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Local Clinician Involvement in Clinical Information Systems: Necessity or Luxury – A Review of International Experiences ASSIST (Harrogate, Preston) October 1 & 2, 2003 Questions to be discussed Is it important to solicit meaningful physician input early and often and act upon it?

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slide1

Local Clinician Involvement in Clinical Information Systems:Necessity or Luxury – A Review of International Experiences

ASSIST (Harrogate, Preston)

October 1 & 2, 2003

Denis Protti - University of Victoria

questions to be discussed
Questions to be discussed
  • Is it important to solicit meaningful physician input early and often and act upon it?
  • Does finding meaningful ways to engage physicians require creating an organizational climate and culture that respects the heart of medicine?
    • Is this the key to maintaining physician loyalty and involvement?

Denis Protti - University of Victoria

slide4
Some management teams believe that ideas should be well fleshed out and ready for implementation before discussing them with physicians.
    • When that occurs, do physicians feel their input is actually sought?
    • And if they recommend changes at that point, will it be difficult for management to retreat and follow another course of action?

Denis Protti - University of Victoria

slide5
How can one best square the need for centralised/standardised policy with getting local support and use?
  • Does the opinion of national clinical bodies matter?

Denis Protti - University of Victoria

outline
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT – Clinicians Involved?

Denis Protti - University of Victoria

the challenge of being an afternoon speaker
The challenge of being an afternoon speaker

Denis Protti - University of Victoria

outline8
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT – Clinicians Involved?

Denis Protti - University of Victoria

epr in danish hospitals
EPR in Danish Hospitals
  • 11/14 counties have an IT strategy for the health care sector.
  • As of 2001, there were a total of 52 EPR projects in the country.
  • The projects were in different phases and were controlled on different levels
  • Between 5% and 10% of all beds in Danish hospitals are covered by an EPR system.

Denis Protti - University of Victoria

what s most interesting about denmark is

What’s most interesting about Denmark is

MedCom

Denis Protti - University of Victoria

pre medcom
Pre-MedCom
  • Late ’80s
    • A GP who also worked P/T in hospital biochemistry lab
    • Chief pathologist at the hospital
    • Head of IT in the county
    • Proposed a project for Funen County IT strategy
      • Electronically transmitting lab results

Denis Protti - University of Victoria

medcom today
MedCom Today
  • Over 90% of 2000 GP clinics/practices are computerized
    • 86% use their computers to send and receive clinical EDI messages
  • 10% of non-users
    • Those who will retire in next 3 years
    • Those just starting without the capital (1-2 year delay)

Denis Protti - University of Victoria

medcom facts
MedCom Facts
  • Used by ¾ of the healthcare sector
    • >2,500 different organisations
  • All hospitals, all pharmacies, all laboratories and ~1,800 general practices take part
  • ~Two million messages a month are exchanged (over 60% of the total communication in the primary sector)

Denis Protti - University of Victoria

medcom facts cont d
MedCom Facts (cont’d)

Denis Protti - University of Victoria

medcom facts cont d15
MedCom Facts (cont’d)
  • MedCom’s standardised messages implemented in 50 IT systems, including:
    • 16 doctor systems
    • 12 laboratory systems
    • 9 hospital systems
    • 4 pharmacy systems

Denis Protti - University of Victoria

medcom facts cont d16
MedCom Facts (cont’d)
  • Physicians pay for their own systems
  • Upcoming agreement with County Association and the PLO will mandate electronic communication
  • Specialists use of computers range from 40-90% depending on the county with their use of EDI clinical messages ranging from 15-70%

Denis Protti - University of Victoria

medcom funders
MedCom funders
  • 1/3 from Ministry of Health
  • 1/3 from County Association
  • 1/3 from Other Sources
    • Ministry of Social Services (recently)
    • Danish Doctors Association (early on only)
    • Dan NET
    • Danish Pharmacy Association

Denis Protti - University of Victoria

seven driving forces
Seven Driving Forces
  • Communication benefits of MedCom
    • Improves dialog with hospitals
    • use to wait 5 days for results of tests (now almost as soon as it comes off the equipment)
    • Automatically notified when patient registered in an Emergency department
    • Discharge summaries now arrive within 1-3 days (use to be 4+ weeks) – standard set by Counties

Denis Protti - University of Victoria

driving forces cont d
Driving Forces (cont’d)
  • Out of Office Hours (OOH) system mandated
  • Started 1997
  • GP available from 1600 - 0800 hours (could be up to 3 GPs present)
  • ~30 across the country – some based at hospitals
  • Negotiated by PLO and County Association
  • GPs doctors had to learn how to use a computer if they wanted to be paid

Denis Protti - University of Victoria

driving factors cont d
Driving Factors (cont’d)
  • Peer influence – collegial pressure
    • GPs go to see each others computers
  • PLO wrote conversion software to facilitate the transfer of patient data from one GP to another
  • Access to the Internet (2-3 times/day)
    • e.g. waiting times for x-rays for all clinics in Funen County
    • can see what procedures are done at each clinic
    • can decide with patient where they should go

Denis Protti - University of Victoria

driving factors cont d21
Driving Factors (cont’d)
  • County Support
    • Provides GP with a diskette of all their patients when first starting (been doing since 1992)
    • Training done by data consultant – visit practice regularly
    • Help desk
    • Practioner coordinator for each specialty (psychiatry, general surgery, etc.)
      • Works 2 hours/month
      • Coordinates wishes of GPs to hospitals and vice-versa
      • IT agenda moved forward through them

Denis Protti - University of Victoria

driving factors cont d22
Driving Factors (cont’d)

7. Standards set by MedCom

  • Contract signed with Counties and PLO obliging everyone to use them
  • Clinicians and vendors involved!
  • MedCom tests and certifies vendor systems
  • Steering committee of paying agencies meets every 3 months to review compliance data

Denis Protti - University of Victoria

slide23
The Danish GPs are so automated that

Denis Protti - University of Victoria

outline24
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT – Clinicians Involved?

Denis Protti - University of Victoria

new zealand facts
New Zealand Facts
  • Over 95% of GP offices are using one of nine Practice Management Systems
    • 75% use their systems to electronically send and receive clinical messages such as laboratory results, radiology results, discharge letters, referrals, delivery of age-sex registers to their IPA/PHO, etc.
  • ~ 50% of GPs now use the Internet on a regular basis from their offices - including communicating with their patients.

Denis Protti - University of Victoria

new zealand facts cont d
New Zealand Facts (cont’d)
  • Specialists use of computers range from 30-90% depending on their region. The private specialist use of a full EMR is limited to 15-20%.
  • Like the Danes, GPs increasingly favor referring patients to specialists who are able to send information back to them electronically.

Denis Protti - University of Victoria

slide28

2,200 New Zealand sites

1,200 Australian sites

1-800 support across Australasia

AGPAL ACCREDITED

Denis Protti - University of Victoria

new zealand facts cont d29
New Zealand Facts (cont’d)
  • Used by 75% of all healthcare sector organizations in New Zealand.
    • All hospitals, radiology clinics, private laboratories
    • ~1,800 general practices.
    • > 600 specialists, physiotherapists, other allied health workers
  • Over 3 million messages a month are exchanged,
      • 95% of the communication in the primary health care sector.

Denis Protti - University of Victoria

driving forces in new zealand
Driving Forces in New Zealand
  • Unlike the Danish success story, HealthLink received no government funding to initiate the service and its growth and success is based entirely on the market model of “supply and demand”.

Denis Protti - University of Victoria

driving forces cont d31
Driving Forces (cont’d)
  • The development of IPA’s (Independent Practitioner Associations) encouraged the uptake of information technology in primary care in New Zealand.
    • IPAs paid the costs for their member GPs to access the HealthLink network as part of their membership services.
  • HealthLink facilitated change by offering an “electronic claiming only” service for claims submission free of charge for the first 6 months.

Denis Protti - University of Victoria

driving forces cont d32
Driving Forces (cont’d)
  • The past decade has also seen the emergence of the new position of “Practice Manager” within a physician general practice.
  • The Practice Manager has become a pivotal person to assist with the installation, management and training for any physician office system.
  • The Practice Manager responsibilities include financial management, IT and the human resource function in larger practices.

Denis Protti - University of Victoria

healthlink increasingly used to assist with chronic disease management
HealthLink increasingly used to assist with chronic diseasemanagement

Denis Protti - University of Victoria

slide34
As a result of these applications of information technology in primary care:
    • Child immunization rates went from 75% to 95%.
    • Control of diabetes improved – for patients with HbA1c higher than 9 pre-enrolment was 34% and this was reduced to 7% post-enrolment
    • There was an 80% reduction in wait time for statins for diabetes patients.
    • There was a reduction in acute admissions - this was running at 9% per annum. By 2002, the growth rate was reduced to near 0%.

Denis Protti - University of Victoria

new zealand s critical success factors
New Zealand’s critical success factors
  • A national health identifier NHI
  • Early adoption of HL7
  • Development and acceptance of the 1993 Privacy Act and the 1994 Health Information Privacy Code along with “practical” implementation of these
  • Mandatory electronic claiming for GMS (government subsidies for GP care)
  • Collaboration with private and public organizations
  • Multi-vendor co-operation and understanding of the business opportunities

Denis Protti - University of Victoria

nz critical success factors cont d
NZ critical success factors (cont’d)
  • Healthlink’s strategy has always been to work very closely with primary care physicians
    • to stay close to them and to support them.
  • HealthLink is intricately and comprehensively tied to the GPs
    • “like the parmesan in the spaghetti is how one observer described it”.

Denis Protti - University of Victoria

an interesting aside
An interesting aside
  • At one stage the New Zealand Government spent several millions of dollars on an alternative product “The Health Intranet of New Zealand”.
  • This failed at the point where they tried to connect the Intranet to General Practice computer systems.
    • The GPs were very unhappy to let government representative agents touch their computers – making the Health Intranet impossible to implement on the ground.
    • The government agents had no understanding of how General Practice works

Denis Protti - University of Victoria

nz critical success factors cont d38
NZ critical success factors (cont’d)
  • HealthLink employs nurses to act in liaison roles with General Practice, and so provide direct contact with the GPs.
  • HealthLink provides a help desk that has become the GP’s first point of contact when requesting help with their EMRs - like the Danes.
  • HealthLink has also stayed very close to the GP system providers – again like the Danes.

Denis Protti - University of Victoria

nz critical success factors cont d39
NZ critical success factors (cont’d)
  • HealthLink spend a lot of effort on demonstrator and beta testing sites.
  • They also work closely with the physician EMR vendors to debate projects thoroughly at all stages – before during and after implementation.
  • Many of the HealthLink initiatives were a result of demand of the primary care physicians
    • e.g. discharge summary from hospitals, radiology test results (DI), orders (still in progress), delivery of claiming data – i.e. responding to market needs

Denis Protti - University of Victoria

the kiwi docs are getting ready for
The Kiwi docs are getting ready for

Denis Protti - University of Victoria

outline41
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT – Clinicians Involved?

Denis Protti - University of Victoria

but first

But first

Selected observations from the American literature

Denis Protti - University of Victoria

slide43
“Much research has been done in an attempt to identify the key factors that predict EPR/EHR implementation success. Over 150 factors have been identified, but only two, top management support and user involvement are consistently associated with successful implementations.”

Sittig D

The Importance of Leadership in the Clinical Information System Implementation Process

November 2001

http://www/informatics-review.com/thoughts/leadership

Denis Protti - University of Victoria

slide44
“Experience suggests several factors that may increase acceptance and use of clinical information systems by physicians. First, broad physician involvement in the selection and implementation of the system from the outset is essential. Systems with no real sponsorship from the medical staff are likely to fail.”

Anderson J

Increasing the Acceptance of Clinical Information Systems

MD Computing; Jan-Feb; 16(1): 62-5; 1999

Denis Protti - University of Victoria

slide45
“Clinician ‘buy-in’ will require that their involvement is substantial and real. The project team must have strong clinician representation from the outset and throughout the project, including the planning, implementation, and post-implementation phases. Clinicians need to believe that the decisions they make matter.”  

Krall M

Achieving Clinician Use and Acceptance of the Electronic Medical Record 1998

http://www.kaiserpermanente.org/medicine/permjournal/winter98pj/emr.html

Denis Protti - University of Victoria

slide46
“The need for physician involvement with clinical information systems has been advocated since the first installations in the 1960’s. Even though the initial systems were rather rudimentary, the systems that were backed by strong physician leadership have been able to evolve and develop into sophisticated tools as information technology has become integrated into all facets of clinical care.”

Schneider M et al

Physician Involvement in Clinical Systems—A Cost-Effective Investment

HIMSS Proceedings, Session 125

2000

Denis Protti - University of Victoria

slide47
Whether or not the CPR project leader is a physician, heavy involvement of physicians is common to all awardees, as members of both the CPR project staff and governing committees. Physicians with direct roles in the CPR efforts typically continue to devote at least some of their time to clinical practice, which appears to be important to retaining credibility with the medical staff.

Metzger JB et al

Lessons Learned from the Davies Program

2000

http://www.cpri-host.org/davies/nuggets.html

Denis Protti - University of Victoria

one particularly relevant american experience
One Particularly Relevant American Experience
  • Kaiser Permanente (KP) is a not-for-profit group model HMO (Health Maintenance Organization) with headquarters in Oakland, California.
  • The organization is divided into regional service areas spanning the United States from Hawaii to the East Coast.
  • It has used a centralized organizational model for their business and information technology operations since 1997.
  • Kaiser has eight million members and 80,000 care-givers across all regions (2/3 in California).

Denis Protti - University of Victoria

slide49
The Kaiser Permanente Colorado Region’s CIS implementation began with 2 medical office pilot sites (80 physicians and 80,000 members) in 1997 and was successfully completed (500 additional physicians and 250,000 additional members) between March and October, 1998.
  • The region has achieved full CIS usage and has eliminated use of its paper records for all but archival purposes.

Denis Protti - University of Victoria

kaiser s research findings
Kaiser’s research findings
  • 80 percent of the success of system implementations the size and complexity of KP-CIS is attributable to managing human factors.
  • Commitment from, and involvement of clinicians in the implementation of a project is of utmost importance.
    • Involvement is best achieved by soliciting active participation from both providers and staff from project initiation through project closure and beyond.
  • .

Denis Protti - University of Victoria

the kp approach
The KP approach
  • When Kaiser Permanente undertakes any project, the project leaders develop a series of Guiding Principles that provide direction during the entire project to the project team and to the larger KP community.
  • Once defined and accepted by executive management, these guiding principles are communicated throughout Kaiser Permanente.

Denis Protti - University of Victoria

the kaiser cis guiding principles
The Kaiser CIS guiding principles
  • The leadership and sponsors must be visible, available, and supportive throughout the project.
  • The rationale for implementing KP-CIS must be understood across the Program.
  • Implementation activities must focus on realistic timeframes that address system usability at the point of care. CIS must be based on acceptable clinical content.
  • Providers and staff must believe that CIS enhances their ability to achieve superior clinical outcomes and improve provider/patient relationships.
  • Providers and staff must be continuously involved in CIS planning, implementation, and maintenance.
  • Regions must take the lead in implementing CIS

Denis Protti - University of Victoria

kaiser guiding principles cont d
Kaiser guiding principles(cont’d)
  • Providers and staff must acquire the skills to effectively use CIS. Skills acquisition must accommodate individual learning styles.
  • Practicing providers and staff members must be engaged as members of the project team to ensure credibility with the staff, compatibility with the local culture and work flow, and clinical utility.
  • Honest, timely, regular, and pertinent communication to the user community is essential to adoption.
  • Providers and staff must be prepared to adapt to the changes that CIS will bring.
  • The appropriate technical and clinical support structures must be in place to ensure adoption and continued use of CIS.

Denis Protti - University of Victoria

lessons to be learned from kaiser
Lessons to be learned from Kaiser
  • Unwavering executive support during the CIS implementation was a major factor in its adoption by the user community.
    • Implementing a CPR produces extraordinary change in nearly every facet of operations. Success would be unlikely without executive commitment to support of these changes.

Denis Protti - University of Victoria

kaiser lessons cont d
Kaiser lessons (cont’d)
  • Identify and appoint physician-advocates throughout the organization.
    • Clinical workflow change is more successful when physician advocates communicate the rewards and benefits to the user community.
  • It is necessary to develop formal communications for physicians who are to use this new CPR to assist them in understanding how the system will impact their work.

Denis Protti - University of Victoria

kaiser lessons cont d56
Kaiser lessons (cont’d)
  • Plan for recurrent objection themes from clinicians.
    • A common provider objection is the perception that they must perform clerical tasks that take time away from patients.
  • Clinician order entry may seem to be more labor intensive for some primary care users than for specialists.
    • For example, internists may have more complex patients than pediatricians.

Denis Protti - University of Victoria

in closing from kaiser
In closing from Kaiser
  • Commitment from, and involvement of, end users (particularly the clinicians) in the implementation of a project was also of utmost importance. Involvement is best achieved by soliciting active participation from both providers and staff from project initiation through project closure and beyond

Wolfe J

Implementing a CPR to Serve Kaiser Permanente’s Eight Million Members

HIMSS Proceedings, session 85

2000

Denis Protti - University of Victoria

everything in life is relative
Everything in life is relative

Denis Protti - University of Victoria

outline59
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT – Clinicians Involved?

Denis Protti - University of Victoria

slide60
Crucially, all of the ERDIP projects have involved clinicians and had clinicians on the local project teams. "We would not have achieved all we have without the level of clinician involvement we've had."

Philip Crouch

ERDIP programme manager

http://www.nhsia.nhs.uk/text/pages/inform/informish6/informp5.asp

2003

Denis Protti - University of Victoria

slide61
“The Walsall ERDIP project was managed by a small team with the support of the NSF groups. This close involvement of clinicians was important and any national programme office will require people with operational experience. It is also necessary to avoid turning larger programmes into a project management industry.”

Walsall Core National Evaluation report

5/11/2002

Denis Protti - University of Victoria

key messages for icrs derived from the south staffordshire experience
Key messages for ICRS, derived from the South Staffordshire experience
  • The EHR is still in its early stages of evolution so that continued learning from formative and summative evaluation, co-ordinated across different communities and different suppliers, will be important.
    • Questions of who will be responsible for this and how it is linked to system supplier performance will need to be answered.

South Staffordshire Electronic Record

Development and Implementation Project:

Final Evaluation Report

July 2003

Denis Protti - University of Victoria

slide63
Dr John Pilling stresses not only the careful preparation necessary for such a scheme, but also the absolute need for clinician involvement throughout and constant liaison, through a committed project team, between all those involved. These are lessons that are of equal validity not just for this PACS project, but for every IT project in the healthcare field.

http://www.bjhc.co.uk/issues/v19-7/v19-7editorial.html

Denis Protti - University of Victoria

slide64
It is not the choice of device but involvement of clinicians that counts.
  • I could go on, but there is no, one solution that will fit all clinical scenarios. It is imperative that clinicians are involved in all these discussions and that we do not decide what types of mobile devices will work for them.

Sue Wilson

Head of IM&T (acute services)

Sherwood Forest Hospitals NHS Trust

http://www.e-health-media.com/news/item.cfm?ID=496

Aug 18, 2003

Denis Protti - University of Victoria

fear not we are making progress
Fear not, we are making progress

Denis Protti - University of Victoria

outline66
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT – Clinicians Involved?

Denis Protti - University of Victoria

npfit s official position
NPfIT’s official position
  • Patient, clinician and supplier engagement is critical to the ultimate success of our solution. We:
    • are meeting regularly with SHA chief executives and four lead CEOs
    • are integrating the work of the 28 CIOs with NPfIT
    • have a consensus from the Medical Royal Colleges on a core patient summary or data spine
    • have consulted with over 240 clinicians and NHS IT professionals in producing the initial OBS
    • have now got a core group of clinical representatives working in the Design Authority
  • We recognise that two way communication and involvement is vital.

Denis Protti - University of Victoria

slide68
Professor Martin Severs from the University of Portsmouth has joined the National Programme as Director of Clinical Assurance – he will take the lead on developing and ensuring clinician involvement in the National Programme.
  • Professor Severs told the conference that in his first three weeks in post he had already reviewed levels of clinician involvement:
    • “I found there extensive levels of involvement of clinicians at all levels of the programme.” He admitted that this finding had “quite surprised” him.

E-Health Insider

National Programme 'Mobilises' for Delivery

27 Mar 2003

Denis Protti - University of Victoria

slide69
“The National Programme stresses that clinicians and other NHS staff have been consulted on specifications and requirements from the outset. Most of the input into the OBS for ICRS has come from clinicians working full time in the NHS, stated Mr. Granger.”
  • “Professor Peter Hutton, head of clinical engagement with the national programme, added: In two to three weeks there will be an announcement on a route in for almost everyone in the NHS to be involved. From that point on we will be taking a lot more note of individual user requirements.”

Granger Confirms Centre to Allocate LSP Contracts

E-Health Insider

August 14, 2003

Denis Protti - University of Victoria

but there are other views
But … there are other views
  • A particular concern is limited engagement with clinicians so far.
    • “Lack of clinician involvement has been a consistent theme in past failures.”
    • “There is a culture here that means you just can’t force solutions on clinicians, they have to be cajoled and persuaded.”

E-Health Insider

April 2003

Denis Protti - University of Victoria

slide71
“Despite some early discussions, many general practitioners and consultants have not heard of the integrated care record service or the information spine.

Nick Booth

Sharing patient information electronically throughout the NHS

BMJ, 327:114-115, 19 July 2003

Denis Protti - University of Victoria

slide72
“News of the National Audit Office’s involvement in reviewing the national programme was first reported in Computer Weekly this week, in a report which stated that the NAO would examine arrangements for managing high-level risks on the NPfIT and arrangements for gaining the local commitment of clinicians.”

E-Health Insider

August 22, 2003

Denis Protti - University of Victoria

slide73
Over many years, NHS informatics developments have suffered from being under-utilised by their potential users…. The position of informatics should be stressed to empower decision makers to take steps to harness its capability, notably through ensuring that clinical involvement in informatics is enhanced and integral to day to day working, without which few health informatics systems will perform up to their promise.”

BCS Health Informatics Committee & ASSIST

More Radical Steps (2003) Initiatives

August 2003

Denis Protti - University of Victoria

questions to be discussed74
Questions to be discussed
  • Is it important to solicit meaningful physician input early and often and act upon it?
  • Does finding meaningful ways to engage physicians require creating an organizational climate and culture that respects the heart of medicine?
    • Is this the key to maintaining physician loyalty and involvement?

Denis Protti - University of Victoria

slide75
Some management teams believe that ideas should be well fleshed out and ready for implementation before discussing them with physicians.
    • When that occurs, do physicians feel their input is actually sought?
    • And if they recommend changes at that point, will it be difficult for management to retreat and follow another course of action?

Denis Protti - University of Victoria

slide76
How can one best square the need for centralised/standardised policy with getting local support and use?
  • Does the opinion of national clinical bodies matter?

Denis Protti - University of Victoria

let the discussions begin
Let the discussions begin

Denis Protti - University of Victoria

icrs roll out
ICRS roll out
  • Phase 1 by end 2004
  • Phase 2 by end 2006
  • Phase 3 by end 2008

Denis Protti - University of Victoria

icrs phase 1 2004
ICRS phase 1 - 2004
  • Booking of outpatient appointments online
  • NHS email and access to online knowledge
  • Electronic laboratory and radiology results
  • Some clinical communications e.g. GP referral letters

Providing simple functionality and making best use of existing systems

Denis Protti - University of Victoria

icrs phase 2 2006
ICRS phase 2 - 2006
  • Access to a more detailed patient record including:
    • specialist results
    • GP prescribing record
    • hospital discharge summaries
  • Digital imaging
  • Computerised referrals and requests

Migrating on to active and interactive functionality

Denis Protti - University of Victoria

icrs phase 3 2008
ICRS phase 3 - 2008
  • Working towards full integration of health and social services including:
    • decision support software
    • screening
    • community wide prescribing
    • computer support for care planning
  • Supporting advanced features e.g. telemedicine

Continuing development and enhancements

Denis Protti - University of Victoria

key milestones
Key milestones
  • Summer 2003
    • Final Output Based Specification to be completed for ICRS
    • Short-list of LSP applicants to be finalised
  • October 2003
    • Initial contracts to be awarded for two LSPs (London and North East England)
    • Contract to be awarded for e-booking service provider
  • November 2003
    • Early implementation work commences
  • December 2003
    • Further three contracts to be awarded for remaining LSPs
  • April 2004
    • National roll out of Phase 1 of ICRS begins in earnest

Denis Protti - University of Victoria