Embedding

Informatics March 25

into
Clinical 2010
Education
The pace of change of health innovation means that on
graduation today’s medical students can expect to be working
in a radically-different NHS. Their ability to work with the
information technology will be critical to effective, safe and
efficient delivery of clinical care. We are exploring how to use a
live clinical information system in our primary care teaching
A Briefing
module. Prior to their general practice placements students
participate in a session where they record a full consultation, Paper for the
explore and use clinical coding, prescribe medication and use
UK Faculty of
specialist clinical tools. Students are actively encouraged to
review each others’ entries and explore the implications for Health
record keeping, audit and continuity of care. We believe that
Informatics
by preparing students earlier for the future IT-based working
environments we have enhanced their undergraduate training.
Introduction

There is a growing recognition of the importance of the use of clinical information systems (CIS) in
professional practice. The goals of the health services in the UK and elsewhere in the world are to
improve the quality of patient care, increase safety and do so cost effectively. The recognition that
sophisticated information management is crucial to achieving these goals lies at the heart of the
current reforms in healthcare and is driving the uptake of clinical systems throughout the world [4,
5]. The NHS National Programme for IT (NPfIT) is modernising the CIS that the NHS relies on to
deliver better, safer care to patients and is attracting considerable interest from around the world as
a leading example of how IT is being used to transform clinical care [6]. Students now studying for a
medical degree can expect to be working in a networked information environment radically different
from that which current healthcare providers, their tutors and the public have been used to with
new information tools shaping the clinical environment in the coming years [1].

The Yorkshire Centre for Health Informatics (YCHI) have an established working group entitled
Clinical Information Systems for Primary Care (CIS4PC) which is dedicated to the development of
relevant and up-to-date clinical education for all primary health care practitioners including doctors
and nurses. The group is working with Leeds Medical School to develop an informatics vertical
theme through all 5 years of the undergraduate medical curriculum at Leeds and a key element of
this has been the use of real clinical information systems in hands-on sessions which we have found
to be extremely successful and engaging for our students.

Our feasibility study considered approaches being taken elsewhere such as the creation of virtual
hospitals and Second-Life environments [10]. We concluded that despite many publications about
prototypes built by enthusiasts none have reached a level of maturity or sustainability which
matches the systems already in use in clinical practice. We also felt that such systems would be too
costly to develop and maintain locally and would not truly reflect the working environment to which
we wished to expose our students. We concluded that it is necessary to embed the use of CIS within
clinical teaching in the undergraduate curriculum such that our graduates are prepared for the
future world and we have therefore taken an alternative approach of using a mature NHS primary
care product as the core platform.

Background

At a national level the Embedding Informatics in Clinical Education (eICE) Project was set up in 2008
by CfH with the aim of promoting and facilitating the teaching of informatics as an essential part of

Prepared by the Yorkshire Centre for Health Informatics Page 1

clinical training programmes. Its first task was to undertake a review of the guidance “Learning to
Manage Health Information” which had been first published in 1999 and then reviewed in 2002.
After a wide-ranging consultation the revised and updated publication was launched at a national
conference for clinical educators in March 2009.

In 2009/10 and beyond the eICE project will concentrate on making the guidance widely available,
promoting its use and carrying out a range of activities to support its implementation. The main
objectives of the project are:

• To promote the need to embed informatics in clinical education to a range of target

groups including education commissioners, education providers and clinical profession
regulators.
• To promote and facilitate the use of ‘Learning to Manage Health Information 2009’.
• To support the development of health informatics knowledge and skills in clinical
educators.
• To develop a variety of resources to support clinical educators to embed informatics in
clinical education.
• To support the development of a clinical educators network.

The project is designed and carried out in line with the following key principles:

• The importance of promoting and including opportunities for interdisciplinary teaching

wherever possible.
• The need to focus on clinical practice and demonstrating how informatics can improve
patient care.
• The necessity of ensuring that activity links to strategic objectives and that the
investment in activity has maximum impact.
• The need to learn from previous projects and ensure lessons learnt are remembered.

The difference between the current and future working environment for clinical students being
trained today will be greater than that experienced by the current generation of clinicians. This is
due to the rapid technological change occurring against a background of increasing financial
pressure. As clinicians they will be accessing live patient data using portable hand-held devices in a
distributed, team-based clinical environment supported by knowledge-based tools to aid the
interpretation of a plethora of new information (e.g. genetic and risk data) generated from a host of
new diagnostic devices and tools.

Prepared by the Yorkshire Centre for Health Informatics Page 2

Primary care almost universally uses CIS in to support clinical care and secondary care is increasingly
adopting clinical systems for routine care [17]. With the increasing networking of systems across
health economies and the development of remote and mobile working [18], novel modes of health
care delivery are rapidly evolving [19]. Similar changes are occurring in secondary care, for example
the introduction of PACS (Picture Archiving and Communication Systems) and digital imaging, though
the rate of IT introduction is slower due to the greater complexity of the organisations and the care
delivery model [20]. One consequence of the introduction of this technology is that care becomes
‘virtualized’, care being provided across networks of professionals and in institutions which may be
geographically dispersed. This has significant impact on the current model of clinical education and
teachers must be aware of the effects on students learning. Without a complete picture of this world
students can find it hard to appreciate complex processes of care which they are expected to
observe. They commonly see only snapshots of care of individual cases rather than the progression
of patient journeys through the health system. Similarly since many CIS functions are hidden or
implicit in the delivery of care many students are bewildered by what they see. Thus, preparation for
placement in clinical environments goes well beyond mere training in IT skills. Students should be
prepared not only for the technological challenges but also for the changing sociological
relationships and ethical challenges that IT-supported access to clinical information will bring.

Existing and Emerging Curricula

Even now, students are taught in an environment where CIS are used universally in primary care [8].
In 1988 only 20% of GP practices had installed computers [8] but the stimulus of the new GP
contract in 2004 ensured completion of computerisation. By 2007 a European Union survey
confirmed that 95% of GPs in the UK were using their CIS during clinical consultations [9]. The range
of uses extends to communication, clinical care delivery, service organisation, quality and audit,
professional development and self-directed learning.

Interestingly, however, a recent study demonstrated a lack of understanding by GPs of the features
of the systems [11]. It concluded that providing technology alone is not sufficient to support the
transformation of care and many systems are failing through lack of training or insight into how best
to extract benefit from the investment. CfH recognised the issues early in its programme and funded
our group to carry out a feasibility study of educational needs and potential technical architectures
which was published in 2007 [7]. Despite this, few curricula have yet been adapted to match even
the reality of today’s NHS IT environment [2, 3].

Prepared by the Yorkshire Centre for Health Informatics Page 3

We predict that CIS will impact on all areas of medicine and that their use should be integrated
across the curriculum to support the student learning. Hence we have suggested that different
aspects of their use could be addressed in relevant courses (see Table 1) with students building a
complete picture of how the technology integrates into clinical practice over time.

Table 1 Distribution of CIS learning needs and topics across the curriculum.

Learning Need/Topic Potential Course Modules

Information Governance Ethics, Primary Care

Order Communications and Results Reporting Diagnostics/Pathology

Patient Pathways Primary Care, Public Health

Electronic Prescribing Primary Care, Pharmacy

Chronic Disease Management Diabetes, Primary Care

Diagnostic support in Acute Medicine Emergency Medicine

Social & Community Care systems Psychiatry

Health Screening Systems Paediatrics, Obstetrics and Gynaecology

Clinical Audit Methods Public Health

Clinical Imaging - PACS Anatomy, Orthopaedics, Cardiology

Team Working Communications Primary Care

Knowledge Management – eLibraries and

Personal and Professional Development
Decision Support

Specialist questions of information governance, anonymisation, confidentiality, data protection and

data quality are best discussed in context during the time they spend with clinicians rather than in

Prepared by the Yorkshire Centre for Health Informatics Page 4

isolated lectures. We are also keen to ensure that students are well aware of the downsides of IT
systems particularly the risks of social exclusion as the expectation that increased patient access to
information will shift the balance towards self-care. Embedding such thinking in the curriculum
planning process is not easy however, partly because many of those involved are senior staff, based
in secondary care with little insight themselves into the challenges which lie ahead. Thus, in Leeds
our vision has been that:

• In Year 1 the CIS could be used during the communications course to explore the
methodologies of electronic information exchange, the security and data protection
issues, the ethics of data transfer and the sociological impacts on team working and
information sharing. Such training would have relevance to the students’ exposure to
general practice where they could appreciate the use of IT systems during the clinical
consultation.
• In Year 2 the CIS could be used to explore the questions of access to clinical evidence
and its use in clinical decisions at individual and public health levels.
• In Year 3 when students increase their clinical teaching and start their placements in
General Practice they could use the CIS to create their own portfolio of clinical cases.
They would by default be expected to pay attention to the quality of information they
collected and recorded and would out of necessity need to respect issues of data
protection.
• In Year 4 during their specialty exposure they would learn of the specific issues related
to such technologies as decision support and be exposed to advanced features such as
PACS and protocol driven care. The student should critique the impact upon the doctor-
patient partnership and reflect upon previous learning in terms of chronic disease care
and communication skills.
• In Year 5 the use of the CIS could help prepare the students for clinical practice for
example by introducing them to concepts such as electronic prescribing, diagnostic test
selection results reporting and decision support.

Ensuring new doctors have insight into information handling and management, in particular how
information which informs clinical decision making is maintained in systems, will be essential for safe
use of systems in the future [11]. Although this pilot project is focused on the medical
undergraduate curriculum we see opportunities for its use in nursing, pharmacy and allied health
professional training and our ambitions extend to the possibility of using it to support
multidisciplinary training especially with regards to team working and communications. Awareness

Prepared by the Yorkshire Centre for Health Informatics Page 5

of the ways information can be manipulated and presented for use by different health professionals
will be essential if we are to exploit the benefits and avoid the pitfalls of mis-application of IT
systems in clinical practice.

There are similar implications for postgraduate training and opportunities to design relevant course
materials in sessions for qualified doctors [3]. We are working in collaboration with post-graduate
educators to access this initiative for their learners. We have also been considering the extension of
teaching into other non-medical disciplines, for example exposing computer science students to the
special requirements of clinical systems development at undergraduate and post-graduate level.
Engaging students early in these areas can only be beneficial to themselves and to the NHS if we
increase the pool of talent capable of developing systems better designed for clinical use.

The Leeds Approach

We now have 2 years experience of using a live General Practice (GP) system in undergraduate
teaching and using this as a platform for exploration of informatics issues. The group has enjoyed a
good working relationship with TPP – the supplier of a widely-used GP clinical information system
(SystmOne) – and has strong support from the regional Strategic Health Authority (SHA) and a
number of local trusts. As many of the organisational, communication and clinical activities are
supported by information systems and related technologies; it is essential to understand these
systems in order to fully appreciate the primary care environment. We promote critical evaluation of
these aspects when looking at chronic disease management, practical prescribing and consultation
and communication skills.

We are consulting with the School of Healthcare at Leeds to support the development of nursing and
the allied health professions and to cultivate multi-professional, interdisciplinary education. We are
currently developing a consultation/communication skills experiential learning package for GP
registrars and independent nurse clinicians. We have secured funding and the support of NHS
Yorkshire and The Humber to disseminate some of this material and developing the informatics skills
of other clinical educators on a regional basis but believe this work is of national significance.

Our approach is novel in that we have worked in partnership with a national clinical information
systems supplier (TPP) to create a complete virtual primary care practice with over 300 virtual
patients in as close a simulation to real life clinical settings as possible. We have a teaching
laboratory with 45 PCs configured to run real informatics systems and our “hands-on” sessions
involve each student taking responsibility for maintaining an individual patient’s electronic record

Prepared by the Yorkshire Centre for Health Informatics Page 6

based on carefully designed scenarios delivered as worksheets and videos of patient consultations. A
key feature of the learning experience is students recognising the professional, clinical and practical
implications of relying on each other’s accurate and effective information systems use. Students
quickly appreciate the need to develop and encourage good practice and are enthused to exploit the
clinical benefits of informatics solutions. This approach is motivated by a belief that work place
learning must reflect the real working environment in order to ensure clinicians are fit for purpose.
We are not aware of another medical school that has achieved this level of success in embedding
practical informatics experiences within their curriculum and we are keen to share this experience
and encourage similar developments.

Figure 1 An example computer cluster session.

We have been tracking the IT skills of our student intake for a number of years and have observed a
steady increase in competence. In a recent survey we found that all of the first year students at
Leeds use the Internet for email and over 80% use it for shopping, listening and downloading music
and online chat. All of them use computers for word processing. Medical training increasingly
includes the use of the Internet as a research tool for accessing medical knowledge and by the end
of their course all students have high levels of IT competency.

Our initial work has centred on our primary care course where teaching is delivered prior to clinical
placements in West Yorkshire. TPP SystmOne has been installed as a strategic product across NHS
Bradford and Airedale and is in use in 90% of GP practices. We have developed a training and

Prepared by the Yorkshire Centre for Health Informatics Page 7

education environment which uses TPP SystmOne as a ‘live’ CIS which replicates the working
environment of the GP and takes account of student experiences of GP systems on clinical
placement [12].

TPP SystmOne Features

TPP’s SystmOne is an advanced Electronic Medical Record system used to manage patient care in
primary and community care settings. It supports comprehensive clinical care, containing complete
medical records, supporting prescribing, diagnostic test orders and reports. It is based on a thin-
client, networked model with sophisticated security controls to allow collaborative working between
care teams work in local health communities. The core data centre supports over 1,000 general
practices and its main database holds detailed clinical records on just over 11 million patients.
SystmOne is an NHS Connecting for Health accredited system.

The complete learning cycle in the primary care module involves an introductory week, clinical
placement and students return to university for assessments and reflections. Our GP placement
tutors had already recognised the need to better prepare students in CIS use before visiting their
practices. 62% of GP tutors already provided tutorials on the uses of their practice system during the
placement [13]. Our hypothesis was that practical exposure to a system prior to their placement
would enrich their learning experience, allowing deeper insight into the clinical processes and allow
the students to question the care delivery by generating discussion with the primary care team.
Table 2 shows how the undergraduate medical objectives are mapped to the Learning to Manage
Health Information subject areas.

Table 2 Undergraduate medical objectives mapped to Learning to Manage Health Information.

Learning Objective Subject Area

Data, Information and Knowledge 4.2.1

Communication and Information Transfer 4.3.4 and 5

Health and Care Records 4.4.1-2-3

Language of Health 4.5.2-5-8

Prepared by the Yorkshire Centre for Health Informatics Page 8

 Clinical Systems and Applications 4.6.1-2-3-5

The technical solution was to develop an instance of a GP practice, the ‘Worsley Practice’, named
after our medical school building, hosted in the TPP data centre securely isolated from the live
patient database. This can be accessed remotely from clusters of PCs in our teaching centre such
that large classes (40-60 students) can be taught, with each having a username and the ability to
manage their own ‘dummy’ patients. Preparation for the classes required us to train a small team of
GP and health informatics tutors and IT literate support students in TPP SystmOne use and to ensure
that each PC had the necessary thin-client access software loaded.

We designed a supervised, 3-hour session, providing hands-on exposure to the CIS and using dummy
patient histories prior to their clinical placements. This enabled them to rehearse what they would
observe on their placement with their GP tutor. The sessions were initially supported by one health
informatics tutor, one GP tutor, two IT support students, and a SystmOne trainer from the Yorkshire
and Humber SHA NPfIT team but are now routinely delivered by a GP tutor, health informatics tutor
and one IT support student.

Teaching Format

The students begin hands on navigation by registering a new patient and transferring data from the
new patient questionnaire. Following this the students were presented with a video of a patient
consultation and given the task of recording its content. They were expected to explore and use
clinical coding, prescribe medication (both acute and repeat items) and use rudimentary clinical
decision support tools. The third task was to use a chronic disease template whilst watching a
consultation and reflect upon task based health care.

The case used was tailored towards chronic disease management since this is a core element of the
primary care curriculum at this point. The use of CIS mapped directly onto the learning objectives of
this part of the course are:

• Understand how patients with chronic disease may be managed in the primary care
setting, including therapeutics and the role of the Primary Care Health Team.
• Know of the information sources available to doctors, patients and carers, how to access
them and their benefits and limitations. These will include sources of guidelines and
disease management protocols.

Prepared by the Yorkshire Centre for Health Informatics Page 9

 • Understand how primary care practices organise their services, use audit, care for
patients with chronic disease and promote health and disease prevention.
• Understand the communication channels through which the practices communicate
with other health and social care professionals, voluntary services, patients, relatives
and carers.

Information systems have been widely-reported to be central components of chronic disease

management [14] and whilst on placement students investigate how chronic diseases are managed
and the systems and processes in use for providing clinical care for patients in general practice.

Students also reviewed and compared each others’ entries and discussed the implications for shared
record keeping, audit and continuity of care. The objective was to highlight the strengths and
weaknesses of coded versus free text entries and bring to their attention the variance in
interpretation they had made in observing the same clinical case.

Initial Outcomes

To date 390 students have taken this introductory teaching session and completed their 6 week
placement in primary care. The majority of students were clearly IT literate and competent with the
basic technology though some needed detailed help. Most coped well with first exposure to a
complex and rich clinical system though some initially found the session overwhelming and needed
help entering clinical data. From our initial observation we felt that many students do not have an
appreciation of the overall process of care despite the ubiquitous use of care pathways in the NHS
planning, and have yet to develop an abstract model of the structure of distributed electronic as
opposed to linear paper records. Without this it is difficult to place the use of the CIS in context and
we are iteratively amending our introductory material to take this into account.

We were encouraged by the degree to which the session stimulated spontaneous discussion about
the differences between coded data, that is auditable, and the rich, non-coded narrative data which
conveyed a fuller, more holistic clinical picture. Students rapidly developed insight into the strengths
and weaknesses of current methods of information capture within the consultation such as the Read
code browser. The most competent students quickly found how to navigate the system and many
were able to appreciate the sophisticated design features of the human-computer interface. Formal
feedback for all of the sessions confirmed these observations with students finding the sessions
informative and stimulating.

Prepared by the Yorkshire Centre for Health Informatics Page 10

In the first year of the teaching (2008/09) 252 students attended the teaching sessions and
completed the course evaluation. 75% felt more prepared for their clinical placement and 89% felt it
was relevant and useful to their current learning and 90% felt it relevant to their future working [16].
Tutors who delivered the sessions found the system easy to incorporate into the classes and
facilitated the practical demonstration of tools such as the semi-automated Read coding and BMI
calculation. Feedback from GPs involved in the teaching programme confirmed the value of helping
the students understand system capabilities before exposure to the clinical problems and the
potential influences of the system on the consultation and the doctor patient partnership.

Benefits and Challenges

Technical and Organisational Challenges

Universities have well established computer networks for student learning and, as we’ve seen in
Leeds, all students have access to and make regular use of these facilities for routine e-mail, Internet
access and document editing. University computing clusters with 30 to 100 PCs are increasingly used
as classroom teaching environments with students accessing systems as part of a lecture or
workshop or less formally as guided self-study. Much of the infrastructure is therefore already
available.

Although each university could invest in servers that hosted example clinical systems for student
learning the configuration of these requires a combination of technical, educational and clinical
expertise which is inevitably expensive both in set-up and ongoing management. The Joint Academic
Network (JANET) connects all UK universities and Further Education colleges and provides a
dedicated network through which medical students can access a central shared hosted service.
JANET provides a high bandwidth, reliable infrastructure similar to the NHS N3 network. The NHS-HE
Forum is helping to develop links between JANET and N3. The most cost effective solution is for a
single hub providing a central resource accessible through JANET.

The hub could include a number of application servers hosting up-to-date versions of Connecting for
Health software applications populated with large datasets of training data from anonymised
sources and containing embedded learning scenarios. Such datasets would require academic
systems administration including automated data cleansing to remove unwanted data input by
students. The hub would depend on an ongoing relationship with key software suppliers to maintain
the software and updates of key data feeds such as the coding system, SNOMED CT. In addition to
the applications themselves the hub would need to provide access to a central repository of teaching

Prepared by the Yorkshire Centre for Health Informatics Page 11

material linked to the data in the systems. The University of Leeds is developing in a sophisticated
Virtual Learning Environment (VLE) and while this is only for use by University of Leeds students a set
of interfaces to support VLE integration should also be provided. More technical detail can be found
in Appendix 1.

Installation of the system on our clustered PCs proved remarkably easy once the relevant access had
been granted, though we did have to overcome some minor issues such as the open access desktops
of prepared machines being automatically re-configured through the University’s network between
sessions. There were also issues regarding the security settings which required a single user account
being given rights to access and configure each of all 40-60 machines at the same time each session.
We expect to be able to automate this in future.

Full system functionality is not yet available because we are not linked to NHS N3, For example NHS
Patient Demographic Service access and ordering and receiving test results. We would expect to
cover these aspects elsewhere in our curriculum, such as in diagnostics and pathology modules.

Despite these constraints we still believe there is advantage of the thin client model over using local
systems since set up and hosting costs are minimised. Though we have used SystmOne, similar
training of the principles of health information management could be provided with any suitable CIS
and we do recognise that there is a multiplicity of systems in the clinical world. There are steps
towards systems standardisation for example through the NHS Common User Interface Programme
[15] it will be some time before system designs converge.

Clinical Risks and Issues

One issue which was not foreseen was the ability to generate printable prescriptions from the
system which looked authentic. An approach was developed to block the printing function and to
only enable the function during the live sessions. This actually provided an opportunity to reinforce
information governance issues with the students by explaining why the right was removed after the
supervised sessions. We have now put in place a formal governance structure to ensure that there is
a controlled, safe environment with restricted access for students.

Potential for Health Informatics

Our work shows that it is possible, with the support of NHS organisations and system suppliers, to
cost-effectively integrate a complex NHS CIS into the university network environment and to use it

Prepared by the Yorkshire Centre for Health Informatics Page 12

to enhance learning about clinical medicine and the doctor-patient partnership in the rapidly
changing world of digital healthcare.

References

1. Department of Health (2008) High Quality Care For All: NHS Next Stage Review Final Report.
Available from:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_085825 [Accessed: 24/03/2010].
2. General Medical Council (2003) Tomorrow’s Doctors – recommendations on undergraduate
education. Available from: http://www.gmc-
uk.org/education/undergraduate/tomorrows_doctors_2003.asp [Accessed: 24/03/2010].
3. Rennison T, Swanwick T, Deighan M and Field, S (2009) Information Management and
Technology Curriculum Statement 4.2. Royal College of General Practitioners, London.
Available from: http://www.rcgp-
curriculum.org.uk/extras/curriculum/statementDetails.aspx?id=11 [Accessed 24/03/2010].
4. Ludwick DA and Doucette J (2009) Adopting electronic medical records in primary care:
Lessons learned from health information systems implementation experience in seven
countries. International Journal of Medical Informatics: 78; pp. 22-31.
5. Schoen C, Osborn R, Doty MM, Squires D, Peugh J and Applebaum S (2009) A survey of
primary care physicians in eleven countries, 2009: Perspectives on care, costs, and
experiences. Health Affairs: 28; pp. 1171-83.
6. Conz N (2009) Setting the record straight. Insurance & Technology: 34; pp. 32.
7. YCHI (2007) Embedding NHS Connecting for Health Content within the Medical School
Curriculum: A Briefing Paper to Higher Education Institutions. University of Leeds. Available
from: http://www.ychi.leeds.ac.uk/ychi/files/pub/UG_Systems_Briefing_Paper_Final.pdf
[Accessed 24/03/2010].
8. Preece J (2000) The use of Computers in General Practice (4th ed.). Churchill Livingstone.
9. Empirica (2008) ICT and eHealth use among GPs in Europe 2007. Available from:
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/gp_survey_fin
al_report.pdf [Accessed 24/03/2010].
10. Maged N. Boulos K, Hetherington L, Wheeler S (2007) Second Life: An overview of the
potential of 3-D virtual worlds in medical and health education. Health Information and
Libraries Journal: 24; pp. 233-45.

Prepared by the Yorkshire Centre for Health Informatics Page 13

11. Avery AJ, Savelyich BS, Sheikh A, Cantrill J, Morris CJ, Fernando B, Bainbridge M, Horsfield P
and Teasdale S (2005) Identifying and establishing consensus on the most important safety
features of GP computer systems: E-Delphi study. Informatics in Primary Care: 13(1); pp. 3-
12.
12. Lea A, Pearson D, Clamp S, Johnson O and Jones, R (2008) Using the electronic medical
record within medical undergraduate education. Education for Primary Care: 19; 656–9.
13. Lea A, Nicholls G, Pearson D, Clamp S, Johnson O and Jones R (2008) A student evaluation of
using clinical information systems for Primary Care placements. Proceedings of Association
for the Study of Medical Education Conference. Leicester.
14. Bodenheimer T, Wagner EH and Grumbach K (2002) Improving primary care for patients
with chronic illnesses. The Journal of the American Medical Association: 288; pp. 1775-9.
15. Microsoft. NHS Common User Interface. Available from: http://www.mscui.net/ [Accessed
24/03/2010].
16. Lea A, Nicholls G, Pearson D, Clamp S, Johnson O and Jones R (2009) Learning about and
using electronic medical records (EMR) in undergraduate education – the Leeds experience.
Proceedings of the Association for Medical Education in Europe. Malaga.
17. Stewart R, Soremekun M, Perera G, Broadbent M, Callard F, Denis M, Hotopf M, Thornicroft
G and Lovestone S (2009) The South London and Maudsley NHS Foundation Trust Biomedical
Research Centre (SLAM BRC) case register: Development and descriptive data. BMC
Psychiatry: 9; 51.
18. Silvestre A, Sue V and Allen J (2009) If you build it, will they come? The Kaiser Permanente
Model of online health care. Health Affairs: 28; pp. 334–44.
19. Chen C, Garrido T, Chock D, Okawa G and Liang L (2009) The Kaiser Permanente Electronic
Health Record: Transforming and streamlining modalities of care. Health Affairs: 28; pp.
323–33.
20. Mackinnon AD, Billington RA, Adam EJ, Dundas DD and Patel U (2008) Picture archiving and
communication systems lead to sustained improvements in reporting times and
productivity: Results of a 5-year audit. Clinical Radiology: 63(7); pp. 796-804.

Prepared by the Yorkshire Centre for Health Informatics Page 14

Appendix 1 – Technical Architecture

Overview

An educational hub serving a full suite of Connecting for Health application systems will be hosted at
a single site on the JANET academic network. The hub will consist of a number of application servers
and an education resource centre with access control managing appropriate use. Student access will
be through standard PC clients via their university networks. Most universities operate a policy of
“locking down” the desktop to a centrally controlled and managed configuration. Emerging CfH
applications which are browser based (Lorenzo, Map of Medicine) can be accessed via a standard
university networked computer without requiring modifications to the configuration. Similarly a
student using a laptop and wireless (Wi-Fi) connection or home computer and Virtual Private
Network (VPN) connection should be able to access the applications with minimal difficulties.

Classroom Teaching Resources

Computer based teaching is increasingly making use of purpose designed student labs with 30 to 100
PCs. Some of these facilities include overhead projection so that a lecturer can present supporting
material or demonstrate an application to the students before they use the computer at their desk
to try the system for themselves. An alternative is for students to work through online or printed
exercises using the application to complete a number of tasks with typically several members of
teaching staff or experienced postgraduates on hand to help with problems or questions. Most
universities are investing in expanding such facilities and making them available – medical schools
should expect to have access to such facilities and be able to book them for their students.

Hub Configuration

There are a number of options for hosting the server applications listed here in order of preference:

• A pure Microsoft server solution - Windows NT server application using SQL Server and
other products from the Microsoft server suite (including IIS server, .Net etc). Current
(pre-Vista) versions of the product suite should be supported.
• An open source/Unix based solution such as Linux or an Apache server.
• A hybrid solution using Microsoft and third party operating systems and applications, for
example Windows NT server with Oracle. This is less desirable because of the potential
complexity it may introduce. In this case the requirement for specific third party

Prepared by the Yorkshire Centre for Health Informatics Page 15

 software should be clearly stated – it may be possible to negotiate academic use of third
party software but otherwise costs may be prohibitive both in licensing and in technical
implementation and support.
• A proprietary third party hardware or software platform – it is likely that the set up costs
for such an application would mean this is not a viable option.

For the pilot the hub should be scalable to support up to 100 users simultaneously performing
similar, if not identical, transactions. The technical specification is intended to ensure adequate
performance in a classroom setting while minimising the management overhead for university and
specialist support staff by conforming as closely as possible to a standard university configuration.
For a UK wide resource the hub should be scaled up to support a large number of exercises
simultaneously taking place at different medical schools around the UK. The application server could
be hosted by the University or, potentially, hosted remotely by the software supplier. Hosting by the
University increases potential costs for local administration both in releasing and implementing new
software releases and in configuration and user account management. Hosting by the software
supplier would be technically feasible if the application is browser based and can be accessed via the
Internet using VPN, SSL, user-ids or similar to address potential security concerns. Data
administration may grow to become a significant issue as scenarios for teaching will need to be set
up by teaching staff and restored once students have completed exercises – with a range of
potential data scenarios and simultaneous teaching programmes running at different levels the need
for a range of different backup and restore procedures will increase.

Data Management

For teaching purposes a set of test data configured to represent a primary care unit and a small
acute trust, populated with anonymised patient and history data is the obvious starting point for
developing a range of class room and exercised-based scenarios. The software suppliers will need to
supply a procedure or utilities to store and restore clean data sets and utilities for managing user
administration in bulk. Good procedures have already been established in TraMS data, where a daily
refresh is scheduled to ensure data is restored to its original form, at the end of each working day.

Client Deployment

For the pilot at the University of Leeds the PC operating system is Windows XP and the desktop is
managed by the university’s ISS department. Students do not have access privileges to install

Prepared by the Yorkshire Centre for Health Informatics Page 16

software applications or plug-ins. A degree of local customisation to the standard desktop can be
arranged with Faculty support staff.

There are two preferred options for client applications:

• Browser based. All client PCs have Internet Explorer as standard - CfH systems with pure
HTML, client side or server side scripting should work without desktop modification and
are therefore the preferred option. Browser based applications which require a plug-in
such as Java can be supported but the version and plug-in details will need to be
specified.
• Thin client. A Windows XP client can be installed by Faculty IS staff on top of the
standard managed desktop. This has some costs, typically several days configuration
testing and about 1 day deployment per 50 PCs. Cost of ownership is also increased as
new versions of the client application will require the same amount of testing and
deployment costs.

Prepared by the Yorkshire Centre for Health Informatics Page 17