How is health information technology changing the way we deliver NHS hospital care?

As NHS England and the health system makes further investments in the deployment of health information technology (HIT) across NHS sites, this review article considers some of the benefits HIT can provide in secondary care, including the potential of creating innovation ecosystems.

Tightrope walking towards maximising secondary uses of digitised health data: a qualitative study.

BACKGROUND: Timely progress with attaining benefits from Health Information Technology (HIT) investments requires UK policymakers and others to negotiate challenges in developing structures and processes to catalyse the trustworthy secondary uses of HIT-derived data. AIMS: We aimed to uncover expert insights into perceived barriers and facilitators for maximising safe and secure secondary uses of HIT-derived data in the UK. METHODS: We purposively selected individuals from a range of disciplines in the UK and abroad to participate in a thematically analysed, semi-structured interview study. RESULTS: We identified a main theme of 'tightrope walking' from our interviews (n = 23), reflecting trying to balance different stakeholders' views and priorities, with sub-themes of 'a culture of caution', 'fuzzy boundaries' and 'cultivating the ground'. The public interest concept was fundamental to interviewees' support for secondary uses of HIT-derived data. Small scale and prior collaborative relationships facilitated progress. Involving commercial companies, improving data quality, achieving proportionate governance and capacity building remained challenges. CONCLUSIONS: One challenge will be scaling up data linkage successes more evident internationally with regional population datasets. Within the UK, devolved nations have the advantage that 'small scale' encompasses national datasets. Proportionate governance principles developed in Scotland could be more widely applicable, while lessons on public engagement might be learned from Western Australia. A UK policy focus now should be on expediting large-scale demonstrator projects and effectively communicating their findings and impact. Progress could be jeopardised if national data protection laws were superseded by any Europen Union-wide regulation governing personal data.

A systematic scoping review of the domains and innovations in secondary uses of digitised health-related data.

BACKGROUND: Substantial investments are being made in health -information -technology (HIT) based on assumptions that these systems will save costs through increased quality, safety and efficiency of care provision. Whilst -short-term -benefits have often proven difficult to demonstrate, there is increasing interest in achieving benefits in the medium and long term through secondary uses of -HIT-derived data. AIMS: We aimed to describe the range of secondary uses of HIT-derived data in the international literature and identify innovative developments of particular relevance to UK policymakers and managers. METHODS: We searched nine electronic databases to conduct a systematic scoping review of the international literature and augmented this by consulting a range of experts in the field. RESULTS: Reviewers independently screened 16,806 titles, resulting in 583 -eligible studies for inclusion. Thematic organisation of reported secondary uses was -validated during expert consultation (n = 23). A primary division was made between patient-identifiable data and datasets in which individuals were not identified. Secondary uses were then categorised under four domain headings of: i) research; ii) quality and safety of care provision; iii) financial management; and iv) healthcare professional education. We found that innovative developments were most -evident in research where, in particular, dataset linkage studies offered important -opportunities for exploitation. CONCLUSIONS: Distinguishing patient-identifiable data from aggregated, de-identified datasets gives greater conceptual clarity in secondary uses of HIT-derived data. Secondary uses research has substantial potential for realising future benefits through generating new medical knowledge from dataset linkage studies, developing precision medicine and enabling cross-sectoral, evidence-based policymaking to benefit population-level well-being.

Leveraging health information technology to achieve the "triple aim" of healthcare reform.

OBJECTIVE: To investigate experiences with leveraging health information technology (HIT) to improve patient care and population health, and reduce healthcare expenditures. MATERIALS AND METHODS: In-depth qualitative interviews with federal government employees, health policy, HIT and medico-legal experts, health providers, physicians, purchasers, payers, patient advocates, and vendors from across the United States. RESULTS: The authors undertook 47 interviews. There was a widely shared belief that Health Information Technology for Economic and Clinical Health (HITECH) had catalyzed the creation of a digital infrastructure, which was being used in innovative ways to improve quality of care and curtail costs. There were however major concerns about the poor usability of electronic health records (EHRs), their limited ability to support multi-disciplinary care, and major difficulties with health information exchange, which undermined efforts to deliver integrated patient-centered care. Proposed strategies for enhancing the benefits of HIT included federal stimulation of competition by mandating vendors to open-up their application program interfaces, incenting development of low-cost consumer informatics tools, and promoting Congressional review of the The Health Insurance Portability and Accountability Act (HIPPA) to optimize the balance between data privacy and reuse. Many underscored the need to "kick the legs from underneath the fee-for-service model" and replace it with a data-driven reimbursement system that rewards high quality care. CONCLUSIONS: The HITECH Act has stimulated unprecedented, multi-stakeholder interest in HIT. Early experiences indicate that the resulting digital infrastructure is being used to improve quality of care and curtail costs. Reform efforts are however severely limited by problems with usability, limited interoperability and the persistence of the fee-for-service paradigm-addressing these issues therefore needs to be the federal government's main policy target.

The NHS Five Year Forward View: implications for clinicians.

The Five Year Forward View is a look at what the NHS could achieve, given the range of resources that may be available. It sets out how the health service needs to change, arguing for a more engaged relationship with patients, carers, and citizens to promote wellbeing and prevent ill health. Here, we outline how the Forward View supports clinicians to provide better, higher quality and more integrated care.New models of care are presented, including multispecialty providers, primary and acute care systems, urgent and emergency care networks, viable smaller hospitals, specialised services, modern maternity services, and enhanced care homes. The commitments to support clinicians are discussed, including specific proposals for primary care, initiatives to improve the health of NHS staff, dealing with gaps in the NHS workforce, and the use of technology and innovation to further enable clinicians.

Robotic telemanipulating surgical systems for laparoscopy: the story so far in the UK.

Surgical robotics is, at present, one of the most dynamically developing areas of biomedical engineering that has been proven to increase the stability and robustness of surgery. Robotics can integrate, assist, control and extend the human capabilities, correcting for manual errors, or record the spatial points-of-interest and motions. This is of importance as an adjunct to many laparoscopic subspecialty procedures, from cardiac to pelvic surgery. Evidence-based medicine is now demonstrating that robotized equipment can greatly add to the preoperative simulation, the ergonomics of the procedure, the preoperative simulation and the risk-free training of the surgeon with precision surgery and less trauma to the patient. This article discusses the robots that are clinically available at present and their importance to the surgeon and patient.

Peroxisome proliferator ameliorates endothelial dysfunction in a murine model of hyperhomocysteinemia.

To test the hypothesis that endothelial dysfunction in hyperhomocysteinemia was due to increased levels of nitrotyrosine and matrix metalloproteinase (MMP) activity in response to antagonism of peroxisome proliferator-activated receptor-alpha (PPAR-alpha), cystathionine beta-synthase (CBS) -/+ mice were bred, tail tissue was analyzed for genotype by PCR, and tail vein blood was analyzed for homocysteine (Hcy) by spectrofluorometry. To induce PPAR-alpha, mice were administered 8 microg/ml of ciprofibrate (CF) and grouped: 1) wild type (WT), 2) WT + CF, 3) CBS, 4) CBS + CF (n = 6 in each group). In these four groups of mice, plasma Hcy was 3.0 +/- 0.2, 2.5 +/- 1.2, 15.2 +/- 2.6 (P < 0.05 compared with WT), 11.0 +/- 2.9 micromol/l. Mouse urinary protein was 110 +/- 11, 86 +/- 6, 179 +/- 13, 127 +/- 9 microg.day(-1). kg(-1) by Bio-Rad dye binding assay. Aortic nitrotyrosine was 0.099 +/- 0.012, 0.024 +/- 0.004, 0.132 +/- 0.024 (P < 0.01 compared with WT), 0.05 +/- 0.01 (scan unit) by Western analysis. MMP-2 activity was 0.053 +/- 0.010, 0.024 +/- 0.002, 0.039 +/- 0.009, 0.017 +/- 0.006 (scan unit) by zymography. MMP-9 was specifically induced in CBS -/+ mice and inhibited by CF treatment. Systolic blood pressure (SPB) was 90 +/- 2, 88 +/- 16, 104 +/- 8 (P < 0.05 compared with WT), 96 +/- 3 mmHg. Aortic wall stress [(SPB. radius(2)/wall thickness)/2(radius + wall thickness)] was 10.2 +/- 1.9, 9.7 +/- 0.2, 16.6 +/- 0.8 (P < 0.05 compared with WT), 13.1 +/- 2.1 dyn/cm(2). The results suggest that Hcy increased aortic wall stress by increasing nitrotyrosine and MMP-9 activity.

Generation of nitrotyrosine precedes activation of metalloproteinase in myocardium of hyperhomocysteinemic rats.

The hypothesis is that homocysteine decreases endothelial nitric oxide (NO) availability by generating nitrotyrosine. In the absence of NO, and in an attempt to reduce endocardial load by dilatation, the matrix metalloproteinase (MMP) is activated. To address this hypothesis, homocysteine (0.67 mg/ml) was administered in drinking water of Sprague-Dawley rats for 8 weeks. To elicit the reversible effects of homocysteine, homocysteine was removed from the water after 8 weeks. The plasma levels of homocysteine were 2.79 +/- 0.5 microM in control (n = 6), measured by spectrofluorometry. The levels of homocysteine increased to 22 +/- 1.3 and 17 +/- 2.8 microM following 4 (n = 6) and 8 (n = 6) weeks of homocysteine treatment, respectively. The level of homocysteine decreased to 5.8 +/- 1.0 microM (n = 6) when homocysteine was removed from the drinking water. The mean arterial pressure (MAP) of control rats was 108 +/- 10 mm Hg and increased to 128 +/- 2 and 130 +/- 3 mm Hg following 4 and 8 weeks of homocysteine treatment, respectively. When homocysteine was removed from the drinking water, the MAP was decreased to 118 +/- 3 mm Hg. Left ventricle (LV) parameters were measured by a catheter in the LV through right common carotid artery in anesthetized rats. The LV tissue was analyzed for MMP activity by zymography. Levels of nitrotyrosine and cardiospecific tissue inhibitor of metalloproteinase-4 (TIMP-4/CIMP) were measured by western blot analysis using the respective antibodies. The specific bands in zymographic gel and western blot were scanned and normalized with beta-actin. The results suggest a continuous increase in nitrotyrosine levels at 4 and 8 weeks after homocysteine administration. The removal of homocysteine did not decrease the levels of nitrotyrosine. The zymographic analysis revealed a temporal increase in MMP-2 activity from 4 to 8 weeks post homocysteine administration. However, removal of homocysteine did not decrease the MMP-2 activity. The cardiac active diastolic function, -dP/dt, was decreased at 4 weeks and stayed depressed up to 12 weeks. The end-diastolic pressure started increasing at 8 weeks; at this point the MMP-2 activity was also increased. The results suggest that in the absence of endothelial NO, and in an attempt to reduce LV load, MMP-2 is activated and CIMP is inactivated, by increasing nitrotyrosine.

Apoptosis in the left ventricle of chronic volume overload causes endocardial endothelial dysfunction in rats.

The hypothesis is that chronic increases in left ventricular (LV) load induce oxidative stress and latent matrix metalloproteinase (MMP) is activated, allowing the heart to dilate in the absence of endothelial nitric oxide (NO) and thereby reduce filling pressure. To create volume overload, an arteriovenous (A-V) fistula was placed in male Sprague-Dawley rats. To decrease oxidative stress and apoptosis, 0.08 mg/ml nicotinamide (Nic) was administered in drinking water 2 days before surgery. The rats were divided into the following groups: 1) A-V fistula, 2) A-V fistula + Nic, 3) sham operated, 4) sham + Nic, and 5) control (unoperated); n = 6 rats/group. After 4 wk, hemodynamic parameters were measured in anesthetized rats. The heart was removed and weighed, and LV tissue homogeneates were prepared. A-V fistula caused an increase in heart weight, lung weight, and end-diastolic pressure compared with the sham group. The levels of malondialdehyde (MDA; a marker of oxidative stress) was 6.60 +/- 0.23 ng/mg protein and NO was 6.87 +/- 1.21 nmol/l in the LV of A-V fistula rats by spectrophometry. Nic treatment increased NO to 13.88 +/- 2.5 nmol/l and decreased MDA to 3.54 +/- 0.34 ng/mg protein (P = 0.005). Zymographic levels of MMP-2 were increased, as were protein levels of nitrotyrosine and collagen fragments by Western blot analysis. The inhibition of oxidative stress by Nic decreased nitrotyrosine content and MMP activity. The levels of tissue inhibitor of metalloproteinase-4 mRNA were decreased in A-V fistula rats and increased in A-V fistula rats treated with Nic by Northern blot analysis. TdT-mediated dUTP nick-end labeling-positive cells were increased in A-V fistula rats and decreased in fistula rats treated with Nic. Acetylcholine and nitroprusside responses in cardiac rings prepared from the above groups of rats suggest impaired endothelial-dependent cardiac relaxation. Treatment with Nic improves cardiac relaxation. The results suggest that an increase in the oxidative stress and generation of nitrotyrosine are, in part, responsible for the activation of metalloproteinase and decreased endocardial endothelial function in chronic LV volume overload.