“By 2018, clinicians in primary care, urgent and emergency care and other key transitions of care contexts will be operating without the use of paper records” says the Department of Health. MedConfidential agrees that Electronic Health Records to pass information electronically along a patient’s care pathway will lead to better care and better patient outcomes (and better privacy), but that’s not all they do.

To ensure the uptake of flows along care pathways, there should be transparency of process. As part of a Data Usage Report, patients should be able to see where their EHRs have gone and why. That data could go anywhere is mitigated by telling patients exactly where it did go, so patients can have confidence it didn’t go elsewhere. The requirement for all care providers to use the NHS number makes this feasible.

There will also be published statistics on the adoption of EHRs. Those statistics should also include what percentage of patients arrive at an organisation with an EHR, or how many need to have an NHS number lookup to create a record (organisations with walk-in patients, including A&E, should be excluded). By institution, they don’t tell us very much, but when you look at pairs of institutions, you can see patterns. How many EHRs did hospital A send to care provide B? How many B receive from A? Where does this process go wrong, and is there anyone chasing up why and fixing it?

In practice, no. Because there’s no strong incentive to.

The place that the chasing up does happen, predictably, is when money becomes involved. The NHS has a balance of accountants whose job it is to make sure that one bit of the NHS bills the other bits the right amounts for the care provided. Given NHS bodies don’t trust each other, those other bits of the NHS then have a different balance of accountants to check all the invoices.

For years, there has been a “temporary” arrangement where those accountants could see identifiable data, because that’s what had to be on invoices otherwise the accountants wouldn’t necessarily pay them. That temporary arrangement should have expired many times, but it keeps being renewed, as the accountants have never changed how they work, and the system doesn’t trust itself. The current incentives are wrong.

It was outside the Caldicott Review’s remit (and time) to look at them, and so the Review had no choice but to suggest that the accountants can continue to look at identifiable information.

In a world with Electronic Health Records that flow along care pathways with patients, that doesn’t have to happen – the constraint on the Review should not apply to the Department. The reporting on those flows can include a summary of care provided at the previous stage from that provider, which provides a separately accountable (to CCG via HSCIC) reporting streams which the accounts can rely on. As it derived from clinical data, any fraud by commercial actors in the system would require clinical fraud, as well as accounting fraud, with it’s far higher penalties. If the counts of care provided from one side are very different to another, that is examined as a clinical issue as well as a financial one.

“Should we pay this invoice?” becomes a simple question based on audited information from multiple automated sources. The counts will show whether all care provided along pathways has yet been paid for by the relevant CCG. Where there are queries, it means there was an EHR flaw which should be addressed, not just for financial reasons, but to improve care. (This is in need of refinement, but the likely question for adoption is “What percentage of new records have an NHS number entered manually, rather than via an electronic records transfer?”. Care per provider per CCG is derivable from EHR flows by third parties).

Invoice reconciliation has been a thorn in the side of privacy and good governance since the inception of the internal market in the NHS – the Department of Health has never bothered to fix it. As EHRs roll out on the same timescale as the Caldicott Review, there is the opportunity to do so.  Besides legislative changes in the consent model, when the CAG regulations are finally laid, they should prevent the approval of s251 for invoice reconciliation “by 2018”. If the organisations of the NHS care about high quality EHRs because Treasury cares about accounting, incentives will be aligned to resolve problems along care pathways, which will improve direct care at the same time.

This is the administrative backwater of the NHS, that only cares about money (which makes it very important to the Department) Disease Registries or the GP opt out are far more high profile and important. But if the destruction of the GP opt out is the primary signal of intent to patients, data flowing to the accountants is the primary signal of intent to NHS managers and institutions on whether the Secretary of State means to deliver on his promises, or whether he will give up if the system ignores him.

This is not a new change – this has long been trailed as coming soon, yet the bullet has never been bitten, and the identifiable data turned off even though it has repeatedly been decided to. Given the changes in the consent model proposed by the Review, if not now, then when?

No evidence was provided by the Caldicott Review for the override of the GP opt out, for the exception of the disease registers, or the override for invoice reconciliation. The Department of Health seems to think it’s easy to override your wish that your data does not leave your GP, but will they ask the accountants to change what it is they count? Or will the Department give itself an opt out on a major flagship policy?