On the heels of a report that is expected to redefine primary care delivery across England, three providers of clinical information systems reported that they will join up to integrate their products, anticipating adoption of the recommendations by the National Health System (NHS).

EMIS (Leeds) and INPS (London), the market leaders for general practice software, along with Adastra Software (Ashford), a specialist in systems for connecting primary and secondary care systems for urgent care clinics, said they will jointly develop a system to support a proposed model for GP-led equitable access centers (GPEACs) outlined in the recently completed "Next Stage Review" led by Under Secretary of State Lord Darzi for the NHS.

A colorectal surgeon, Ara Darzi is a consultant at St. Mary's Hospital and Royal Marsden NHS Trust who in 2002 was awarded knighthood for his services to medicine and surgery.

After a series of reports covering each of the eight regions covered by England's Strategic Health Authorities, Darzi in his summary delivered June 30 to the prime minister, chancellor of the exchequer, and secretary of state for health sets out how the NHS can respond to the challenges of the next 10 years.

Those challenges include meeting the rising expectations that are driven by demographics, continuing development of an information society, advances in treatments, and the changing nature of disease.

Among the recommended measures is a focus on accelerating changes "that frontline staff want to make to meet those challenges, [while] continuing to raise standards."

A key assumption, "which remains largely aspirational at present," according to the British Medical Association, is access for NHS staff to information about care, including a new NHS Evidence Service where staff can view through a single web-based portal authoritative clinical and non-clinical evidence and best practice.

Development and configuration of next-generation health informatics already is under way, according to the three collaborating companies, who aim to offer a conjoined system "well before the April 2009 deadline for many GP access centers to go live."

EMIS and Adastra announced a joint project in April to deliver instant access to summaries of patient primary care records for after-hours urgent care clinicians.

The initial pilot was launched for the Gateshead Primary Care Trust, near Newcastle upon Tyne.

The two companies also were cooperating on a project for the Liverpool Primary Care Trust to link link primary and secondary care delivery informatics.

Adastra systems are used in 95% of unscheduled care hubs in the NHS system and the Republic of Ireland, while EMIS systems support more than 56% of GP surgeries.

The third partner, INPS, is part of the CEGEDIM Group (Paris), and provides clinical management systems as well as Vision software, which is compliant with the NHS' Connecting for Health programs Choose & Book, Electronic Prescription Service and GP2GP.

The companies said the new product will build on the components and data of the three existing systems, assuring full interoperability before adding additional functionality to meet next-generation requirements.

The reforms and recommendations in the report anticipate a new model for care delivery that recognizes demands driven by demographic shifts, primarily the rapid aging of the population.

The British Medical Association (BMA; London) devoted considerable discussion in its response to the London proposals released in September 2007 to significant shifts in how primary care will be organized and funded by the NHS in the future, especially the call for polyclinics and a heavy emphasis on community-based care.

Telemedicine, which is dependent on health informatic systems for following a patient through the care system and for follow-on care, drew the wrath of the BMA, which said flatly, "We believe that the introduction of telemedicine for intensive care would have a detrimental effect on outcomes, given that critical care is a 'hands-on' skill and requires a multidisciplinary team approach, both of which telemedicine would not be able to provide.

Another concern of the BMA being addressed by the collaboration among the health IT providers is "the widespread introduction of urgent care centers, accessible by patients both in-hours and out-of-hours, which has the potential to sideline GP practices from the delivery of urgent care.

Using the patient history and medical records held at GPs and primary care team-level help to avoid inappropriate hospital admissions, said the BMA, brings the coordination of patient care that will lead to the best possible health outcomes.

The BMA concludes that Darzi's proposals require "significant advances in information technology and an increased use of electronic data in order to allow continuity of care between providers."

NHS valued, but challenges await

Sixty years from its inauguration, the UK's National Health System (NHS), funded through general taxation, is "still the fairest and most cost-effective health system in the world," said Niall Dickson, chief executive of The King's Fund (London), commenting on the 60th anniversary of NHS. "It removes fear and creates what is in effect a huge compulsory insurance scheme that is valued by patients, staff and the public.

According to Dickson, the last six decades have seen "remarkable advancements" in medical technology, new drugs and faster treatments. "Anyone around at the inception of the NHS would no doubt be hugely impressed by the transplant surgery and chemotherapy that patients now routinely benefit from, or how the NHS has combated AIDS or improved the way we care for people with mental illness. In that time the NHS has changed from a 400 million business (roughly 11.5 billion in today's prices) compared with the 107 billion it costs today."

"But this is not to say that the NHS should be immune from change — major challenges lie ahead that will largely determine whether the NHS, funded through general taxation and available to all free at the point of need, will survive. Coping and caring for an ageing population, many of whom will have dementia; combating the rising tide of obesity and other lifestyle conditions; and keeping pace with new drugs and medical technologies will make fresh demands on our finite resources. The other major challenge is to make the NHS significantly more responsive to patients.

Dickson said it would be crucial to reform the NHS from a state-run monopoly business to a commissioner of comprehensive health care, free at the point of need, where NHS care can be provided by public, private or voluntary sector organizations.

"Doing this and addressing public concern that the NHS remains fair and equal will go a long way to safeguarding its future for another 60 years," Dickson said.

The King's Fund is an independent charitable foundation working for better health, especially in London. It carries out research, policy analysis and development activities, working on its own, in partnerships, and through funding.

Diabetes linked with amputations

A hundred people a week in the UK have a lower limb amputated as a result of diabetes, warns Diabetes UK. The health charity says to reduce this figure there is an urgent need for greater awareness of the impact of the condition, which as well as lower limb amputation can lead to other devastating complications such as heart attacks, stroke, blindness and kidney failure.

Amputation is a complication of diabetes caused by damage to the nerves and blood vessels that serve the limbs. Alarmingly, up to 70% of people die within five years of having an amputation as a result of diabetes. Currently more than half of the general public do not associate diabetes with amputations and worryingly one in three people with diabetes do not realize that having the condition puts them more at risk of having an amputation, the organization noted.

"This situation is shocking given that most amputations can be prevented with better awareness and management of the condition. People with diabetes need to have optimum support, guidance and clinical care to help minimize the risks of amputation," said Douglas Smallwood, chief executive of Diabetes UK.

"We want to see all people with diabetes have better access to podiatrists and to a regular foot check as part of their annual medical review. People with diabetes who are assessed as being at risk of foot problems need to have access to high quality integrated specialist foot care services to save the foot and reduce the likelihood of amputation."

According to Smallwood, there are 2.3 million people already diagnosed with diabetes in the UK and over 500,000 people who have the condition but are not aware of it. In the UK, 5,000 people with diabetes have an amputation every year. Diabetes is the second most common cause of lower limb amputation in the UK after trauma. People with diabetes are 15 times more at risk of lower limb amputation than people without the condition, he noted.

The organization also says that people at high risk for amputations are those who have a previous history of ulcers, neuropathy or nerve damage, circulation problems, foot deformities and those who cannot self-care. Foot ulcers can be treated successfully, especially in the early stages, Diabetes UK said. If they are left untreated though, the risks of infection are high and in extreme cases this could lead to gangrene and even amputation. More than 10% of foot ulcers result in amputation, the organization said.

Diabetes UK is working with the Foot in Diabetes UK Group and the Joint British Diabetes Societies Inpatient Care Working Group to produce guidance for the proper management of acute onset, or deteriorating, disease of the diabetic foot. The guidance is expected to be available later this year.

U.S., Vietnam agree on food, drug safety

The U.S. and Vietnam have signed a memorandum of understanding (MOU) to enhance the safety of food, feed, drugs and medical devices traded between the two nations.

The plan is the product of discussions between U.S. Secretary of Health and Human Services (HHS) Mike Leavitt and senior Vietnamese officials in Hanoi just two months ago and it exemplifies the new import-safety strategy adopted by the U.S. government last November. Historically, U.S. authorities have primarily relied on intervention at the border to intercept unsafe goods. The new strategy, crafted by a cabinet-level interagency working group on import safety chaired by Leavitt, calls for actively working with trading partners to help ensure they build quality into every step of a product's life cycle.

"Trade between our two nations has grown exponentially in recent years and our societies are better off as a result — and our cooperation in health is stronger than ever," said HHS Deputy Secretary Tevi Troy, in signing the memorandum. "With this agreement, we're increasing our joint efforts to ensure the safety of goods our citizens consume on a daily basis. This is an important step forward for the health of the American and Vietnamese people."

The memorandum calls for cooperation in the following areas:

• Information-sharing — the U.S. and Viet Nam governments will exchange information on their respective regulatory systems, such as details on laws and regulations; guidance documents; lists of drugs approved by FDA for use in aquaculture; training opportunities on key topics, such as safety surveillance of products after marketing; and timely information on potential or emerging issues of product safety (food-borne illnesses, food contamination, etc.).

• Workshops and training — the two countries hope to conduct or participate in workshops or other training that concerns food, animal feed, and medical products, including those offered by international organizations. The two sides will also make efforts to find opportunities for joint training for food-borne illnesses and the oversight of food traded internationally.

• Best practices in clinical trials — HHS/FDA and its counterpart agencies intend to cooperate on training and inspections of clinical trials for the development of medical products.

• Seafood safety — In cooperation with Vietnamese authorities, the U.S. will undertake a detailed review of safety issues regarding fish and fishery products exported from Vietnam to the U.S.

The memorandum takes effect immediately, has an initial life of three years, and is subject to revision and renewal, contingent upon the approval of both nations.

Since signing of the United States-Vietnam Bilateral Trade Agreement in 2001, commerce between the two nations has increased eight-fold, fueled, in part, by the agriculture and aquaculture sectors. Two-way trade exceeded $12.5 billion in 2007, according to the Foreign-Trade Division of the U.S. Census Bureau.

New cancer treatments eyed

Scientists of the Division of Theoretical Bioinformatics at the German Cancer Research Center (Deutsches Krebsforschungszentrum DKFZ; Heidelberg) have simulated on a computer how cells decide whether or not to migrate. Using their results, the researchers were able to predict the molecular targets within a cell that have to be hit so that its behavior changes in a particular direction. This method may help to develop new treatments against cancer metastasis. The scientists have published their results in the latest issue of Molecular Systems Biology.

One hundred and thirty years ago, Paul Ehrlich, pioneer of chemotherapy, speculated that when a cell gets sick, this is caused by a molecular change that has taken place inside the cell. Ehrlich surmised that if one could specifically hit this place of change, the "molecular target," then the disease could be cured.

When it comes to cancer, this concept has only limited applicability, because tumor cells are altered in many places, the DKFZ said. For cancer treatment to be successful, it needs to hit several molecular targets — and in a specific order, too. However, with the number of targets growing, the number of possible combinations of hits increases exponentially. If one aims to influence the genetic activity of a cell, there are several thousand targets to choose from. In this case it is impossible to test all possible combinations experimentally in order to find an efficient therapy. In this area, biologists and medical researchers are seeking help from mathematicians or physicists. They provide computer models that simulate a cell's behavior and, thus, make "testing" possible at all. This new research field is called systems biology.

In an interdisciplinary collaboration, research groups at DKFZ have now succeeded in elucidating the process underlying a cell's decision about how it is going to behave. Scientists in the teams of biologist Dr. Axel Szabowski, physicist Dr. Hauke Busch and mathematician Professor Roland Eils have investigated what makes human skin cells migrate into a wound to make it heal. They showed that the cells take several steps to decide to "start moving," how fast to do so, where to go and when to stop again. For the process to start, various external signals have to be received in a particular order. The scientists subsequently simulated this process on the computer. In doing so, they succeeded in predicting the molecular targets by which a cell's behavior can be changed in a particular direction, the DKFZ said.

According to the DKFZ, metastasizing cancer cells, too, migrate through the body — though in their case, it is undesired. They decide to migrate even when normal cells would not move. Using the new simulation method developed by the DKFZ researchers, it is possible to simulate how the genes involved in this process interact and, thus, find out the molecular targets and the order in which they need to be hit so that tumor cells stop migrating.