When four East Anglian hospitals needed to instal a new generation of computers they decided to join forces. With resources tight, very specific needs and a tough set of selection criteria, the group took 12 months to find the right supplier.
Hospital managers face stark choices when they have to decide on their IT spending: should they upgrade the mainframe or buy a kidney dialysis machine? Resources are always tight in the health sector and there are plenty of life-saving ways to spend money. But computers are urgently needed to streamline hospital administration and link the increasingly broad range of hi-tech equipment.
Hence the decision by four hospitals in East Anglia to join forces in early 1992 when they needed to instal a new generation of computers. The group comprises Addenbrooke's in Cambridge, Norwich Acute Unit, West Suffolk, and James Paget of Great Yarmouth. They are not the first hospitals to form a consortium. But their £8.3 million contract with McDonnell Douglas Information Systems (MDIS), awarded in September this year, makes theirs the biggest joint hospital project so far - a model for future procurement in the NHS which spends £250 million a year on computer equipment and running costs.
The East Anglia contract was comfortably below budget thanks largely to the power of collective bargaining. Getting four hospitals to act together creates significant customer strength, says Ian Noble, project director for the consortium. 'I'm convinced there would have been a great deal of divide and conquer on the part of suppliers if the hospitals had acted independently.' But there are other benefits in forging an alliance, reckons Noble. One such is shared technical expertise. In the past, decisions about major IT investments for hospitals were often imposed by Regional Health Authorities. Under the health service reforms, however, hospitals are taking individual responsibility for their own IT development. 'Big IT projects are comparatively new for the health service so skills are in shortsupply. By collaborating we get the critical mass of specialists that we require.' Problem solving is also shared. If one hospital hits a difficulty, the chances are that the others might run into similar obstacles. Membership of the consortium gives each partner access to the others' learning experiences.
The co-operative approach is not without drawbacks. The new internal market for health care means that the group's members must compete for patients. However, this has not deterred the East Anglia project participants.
'They felt they could work together because although they compete for contracts, each hospital has the same basic need for patient records,' says Noble. It is rather like commercial companies collaborating on research and competing on practical applications. The hospitals will seek to differentiate themselves on price and quality of service through clever use of decision support tools, statistical analysis and the control of physical and staff resources - an activity which is known as case mix.
Another problem with collaboration is that the speed of progress tends to be driven by the weakest member. In the words of Mike Pollard, chairman of the consortium and chief executive of James Paget: 'A convoy is only as fast as its slowest ship.' The partnership is further complicated by the disparate nature of the hospitals involved. James Paget and West Suffolk provide general medical care for their districts whereas Norwich and Addenbrooke's offer specialised frontier-type medicine. 'When it comes to wiring the systems up, their experiences will be very different,' says Pollard.
Noble is convinced though that the advantages of collaborating far outweigh the drawbacks. Prior to taking on the East Anglia project he worked on two major joint ventures in banking - EFTPOS (Electronic funds transfer at point of sale) and APACS (Association for payment clearing services). EFTPOS was funded by a group of major banks to develop standard methods of electronic payment. It collapsed in1990 when the banks could no longer see a commercial future in the idea. But in the meantime Noble had moved to APACS where he worked on the prevention of plastic card fraud. He found that collaboration was most successful when it had a very specific focus - in this case, fear of plastic card fraud which at that time was costing £150 million a year in the UK. 'You find people in the individual companies whose job is to solve similar problems,' he says. 'Then you persuade them that their best interests are served by joining forces. For example, if you are losing millions of pounds by cards being intercepted in the post, you need to talk jointly to the Post Office. You might also decide that there is a business benefit in sharing experiences - telling your partners that it helps to put the cards in brown envelopes rather than white ones or stamping a "valid from" date on the card.' The medical profession is ideally suited to collaboration because people tend to be so highly committed, says Noble. 'You are pushing at an open door asking them to work together because they are focused on patient care and co-operation. Also, they recognise that resources are spread quite thinly - whereas in banks there is lots of waste and people may be less targeted on trying to solve the problem.' At APACS Noble also learnt the importance of involving users in big decisions such as IT investment programmes. Hence the attraction of the East Anglia consortium - apart from himself, everyone in the group is part of a hospital. The users are implementing their own systems. The disadvantage is that their enthusiasm and technical expertise can carry them away - a group of doctors in one hospital rewired a network over the weekend to add in some extra PCs they needed.
The banking world also introduced Noble to the concept of customer centred systems. During the mid-1980s he worked for NWS Bank in Chester. At that time the financial services industry was going through enormous upheaval, restructuring its systems to focus on customers rather than products. Many institutions have still not achieved the transformation. 'The banking industry is hampered by having made a huge investment in technology to deliver account-based systems,' claims Noble. 'Making the transition is one of the biggest technical problems that these institutions face.' Hospitals need to make the same change but they are not nearly so encumbered by the burden of past purchases. Even so, they have isolated 'pools of information', says Noble. Traditionally, each department has collected its own data such as the names, addresses and GPs of its patients. Anyone visiting several departments would have to repeat the information for staff to re-key into a separate computer system. Moreover, scanners and laboratory machines often invite users to key in patient data.
The goal of the consortium is to create a unified system which will hold all the patient data centrally. Not only will it put an end to time-wasting repetition of patient details, it will also make complete patient histories available at the touch of a button throughout the hospital. This is a colossal processing load, says Noble. 'The average medical records department holds around 3.5 billion pieces of information relating to current patients. These systems will be able to scan the whole lot to extract a single piece of information - say the result of a test carried out six months earlier - in one second.
At present, when a doctor orders a set of pathology tests, it is not until the porter brings the samples on a trolley that the laboratory knows what tests are required. The computer system will inform the lab straight away so that in urgent cases appropriate equipment can be set up ready and waiting. Once the tests have been carried out, the results will immediately be available, not just in the laboratory, but in the ward, in the doctor's office 'and if necessary in the coffee lounge', says Noble. In future, even services such as catering and laundry will be included so that special dietary requirements or extra sheets can be ordered from anywhere in the hospital.
To ensure that nothing was missed out in defining the original requirements, lengthy consultations were held with all categories of hospital staff, from radiographers and pathologists to administrative, catering and clinical staff. At least 150 people were involved in the discussions, says Noble.'I'd be disappointed if anyone in the hospitals said they didn't know what we were up to.' A document outlining 250 individual requirements was published in August 1992 precipitating 39 requests for copies from suppliers, followed by 16 serious responses. Then the process of selection began.
NHS procurement is governed by EC/GATT regulations intended to ensure fair competition. They oblige customers to debrief all would-be suppliers on the reasons why they were not selected. 'Although this is in some ways a tedious process, it is also an enormously valuable exercise which forces you to examine your own selection criteria very hard,' says Noble.
Decisions are often influenced by a mixture of subjective and objective views, but people are not always honest with themselves about the subjective component, he reckons.'This system makes you face up to the reasons why you are making certain decisions.' Suppliers can certainly be rejected on the grounds that they did not co-operate, but the customer might need to justify the allegation and provide the evidence if challenged.
To aid the selection process, the East Anglia consortium laid down very specific requirements for every stage. Pivotal was the need to pull together the islands of information - the winning candidate would have to prove that it had this ability. For instance, Noble rejected one supplier who offered to glue together the best software on the market for each individual application. Suppliers who offered a common core took precedence, even though their separate modules might not have been quite as functionally rich.
This screening process reduced the contenders to eight. Users were then invited to test the systems. 'User feedback is essential,' says Noble, 'because suppliers will always try to disguise the weak points of their systems.' For example, a system might require doctors to order pathology tests individually, whereas the doctors might want tests grouped so that a request for one automatically triggers several others. Such problems do not come to light until users are able to experiment with the system.
The trials reduced the number of suppliers to four possibles: US-based TDS; MDIS of the UK; Digital with SMS; and Data General with Meditech. The final judgement was based on technical capabilities, applications and customer support. The same two companies came out on top in all three areas - MDIS and DG. Since both suppliers could clearly meet the requirements, the final decision was made on price, with adjustments to allow for the amount that would need to be spent on training. MDIS was the ultimate winner. The 12-month selection process was over.
he core patient processing systems should be running in all four hospitals by April 1994. There will also be a module that deals with reporting back to the purchasers - District Health Authorities or fund-holding GPs. Over the following year, longer-term costing, contract planning, case mix analysis and medical auditing will be added. For example, clinicians will be able to detect the average length of stay in the hospital, or identify how many patients come in with secondary infections.
Noble's contract comes to an end in June next year. By that time each hospital should be self-sufficient, capable not only of running the systems as they are now, but of enhancing and extending them in the future. The crucial thing is to maintain compatibility, says Noble. 'We must dissuade users from being tempted to buy glitzy packages which look attractive for specific functions but are incompatible. The benefits of being part of the corporate system far outweigh the reduced functionality.' Adherence to the central system will also affect the purchase of specialised equipment such as scanners and pathology machines. They, too, must be compatible - there should be no re-keying of data. Emerging technologies such as electronic imaging and optical storage will also need to be evaluated in this way. 'We can already transmit data but in future we will want to send the x-ray itself rather than the doctor's interpretation of the x-ray.' The industry still has far to go, says Noble. 'If I had included document imaging in the original requirements it would have been very difficult to get practical replies.' The same goes for bedside systems - the computer equivalent of the clip-board at the foot of the patient's bed. Ward-based systems simply won't get used if the doctor or nurse has to go to the end of the corridor to enter a patient's temperature or blood pressure at a computer keyboard, he says. One solution might be the new generation of electronic notepads as yet still in their infancy.
Even technology which is supposed to be proven falls far short of requirements, reckons Noble. Take the much-vaunted open systems which are supposed to let computers from different manufacturers work together and run the same software.'I've not come across any cases of people transferring their software directly from one set of hardware to another,' says Noble.
Despite the IT industry hype, a lot more serious development is needed if users are to achieve their goals into the late 1990s, he says.'In two years' time, our hospitals will be asking for more and the industry will need to provide it or the systems will come to a dead end.' As to where Noble will be - he would like to remain in the health sector which he believes has a lot to teach UK industry, especially on the benefits of collaboration. The message seems clear for anyone faced with the task of buying a big computer system - find yourself an ally. Even a business rival might do more to benefit your organisation's IT than manufacturers and suppliers.
