New openEHR technology and clinical collaboration in vital steps toward improved patient care and true interoperability: Scotland’s first digital ReSPECT emergency care plan

Abstract

Objective

To deploy a digital application of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) across health boards (HBs).

Methods

Clinicians, patients and other regional stakeholders collaborated with the Scottish National Technology Service (NTS) defining requirements. Development was agile with user feedback.

Results

The ReSPECT web application developed on Scotland’s National Digital Platform used an openEHR Clinical Data Repository. Plans can be viewed and edited across settings. Deployed in 2020, by July 2025, 8 of 14 HBs were onboarded and >5500 patients had digital ReSPECT plans.

Discussion

openEHR structures clinical data in a modular way, enabling other applications to use the same data layer. Close collaboration between technicians and users fulfilled the application’s requirements and solved problems together.

Conclusions

Collaboration on the digital ReSPECT accelerated deployment, enabling more people’s wishes and clinical recommendations to be captured and shared across care settings and transitions. openEHR technology enables new data uses.

Background

Clinical drivers

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process facilitates discussions regarding realistic emergency treatment options, including cardiopulmonary resuscitation (CPR) in the event of future deterioration.^{1 2} The process was developed by a group of >40 professional and patient organisations from evidence supporting the benefits of contextualising CPR decision-making within wider future care planning.³ The ReSPECT plan includes medical information, mental capacity, legal welfare attorney, next of kin and recommendations based on patient wishes regarding realistic emergency care.³

ReSPECT plans have been implemented successfully in sites in England.⁴

National Health Service (NHS) Forth Valley (FV) piloted a paper plan and found that the absence of a digital version was a barrier to uptake and safety.

Policy and technical drivers

Scottish Government’s Digital Health and Care Strategy adopts a ‘Digital Platform’ approach, encouraging open data standards to improve interoperability and avoid vendor lock-in.⁵ The availability of modular openEHR technology to build the digital ReSPECT plan should allow flexibility, as structured data from the data layer can be used by other applications.¹

Objectives

1. To increase the use of the ReSPECT process by developing a digital application improving efficiency, safety and user experience.

2. To integrate with digital record systems including: in hospitals, primary care, hospice and out-of-hours and the Scottish Ambulance Service (SAS).

Ethics

No ethics approval was required. A Scotland-wide Data Privacy Impact Assessment was shared with health boards’ (HBs) governance teams during onboarding. Patients agreed to the secure digital storage and processing of their data in line with UK data protection law.

Methods

Clinical

FV collaborated with National Technology Service (NTS) to develop and test a digital ReSPECT application, initially in the acute setting. A stakeholder group with a key role for patients (also including clinicians, technicians and governance professions) refined requirements

Technical

The ReSPECT openEHR template was developed using web-based tooling in collaboration with clinical experts.⁶ An external company developed the first application. However, this iteration could not support more than one user concurrently, and so was insufficiently mature. Thus, development was moved internally to NTS. NTS improved the application using iterative agile methodology, within the Scottish National Digital Platform, using platform components including the EHRbase implementation of openEHR, Azure Active Directory for authentication and identity management and an Enterprise Master Patient Index using NHS Scotland’s Community Health Index Service. Openly specified application programme interfaces (APIs) were authored to standardise integrations (eg, with FV’s Clinical Portal.)

Pilot in Forth Valley

Clinical users were trained and the first digital plan was created in March 2021 with ongoing feedback.

Roll-out to other HBs

The ‘ReSPECT Collaborative’ enables stakeholders from across Scotland to share best practice in deploying the clinical ReSPECT process and using the application. The collaboration between clinicians, patient organisations, eHealth teams and NTS was essential for successful deployment.

Results

By July 2025, >5500 digital ReSPECT plans had been completed. In FV and Tayside HBs, any setting with access to the clinical portal can view ReSPECT plans. Direct access to the application is available for authenticated users. Following the ReSPECT plan publication, an automated integration with the document management system (DMS) provides a copy to general practices (GP). GP unscheduled care can view ReSPECT via the emergency care summary⁷ (ECS), where the individual’s practice has copied this. Advisors in SAS can view ReSPECT via integration with the web service for ECS.⁷ The ReSPECT web application can save a versioned plan as a PDF, enabling printing and wider sharing. Tayside, the Western Isles and Dumfries and Galloway HBs were onboarded in Winter 2022. Four further HBs had access to the ReSPECT application by September 2024 (figure 1). Digital access to ReSPECT plans means that more complete, easily structured, patient-centred information is available all in one place to SAS and GP unscheduled care, when patients face a health crisis.

Figure 1.

Increasing digital ReSPECT plans. ReSPECT, Recommended Summary Plan for Emergency Care and Treatment.

Discussion

This implementation compared with wider literature

An openEHR platform with a clinical data repository (CDR) is attractive for interoperability and data sharing because it separates the clinical data from the application and persistence layers. Thus, in an openEHR-based architecture, applications (eg, electronic health records from different vendors) can use APIs to operate on data from the CDR and present it according to the preferred user interface. Such an ‘Open Platform’ was envisioned by the Apperta Foundation.⁸

A survey of openEHR Clinical Data Repositories found 17 implementations worldwide.⁹ UK implementations include the London ‘Universal Care Plan’.¹⁰

Clinical strengths of the ReSPECT application

The application provides access, legibility and safety benefits by making it easy for users to view and use the ReSPECT plans in various settings. A patient identification banner in all views, limited mandatory data and a summary give users an overview in busy environments. Versioning functions support updating, clinical governance requirements and enable flexible workflows. Access and data audit improve security and medicolegal traceability. Integrations encourage use by enhancing visibility and application access. The plan can also be published as a PDF and printed to give to patients. Thus, the application improves communication of value-based shared decision-making in an emergency situation, especially when the care setting or clinical team is changing. We anticipate that further work will capture qualitative and quantitative benefits to patients.

Technological strengths

The National Digital Platform architecture uses common service components with an openEHR CDR for records storage, providing flexibility for the future. The clinical data is structured using openEHR, allowing it to persist with precise semantics across new use cases and applications. New concepts could be represented in other openEHR templates and deployed using the same framework as this already conforms to end-user requirements.

Strengths of the partnership approach to roll-out

This facilitated information-sharing between experienced and novice teams, aiding problem-solving and improving the application.

Limitations

Adding ReSPECT data to the ECS requires a manual step which may be time-consuming for staff. Data integration challenges affecting general practice have been partially mitigated using the DMS. Authentication methods from social care have blocked care home access. Currently, patients are unable to directly access/update digital ReSPECT.

There was considerable disruption to progress from the COVID-19 pandemic.

Implications for policy

ReSPECT plans include documentation of ‘CPR recommendations’. In Scotland, the policy is to document when a recommendation not to attempt CPR is made on a paper ‘red form’ designed for this purpose. The policy remains to complete a red form (in addition to the ReSPECT plan) when a recommendation not to attempt CPR is made. The policy landscape in Scotland has shifted from funding the wider roll-out of digital ReSPECT to a broader anticipatory care approach called ‘Future Care Planning’: our approach has laid the foundations for future care planning applications. The use of openEHR technology, which can pull and reuse structured data in a new user interface as required, as well as our multistakeholder approach, is recommended for the success of future initiatives.

Conclusions

This innovative collaboration between NTS and regional HBs to develop the ReSPECT application has expanded digital capability for emergency care situations. Close clinical involvement from the beginning has ensured it meets users’ requirements and keeps patients’ needs at the centre. The openEHR specifications for Scotland’s National Digital Platform CDR potentially allow data reuse by other clinical and/or patient-facing future care planning applications.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.