service provided by councils and their partners, this is its first application in healthcare.

IT offers the Scottish Government and other public sector organisations the opportunity to work together to deliver improved health and social care services. For example, the Customer First Programme is developing a national infrastructure to support local authorities in delivering services; a national entitlement card, and a citizen account system, to allow councils to keep accurate up-to-date records on their customers. The Scottish Care Information - Diabetes Collaboration is the first example of healthcare providers working with the Customer First Programme to deliver tailored health information for people with diabetes.

Our vision for 2017 includes the Scottish Government working with the Customer First Programme on areas where its infrastructure can be shared with NHSS.

The Scottish Government has provided funding to the Improvement Service and CoSLA to develop online services, and to streamline business processes. Through the DirectScot portal project, the Scottish Government aims to improve access to information and Government services. We will provide a link from this site to NHS24's Health Information Service. The health information service is provided through NHS Inform www.nhsinform.co.uk, a single source of quality assured health information and NHS 24 self care advice provision through www.nhs24.com

GP Dr Jim Campbell, Townhead Surgery, said
"The development of the online patient portal has given us a wonderful opportunity to work closely with groups of patients to identify how they can take control of their health".

A patient portal user, said:
"Think it is good for prescriptions and for keeping up to date with moods, and life goals when I get time to get in more. Also the links are good." "I like the look of the portal, it‟s easy on the eye, easy to understand." "Very user friendly"

A Renal PatientView User, said:
"Patients don‟t always take in what medics say and to be able to take time to read it properly in the comfort of your own home is wonderful! Keep up the good work."

NHS24 is an integral part of NHSS and its activity is focused on delivering and progressing three areas of work: improving health; unscheduled care; and improving access to NHSS services. It already delivers telephone and online services to people across Scotland 24 hours a day, 365 days a year through its national telephony, call centres and established websites. It provides services in partnership with NHS Boards and provides people with a range of self care advice, receiving around 1.5 million calls per year to its unscheduled care service and over 750,000 hits^[14] on its website www.nhs.com.

Our vision for 2017 is based around a common set of IT services and people being able to communicate with NHSS using the communication channel of their choice.

Making it real - NHS Ayrshire & Arran Patient Portal A secure website allowing patients to access and update their own health records online is running at the Townhead Surgery in Irvine and Kilwinning Medical Practice. Patients can: request appointments online; request repeat prescriptions; access test results; record, track and monitor their blood pressure; set targets for weight and other goals, and record and track blood sugar level. The portal allows patients to become partners in their own care and has the potential to deliver healthcare services more efficiently and safely. The portal builds on the success of an electronic access project run by the Townhead Surgery since 2002, which has seen more than 26,000 repeat prescriptions ordered by patients. An app for smart phone users is being developed. There is evidence that the patient portal is being used as an alternative to visits and telephone calls. 32% of users visited Kilwinning less often and 23% of users visited Townhead less often. 76% of Kilwinning users telephone less and 60% of Townhead users telephone less.

The purpose, architecture, design and content of that platform will be informed by our public debate. In the interim, we will develop a national strategy covering the range of electronic contact that individuals have with NHSS. This will provide a coherent and citizen centred framework for these developments.

eHealth initiatives can inform and support people in their own homes to better manage and maintain their health, and to better control ill health, particularly pulmonary disease, diabetes and kidney disease. Delivering these services electronically supports people's expectations about engaging with public services as seamlessly as they do other services, e.g. online banking and shopping.

There are other ways in which even very simple technologies can bring about people's empowerment through information. Studies into the effect of email have found that amongst the benefits most valued by patients is that they can save and reread the medical advice given to them^[15]. This is something that face-to-face interactions rarely allow. A source of concern about healthcare that is delivered remotely is that it could exacerbate isolation and exclusion. However, increasing demand for eHealth, even to the point where it becomes the preferred option for some, will not prevent people from choosing face-to-face services. Allowing people to choose eHealth services may actually allow face-to-face services to be better targeted at those who will benefit the most from them.

By 2014 the eHealth Programme will have developed a national strategy covering the range of electronic contact that individuals have with NHSS. This will provide a coherent and citizen centred framework for these developments.

By 2014 a national strategy to guide further work in this area will have been developed and agreed.

3 To contribute to care integration and to support people with long term conditions.

By integrating networks of care we aim to improve health and wellbeing by increasing our emphasis on health improvement and anticipatory care, providing more continuous care and more support closer to home. Since 2006, the Scottish Government has prioritised care integration to ensure that whenever possible health and social care services are provided in people's own homes and local communities, rather than in care homes and hospitals, and that the transition between care providers is made as seamless as possible. This requires a partnership approach between NHSS, Local Authorities and third sector care providers. It also requires multidisciplinary working and appropriate information sharing at all levels. The availability and use of modern IT and information sharing tools is essential. Together with colleagues in local authorities, we will develop an IT strategy that is specifically focused on health and social care collaboration and integration.

Around 90,000 older people receive some kind of care, whether in their home, a care home or long term hospital care. We expect there to be 25% more (i.e. an extra 23,000) older people who will need some form of care in just the next 6 years. We have a delivery landscape that was simply not designed to cope with the demands that it will soon face. In 2010 Reshaping Care for Older People was launched and it looked at the best approach to address the needs of our aging population^[16]. A £70 million Change Fund for NHS Boards and partner local authorities was created for 2011-12. This is supporting the delivery of new models of care. These new delivery models rely on the right information being available to the right people at the right time. eHealth is an essential part of their delivery infrastructure and we will work with the Quality Improvement Hub ('the Hub') and other partners in their development. Telecare and telehealth are key eHealth 'tools' that Local Partnerships may deploy in support of local transformational plans and we look forward to these being an important part of local Change Fund activities and Community Planning priorities.

Making it real - NHS Tayside's long term conditions eHealth clinical system This encourages communication and sharing of data between primary and secondary care. The system currently works for diabetes, cardiology and COPD and will be extended to more conditions in the future

People with long term conditions are the major users of health and social care support services. Over 2 million people in Scotland live with one or more long term condition and their occurrence is set to rise significantly with an aging population. Long-term conditions currently account for around 80% of GP consultations, this is unsustainable. eHealth can support people with better information and minimise unnecessary face-to-face contact with health services, essential if we are to meet the future challenges of an aging population and reductions in health spending. Telecare and telehealth technologies can also provide effective self management support tools for people with long term conditions, which enable them to live independently at home with a much greater understanding of their condition and an improved quality of life.

The Palliative Care Summary (ePCS) is an extension of the ECS and is intended to be used for people with palliative care needs. It contains detailed information on diagnoses, patient wishes and anticipatory care plans. Like the ECS it is intended for use by clinicians in an emergency and out of hours (OOHs). The electronic Key Information Summary (KIS) is a further extension of the ECS. It will extend the ECS and ePCS across a broader range of clinical situations to support sharing of key information from anticipatory care plans. A KIS will be created in partnership with any person for whom detailed information needs to be made available for healthcare workers providing care when the GP practice is closed. It is intended to replace the "special notes" for weekend care, faxed summaries for OOHs and anticipatory care forms for people with long term conditions. It will also be used for people with mental health issues or unusual conditions, who might have difficulty remembering crucial details if they become ill.

Making its real - eHealth contributing to care integration and integrating health and social care services
Nine long term conditions and eHealth projects were allocated £1.6 million from the eHealth Programme in 2010-11. Projects that will, when fully implemented, contribute to significant improvements in the quality of health and social care services across Scotland. The projects cover a wide spectrum of eHealth activity in health and social care across NHS Boards and Local Authorities. They include:

Forth Valley is integrating the KIS with 9 GP practices and enabling ACPs to be shared

Highland & Grampian are implementing KIS across GP practices. This will enable healthcare workers to access appropriate information in the event that an escalation in care is required and for information to be shared with OOHs and NHS24

Lanarkshire is looking at the entire information pathway for groups of people with long term conditions. It will investigate where and how eHealth could be best used to support better care, and bridge gaps in information pathways between primary and secondary care.

Our vision is to have an ePCS and/or a KIS in place for everyone in Scotland who needs one.

Self care, self management and person centred approaches can reduce the impact of long term conditions on NHSS. They empower people to manage their conditions and put individuals in control of their care. The role of health and social care providers is to promote wellbeing and support people to remain as independent as possible. Self-directed support gives people the choice as to how their support is arranged and the right to take as much control as they wish. Some interventions will be very specific due to the complexity of the person's long term conditions. For example, patients on Orkney who have complex diabetes can have consultations with the consultant based in Aberdeen via video conferencing. During this consultation the patient and the consultant are able to discuss their progress, review their home glucose monitoring results and agree actions to improve their self care at home. Others will be broader, e.g. smoking cessation advice for people with COPD.

In addition to the telephone and online support NHS24 offers people living in Scotland, NHS24 is responsible for the delivery of the Scottish Centre for Telehealth & Telecare's (SCTT) four national telehealth programmes and the telecare action plan for Scotland^[17]. The national telehealth programmes include support for people with long term conditions, paediatrics, stroke and mental health problems. People with COPD are routinely offered the opportunity to manage their condition using telehealth tools, and access to pulmonary rehabilitation and smoking cessation. The stroke programme enable people across Scotland with confirmed ischaemic stroke, filling the required criteria, access to potentially lifesaving thrombolysis treatment and provide improved access to specialist rehabilitation services. Whilst the mental health programme includes the provision of equitable access to all mental health services regardless of patient geography. Giving people better information about their conditions has been shown to empower individuals (and their carers) and support self management. Telehealth and telecare can be used to support the whole spectrum of long term conditions and to develop, in partnership with health and social care workers and patients, potential areas for better self management.

Making it real - Telehealth in Argyll and Bute The Argyll and Bute Partnership set out to: support people with LTCs; develop expertise in local staff to use remote monitoring as part of peoples‟ care; to link the work on monitoring LTCs to the reduction in crisis admissions to hospital; and to assist patients to manage their health more effectively. Three types of technology were trialled: home telehealth pods (for people with COPD); surgery pods for more general health monitoring; and pods placed within community facilities. Information gathered by the home pods was sent electronically to a secure server and checked daily by community nursing teams, enabling action to be taken where necessary. The surgery pods were configured to transfer data directly to the EPR system and the information from the community pods, which were used mainly by people with hypertension, was transferred onto a secure site for health professionals to review. The overall findings of the evaluation were positive and supported the continuation of the scheme. The reduction in hospital admissions observed for people with COPD was sufficient to support a continuation and expansion of the scheme within the wider Highland area. More details can be found at www.jitscotland.org

Telecare is an important eHealth tool which supports people, particular the elderly or those with long term health conditions, to live at home for as long as they want to. Up to 2011 telecare has been supported with £20 million from the Telecare Development Programme. Around 29,000 people have received a telecare service since 2006 and over 2,000 of these people are known to be diagnosed with dementia^[18]. Scotland is currently performing well in the development and implementation of telecare and telehealth services^[19]. It is estimated that efficiencies (in the form of care home and hospital bed days saved/avoided admissions) of around £48 million have been made.

The Scottish Government will continue its support for telehealth and telecare through the provision of £1 million per year for the SCTT.

The Scottish Assisted Living Programme (SALP) is the next stage of the development of telecare and telehealth in Scotland. In partnership with the UK's Technology Strategy Board, the Programme includes the DALLAS (Delivery of Assisted Living Lifestyles at Scale) competition. A national programme board has been established to take forward the SALP and it is intended that the learning from phase 1 will be captured and used to inform national roll-out up to and beyond 2015. NHS24/SCTT is leading the programme in Scotland on behalf of the Scottish Government, which aims to improve the management of long term conditions (initially COPD) to inform pathway development and service models. Scotland will be one of three to five communities, each with up to 10,000 people with long term conditions across the UK^[20].

A telecare user said:
"It (telecare) makes a difference. It means that you‟re not on your own."

Another telecare user said
"We were at the point where we needed more home care. I was totally stressed out. But once we got telecare it made a massive difference, it relived a lot of pressure."

A carer said:
"One of our family would usually have to be on "granny watch‟ at all times in the evenings and weekends, but now we can go about our normal lives, knowing that we will get called if there is a problem."

Not withstanding the above, one of the key challenges remains to secure mainstreamed and integrated telecare/telehealth service provision, and thereby support the independence and wellbeing of as large a number of potential users as possible.

Our vision for 2017 anticipates this being achieved through a mixed economy of care (public sector, private sector and Self Directed Support).

Our vision for 2017 includes the further expansion of telehealth and telecare in the treatment and care of people with long term conditions and care for older people. We will collaborate with NHS24/SCTT to further expand technology enabled service redesign which is cost and clinically effective.

By 2014 a new health and social care IT strategy will have been developed in partnership with local authorities. This will have paved the way for improvements in information sharing between health and social care workers and greater integration of health and social care services, for people of all ages, across Scotland.

By 2014 the ePCS and KIS will have been rolled out nationally across Scotland for those who need it.

4 To enhance the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality.

Information, and particularly patient information, is a vital tool for NHSS; the effectiveness and safety of health care services depends on it. We have a duty to use patient information well, responsibly and with care.

Improved clinical availability of patient information is particularly important as we work towards our quality ambitions for healthcare services in Scotland. It is essential that all healthcare workers have access to the appropriate information when required. Appropriate information may include not only clinical information relating to a patient's medical conditions, but information on their ethnicity, any special needs or requirements and their wishes. Improvements in the quality and availability of patient information that healthcare workers receive will enhance patient safety and effective clinical treatment, with specific benefits including:

• the availability of person-centred, not system centred information
• clinical information being available at the point of care to improve clinical decision making
• more up to date and complete patient records
• reduced harm to patients due to increased knowledge of medical information
• a reduction in unnecessary duplicate tests; and
• increased support for joint working across NHS Boards

There will also be efficiency savings in terms of how healthcare services are delivered. Expected benefits include:

• less time spent looking for and retrieving clinical information
• reduced reliance on paper based systems
• the potential for single sign-on to multiple clinical systems
• the potential for simultaneous access by healthcare teams; and
• less need for replication and synchronisation of large data stores, as information is accessible from multiple systems on demand

Martin Egan, NHS Lothian's Director of eHealth said: "I believe that the delivery of a feature rich clinical portal will significantly enhance care delivery across the region and will make much more effective use of clinicians‟ time within front line patient service."

NHS Boards are doing this via increased use of portal technologies (windows to electronic information); a single sign-on entry point through which various parts of a patient's information record can be assessed securely. We envisage integration platforms being essential in making this happen across Scotland.

Our vision includes all territorial Boards using portal technologies (or electronic windows to information) and the priority information items agreed by clinicians being available at the point of care.

Making it real- West of Scotland Electronic Renal Patient Record The Strathclyde Electronic Renal Patient Record (SERPR) was implemented in 2010. It is hosted and managed by NHS Greater Glasgow and Clyde. Other Boards involved in its development and implementation are: NHS Lanarkshire, Ayrshire & Arran, Forth Valley, Dumfries & Galloway and Golden Jubilee. SERPR delivers a number of clinical benefits including: laboratory data for new patients available in 10 to 20 minutes; patient demographics uploaded instantly; reduced reliance on paper case notes; easier and faster data entry for clinical staff; and a unified system across 6 Boards enabling greater information exchange.

It is vitally important that people who receive healthcare services have confidence in eHealth systems and procedures to respect their privacy and handle their information properly. Single sign-on and audit tools are two key elements of the Information Assurance Strategy, and essential components of portal technologies (and electronic windows to information). Single sign-on removes the need for clinicians to enter multiple passwords to use different systems. Rules on who can access information are in place. NHSS organisations have monitoring systems in place that can identify who is looking; what they are looking at and where and when this activity takes place.

Over the course of the strategy all territorial Health Boards will have introduced single sign on for healthcare workers and have privacy breach detection tools, and we will have implemented an agreed Information Assurance Strategy and associated programme of work.

The Quality Strategy contains a commitment to recording and transmitting the additional needs of people using health services throughout NHSS, as part of the NHSS's commitment to understanding the needs of different communities^[21]. This additional needs information has been set out in the Equality Act 2010^[22] and has an important role in eliminating discrimination, reducing inequalities, protecting human rights and building good relations by breaking down barriers that may be preventing people from assessing the care and services they need, as well as meeting the new public sector duty^[23]. Health will assess IT options in support of this equality duty, and the List of Actions and Provision to support the patient pathway that has been developed^[24].

eHealth has the potential to enable improvements in communication and integration between primary and secondary care providers and between NHSS and community based care. The availability of information is fundamental to effective care integration.

By 2014 all territorial Health Boards will be using clinical portals (or electronic windows to information) and the priority information items agreed by clinicians will be available at the point of care.

By 2014 work to implement an agreed Information Assurance Strategy will be well established.

5 To improve the safety of people taking medicines and their effective use

Medicines reconciliation (MR) ensures that all the medication a person is currently taking is correctly documented at each transfer of care i.e. when admitted to hospital, moving to different clinical areas within a hospital or at discharge into the community. It has been introduced with varying degrees of success across NHSS through the Scottish Patient Safety Programme, which has a target of 95% for accurate medication history documentation and recording within 24 hours of admission to hospital. Inaccurate documentation can result in the potential for missed dosages of key medications, delays in the start of new treatments and in identifying drug interactions and allergies; inaccuracies which may then be transferred to the GP or care home on discharge. They are often discovered by pharmacists, though not necessarily within 24 hours. The Scottish Government, through the Quality Alliance Board^[25], has prioritised improving the quality and safety of practice around MR for unscheduled and scheduled care of the elderly to reduce adverse events at the point of admission and discharge.

Making it real - the Discovery Project in Lanarkshire
In spring 2010 NHS Lanarkshire ran a pilot project on ECS use in scheduled care. The objectives were to fully evaluate, and capture the benefits and clinical impact from the use of ECS in the management of elective patients in hospitals. In the clinical opinion of the practitioners access to this information prevented harm to 23 patients. Had this information not been available, these patients would have required monitoring to confirm that no harm had occurred and/or required intervention to prevent harm. In 3 patients it would have contributed to or resulted in temporary harm. Most of the harm prevented arose from failure to continue all prescribed medication on admission to hospital, including treatment for chronic conditions. There would also have been the potential to prescribe interacting medicines. Pilots have taken also taken place in NHS Lothian and Tayside to evaluate the potential improvements to patient safety in non emergency admissions and outpatient clinics.

It is important that the process of MR implemented is effective 24 hours a day, 365 days a year. It is also important that MR can be completed by the appropriate healthcare workers, that it is undertaken within 24 hours of admission to hospital and that the requirement for pharmacist interventions are reduced. The elderly population is at greatest risk of medication related problems because of age related physiological changes, the presence of multiple chronic diseases and conditions, and the types and numbers of prescription and non-prescription medications they consume (polypharmacy).

The Emergency Care Summary (ECS) contains patients' prescription information and information on any allergies. It is intended for use by healthcare workers in an emergency and OOHs, and it is now a vital part of MR at the interface between primary and secondary care.

The ePharmacy Programme is exploring the potential benefits from sharing information on what has been dispensed for a patient, alongside what has been prescribed, through the Pharmacy Care Record, held in community pharmacies, to assist in MR. This helps ensure that the information available on the ECS is a more accurate a record of what medication people are actually taking.

Enabling summaries of patient medication available on admission to scheduled care will be vital in enabling NHSS to meet its MR goals.

Staff Survey Comment, Discovery Project in NHS Lanarkshire:
"ECS is probably the best tool available for healthcare professionals to support the medicines reconciliation process. Although there are limitations with the system, I believe that ECS contributes significantly to patient safety and is a convenient, responsive system that has a built in auditable record of which records have been accessed and by whom. It should be rolled out wherever there is a need to perform medicines reconciliation".

Making it real - NHS Tayside
incremental discharge letters and medicines reconciliation:
An in-house electronic discharge letter system is being developed and rolled out across the acute hospitals in NHS Tayside. It will cover all patient groups irrespective of ward or speciality. The system is linked to the ECS, which provides information on medication from GPs and allergies. Medicines reconciliation is undertaken and recorded when a patient is admitted and it is possible to stop medications and add new medications to the list that appears on the discharge letter with the ECS imported/altered medications. All 69 GP practices receive the letter electronically using Electronic Document Transfer.

Our vision for 2017 includes improved communication and reconciliation across all transitions of care, and making electronic patient medication summaries available to appropriate healthcare workers in both scheduled and unscheduled care. As a priority we will explore with stakeholders how a shared common electronic medication summary can be made available to healthcare workers through the use of portals, electronic windows to information and/or web based technologies.

ePrescribing systems are widespread in primary care, with almost all GP generated prescriptions in Scotland now coming from GP IT systems and by April 2012 all GPs in Scotland who were using GPASS will have migrated onto the two nationally procured IT systems. In secondary care they are, as yet, less widespread though the number of systems in use is growing. Some Scottish hospitals have implemented systems that only undertake one part of the process - for example, support for MR on admission or discharge prescribing. There are other situations, such as in oncology or critical care, where specialised systems are used, tailored to the very particular needs of these patients.

Making it real - HEPMA in NHS Ayrshire & Arran
HEPMA been implemented, in Ayr and Biggart Hospitals on a ward by ward basis and covers prescribing, nurse administration, dispensing, medicine supply and prescribing at discharge. It is used in real time at the bedside and provides support to guide prescribing choices, allergy alerts, and formulary choices. Benefits include: identification of high risk medicines, targeted antimicrobial management, fewer missed doses, fewer transcription errors as the points of transcription are reduced to a single point, medicines reconciliation throughout the patients stay and improved communication with the GP. Since implementation over 64,000 individual patients has been registered, many having multiple admissions, in excess of 2,600,000 medicines have been prescribed; over 13,500,000 medicines have been administered

The Scottish Parliament^[26] and Audit Scotland^[27] have urged the Scottish Government to roll-out a Hospital Electronic Prescribing and Medicines Administration (HEPMA) system across Scotland. HEPMA supports the prescribing, ordering, administration, reconciliation and supply of medicines, as well as supporting a robust audit trail and enabling greater standardisation of practice. The agreed national approach to HEPMA was that a national procurement to provide the capability for all NHS Boards to move to full HEPMA functionality would be carried out. This was delivered in the national PMS procurement and the system chosen was the same one that has been implemented across a range of acute sector wards in NHS Ayrshire and Arran. HEPMA is currently available as an optional module for Boards in the PMS contract.

Making it real - medication management in NHS Forth Valley
eWard is used to record medicine reconciliation on admission. As part of service re-design, eWard has facilitated more efficient and effective use of the pharmacy workforce allowing patients that need their medicines reconciled to be targeted within 24 hours of their admission. In addition, eWard delivers reliable medicines reconciliation on discharge, providing information on medicines to be continued and stopped to the GP within 6 hours of a patient‟s discharge. It has also streamlined the prescribing and dispensing of discharge medication, providing a more person centred, responsive service

A number of Boards are developing business plans to implement HEPMA in secondary care settings. In many of these cases an incremental approach to implementation is likely to be adopted, with initial focus on higher risk patient groups. The longer term vision is for all Boards to implement HEPMA with integral clinical decision support and interfaces to other clinical IT systems, such as laboratory systems.

A short life working group has been established by the eHealth Strategy Board to balance the shorter term objective of improving MR with the longer term medication management objectives of HEPMA against a reduction in the capital available for eHealth developments. The Group has been asked to: consider the needs of all stakeholders in the medicines process; focus on pragmatic and incremental solutions, including better use of what exists; and consider a range of incremental options leading to full HEPMA implementation (based on the nationally available system). The group will report back to the Strategy Board in late 2011.

We will implement the recommendations proposed by this short life working group.

People on lots of medication who fail to take prescribed drugs at the right time and right dosage risk their health and independence. They can end up being re-admitted to hospital or placed in residential care for their own safety. This has considerable cost implications for health and social services. The roll out of the Chronic Medication Service (CMS) as part of the community pharmacy contract in Scotland aims to improve patient care through a systematic approach to the pharmaceutical care of patients with LTCs by improving a patient's understanding of their medicines, maximising the clinical outcomes from therapy, minimising adverse drug reactions and addressing existing and potential problems with medicines. The Pharmacy Care Record (PCR) supports community pharmacists in providing CMS through the development of an individualised pharmaceutical care plan, a copy of which is given to the patient.

We will support Boards to improve effectiveness of prescribing by reducing variability in prescribing patterns and promoting compliance with best practice guidelines.

eHealth (specifically telecare) can make a difference through supporting people in their homes to live independently and take their medication appropriately. This is very important where people are on numerous medications for the same or different conditions and where people are elderly, have complex or multiple health conditions, and/or have disabilities. Home care visits and telecare services, such as telephone prompts, dosset boxes, calendar clocks and talking labels can be used to ensure medication is taken. They can not only bring about significant improvements in the quality of life for individuals and their families, but deliver important efficiency gains for health and social care providers; helping to reduce waste and ensure that medicines are used effectively.

Making it real - pill dispensers assisting in the management of medication in the people's homes
The dispenser is programmed with dosage and times. An alarm sounds to prompt the user to take their medication and the dispenser will allow only the tablets for that specific dose to be available. If the medication has not been taken, the dispenser reminds the user that a dose is due. An alarm will sound if the medication is not accessed within the following hour. Where the dispensing equipment is linked to a call handling and monitoring service, the alert allows appropriate follow up action to be taken. Some services also use text alerts to mobile phones as a medication prompt. One Renfrewshire user, who previously had numerous hospital admissions due to overdoses, has been maintained at home for a lengthy period without any admission to hospital.

By 2014 we will have enabled an accurate and up-to-date electronic medication summary to be available to the appropriate healthcare workers involved in a patient's journey through the healthcare system.

6 To provide clinical and other local managers across the health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery.

Information is vital to improving quality, both when looking for areas where improvements can be made and when feeding back on progress. It also has an essential wider role in making possible high quality research and development.

Making it real - Evaluating the impact of Scotland's smoke free legislation
Scotland was the first country in the UK to implement a ban on smoking in public places. Prior modelling work and evidence from other countries indicated that such a ban was likely to reduce second-hand smoke exposure, with a consequent reduction in morbidity and mortality from heart disease and other causes. To assess the impact of the ban on hospitalisations for childhood asthma, researchers at the University of Glasgow used the Scottish Morbidity Record (SMR01) linked dataset to ascertain the numbers of admission and deaths attributable to asthma before and after the ban was introduced in March 2006. This study, the first nationwide study anywhere in the world of the impact of smoke free legislation on childhood asthma, found that admissions fell by 18% following the ban, compared with a 5% annual reduction in the years before the ban.

Scotland is an acknowledged leader in the use of eHealth records for research. Existing systems for linking individual patients' hospital records have supported a wide range of ground-breaking population health and clinical research, and this has generated intense interest, in Scotland and elsewhere, in extending linkage to other health records, such as primary care and prescribing data, and to non-health records, such as education, income, Census and survey data. Research using routine data has huge advantages in terms of cost, population coverage and reduced burden on research participants, but to realise this potential, further innovation is needed in our approach for indexing and linking records, storing the resulting datasets, and making them accessible to researchers within a streamlined, efficient and secure system of research governance.

We will ensure that we participate fully in UK developments, including the linkage of Scottish UK Biobank participants' health records, and the development of a UK-wide network of e-health record research centres.

We will also examine different approaches to incentivise research within NHSS, building on the work of NHS Research Scotland, so that Scotland becomes an even more attractive location for inward research investment. In order to achieve this, we will establish an eHealth research and innovation advisory group. It will be the responsibility of that group to develop its scope and programme of work.

Real time and near real time local data has an important role in supporting local decision making and quality improvements. As an early priority an action plan will be put in place to support real-time local performance monitoring. This will describe options from quick but high value initiatives about new presentation of data to longer term initiatives about Boards analysing their own data and presenting it to decision taker in ways that improve quality, efficiency and safety. This framework will be developed in partnership with Boards' IT and Information Managers and will build on excellent work already underway in Boards and ensure that the lessons learned from these initiatives can be shared with others.

In the first instance our activity will be focused on the acute sector (territorial Boards, the Golden Jubilee National Hospital and the State Hospital) and the Strategic eHealth Fund will be used by these Boards to ensure that their clinical managers and appropriate local managers have the timely management information they require to inform their decisions on service quality, performance and delivery.

In addition, the National Information and Intelligence Framework for Health and Social Care for Scotland 2012-17 will inform eHealth strategy developments. It will establish a framework for the collection and development of information which will help Scotland ensure that information and intelligence meets the needs of key policy developments, such as the Quality Strategy, Getting It Right For Every Child (GIRFEC), Integration of Health and Social Care, Reshaping Care for Older People and the Carers' Strategy as well as the needs of the NHSS, Scottish local and national government and our wider partners.

By 2014 we will have established an eHealth research and innovation advisory group

By 2014, the local use of information for quality improvements will be enhanced by the eHealth Programme developing a strategy for real time and near time performance data

By 2014 the NHS Boards which are active in the acute sector will have in place systems which provide their clinical and other managers with timely management information