Informing healthcare A clinicians perspective

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Informing healthcareA clinicians perspective

• John Williams
• Consultant Gastroenterologist
• 28 November 2002

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(No Transcript)
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What information do I need about a patient?

• As much as possible about his or her
• problems
• story
• concerns
• preferences
• past history
• social background
• medication
• progress, including treatment by other
  practitioners.

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• all in an 8 to 20 minute consultation, during
  which I also need to examine the patient, explain
  the diagnosis, formulate and discuss a management
  plan and arrange the next steps

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• I also need immediate access to information when
  I get a phone call, letter or test result, or a
  flash of inspiration about a difficult case -

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• I also need immediate access to information when
  I get a phone call, letter or test result, or a
  flash of inspiration about a difficult case -
• and so does the nurse practitioner who works with
  me

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• I also need immediate access to information when
  I get a phone call, letter or test result, or a
  flash of inspiration about a difficult case -
• and so does the nurse practitioner who works with
  me
• We also need to be able to look up guidelines,
  protocols or research reviews at short notice

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..I also want to know about the service I
provide.

• What are my waiting times?
• What are my outcomes?
• How well are my patients doing - from my
  perspective?
• How well are my patients doing from their
  perspective?
• What cases are my trainees seeing, and with what
  result?
• What changes do I need to make in the service?
• What will be the impact of these changes?

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..and the service provided by others

• What services are available?
• What are the interests and expertise of the
  provider?
• How well does the service perform?
• What are the waiting times?
• What is the procedure for referral?
• What should I tell the patient?
• How do I seek advice without referral?

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The patient also has needs..to

• Book a timely convenient appointment
• Seek information and advice over the phone
• Know what to expect when seen
• Have confidence in the service and the
  practitioner
• Know that their beliefs and concerns are
  understood
• Avoid unnecessary repetition of information
• Look up and have confidence in further
  information about their diagnosis or procedure

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What about communication..

• Within teams
• Between teams
• Between professional groups
• Between sectors

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Communication within teams

• Mainly through the record - its primary purpose
• But also often verbal, ad hoc, poorly recorded
  (eg white boards and post-it notes in primary
  care lost patients in secondary care)
• Structured communications are better
  (Multidisciplinary teams make better decisions if
  proformas are used)
• Agreement on diagnoses and procedures is crucial
  for valid coding and accurate central returns

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Audit of records and communication
During a recent RCP pilot of an audit template,
the records of 149 acute medical admissions in 5
hospitals were evaluated.
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• Discharge Summary
• Of 87 printed discharge summaries present in the
  notes, omissions included
• 17 - diagnosis
• 19 - procedure

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Communication between teams

• Often unstructured, in person or by telephone or
  by email
• eg handover between SHOs (shift working)
  consultant to consultant discussion
• Not documented, ad hoc
• may be dangerous - clinical disasters often last
  mistake in long line of minor failures in
  communication
• Events are not recorded as a sequential patient
  focused record - some disciplines even still keep
  their own notes

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Interprofessional communication

• No common structure
• Often different language
• No common headings
• Inefficient
• Changing roles (eg nurse practitioners) increase
  the importance

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Whats inside the folder? A case note study...

• Based on the notes of Eiffion Jones, one time
  patient of Neath General Hospital

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A plethora of forms

• 47, all different
• Many loose not in date order
• No integration of perspectives
• All need demographic details
• 26 ask for clinical information
• 9 request a diagnosis

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Request forms

• Consultant opinion
• Physiotherapy treatment
• Removal of sutures
• Follow-up appointment
• Appliance request
• Occupational therapy
• Self injury referral
• Referral to social worker

• Request for radiology
• Microbiology
• Histology/cytology
• Chemical pathology
• Special test
• Blood transfusion
• Haematology
• Special diet
• Drugs to take home

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Intersector communication

• Built in delay
• Sender doesnt send what recipient needs
• No common standards
• Poorly integrated into records -
• re-entry/duplication/cutting up of letters
• Usually absent unless related to secondary care
  episode
• Guidelines little used

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Forms for the transfer of care

• GP referral letter
• HMR 2D (W) Discharge summary
• Transfer of care form A
• Transfer of care form B - check list
• Formal discharge summary
• Physiotherapy report
• Outpatient letter

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• Discharge Summary
• Of 87 printed discharge summaries present in the
  notes, omissions included
• 17 - diagnosis
• 19 - procedure
• 21 - follow-up arrangements
• 75 - information given to patient

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Impact

• Poor quality of care
• Unhappy professionals and patients
• Risks to patient care and safety
• Duplication of effort and resources
• Invalid central returns

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How will the new strategy help?

• One record for each patient - data entered once -
  structured and coded when appropriate, using
  various short-cut mechanisms
• Use these data, recorded for the primary purpose
  of individual patient care, to generate secondary
  data for aggregation
• Clinicians from all professions supported in
  their day to day work by automation of processes

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Electronic records

• Structured core
• free text
• coded clinical data capture
• (presenting complaints, family, social past
  history, symptoms, signs, diagnosis, procedures
  as appropriate)
• multi-item questionnaires scores
• longitudinal individual records
• structured clinical messaging
• data for analysis (for activity, audit,
  performance monitoring, training, research
  planning)

• Automated processes
• scheduling and booking
• test ordering
• results reporting
• prescribing
• communications (summaries, letters, referrals,
  etc)
• reminders alerts
• access to knowledge (guidelines, protocols,
  evidence, advice, information)
• telecommunication
• e-working

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One patient - one record

• Timely, up to date, comprehensive, patient
  focused information
• Many communications will become redundant - ?
  only necessary when an action by another
  professional is indicated
• Reminders, alerts and other decision support will
  enhance patient safety
• Will support new models of service delivery -
  clinical networks, telephone consultation,
  patient self-management etc

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How will the new strategy help?

• Data entered once through the patient record -
  where appropriate structured and coded, using
  various short-cut mechanisms
• Data validated by clinicians as part of clinical
  processes, especially communications
• Clinical coders in expert QA and support role

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The core of the electronic record

• Structured record with free text
• Automatically coded for common conditions
• Clinicians term coded term shown to enable
  validation
• Completed for all patient - professional
  contacts
• All professionals can be identified

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There are many issues to be addressed if this is
to be achieved, including..

• Education and training
• Professional consensus
• Culture change
• Standards - clinical and technical
• Patient involvement
• Confidentiality and security
• Agreement on mandatory data fields
• Improvements in data validity

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There will be opportunities for research..

• Randomised controlled trials using routinely
  collected data, including patient focused
  outcomes
• Epidemiological studies linked to lifestyle and
  social data (eg Biobank Millenium cohort)
• The information strategy is cross-referenced to
  the RD strategy

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Summary

• An exciting strategy
• Potentially huge benefits
• Many hurdles, but
• Achievable and worth the pain