RCGP

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RCGP

• Patient records fit for modern health care
• CONFERENCE ON THE DATA ACCREDITATION STANDARD FOR
  THE IMT DES, The Brewery, Chiswell Street,
  London
• Professor Mayur Lakhani FRCGP
• Chairman of UK Council

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My presentation

• Patient records fit for modern health care
• The case for high quality electronic patient
  records in the context of modern health care
  what is it like to a patient and a health care
  professional?
• The case for standard setting and accreditation
• Take home messages both for clinicians and the
  PCTs teams

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About the RCGP

• Set standards for the quality of care
• provided by GPs
• Provided by teams in a practice practice
  quality awards
• Education and training of GPs
• The MRCGP Examination
• Voice of general practice when it comes to
  quality and standards
• Involvement of patients in decision making and
  assessments
• Strong health informatics function

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Celebrate the Quality of Electronic Patient
Records in Primary Care

• Recognise the achievement of the QOF and the part
  that ICT played in this (Practice systems and
  QMAS)
• Great strides have been made in developing the
  electronic record in family medicine in the UK
• Celebrate this! we have come a long way

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What causes medical errors?
Hellebek, Ejdrup
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IMT DES Welcome it! good news for patients

• It is about Better Patient Care
• it is not about the technology!
• Good records are an integral part of healthcare -
  they are not an add on
• Supporting local health economies
• Through education, training and support of
  Primary Care Health Team

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Modern Health Care
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Delayed diagnosis of cellulitis, complications
penicillin allergy

• A lady of 48 with an undiagnosed severe mental
  health problem missed an appointment at the GP
  practice. 2 appointments missed in one day
  access, mental health problem.
• She attended a W.I.C. one week later and a
  diagnosis was made of cellulitis and a
  prescription for flucloxacillin was made under a
  PGD.
• The next day a florid rash developed the
  patient was known to be allergic to penicillin
  but did not state it at the time allergy
  well-documented in GP records but not at WIC

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Delayed diagnosis of cellulitis, complications
penicillin allergy

• Own GP changed abs to erythromycin but patient
  could not afford prescription and re-presented at
  the W.I.C but she did not wait to be seen.
• Subsequently patient was briefly admitted to
  hospital with cellulitis and fever (no letter
  received.
• GP contacted W.I.C. to give background
  information and summary as likely to be frequent
  presenter at W.I.C. Information about allergy
  shared

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Interfaces in Health Care

• GP practice
• Nurse triage
• Out of Hours Co-op
• Walk in centres
• A and E
• NHS Direct

• Alternative primary care providers
• GPwSI
• PwSI
• Intermediate Care
• Hospital Care

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Modern Health Care

• Practices do not work in isolation part of a
  complex network of health care providers and
  virtual teams

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Wanless Report (2002)

• national, integrated ICT systems across the
  health service can lay the basis for the delivery
  of significant quality improvements and cost
  savings over the next 20 years.
• Without a major advance in the effective use of
  ICT (and this is a clear risk given the scale of
  such an undertaking), the health service will
  find it increasingly difficult to deliver the
  efficient, high quality service which the public
  will demand.
• This is a major priority which will have a
  crucial impact on the health service over future
  years.

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Values -Informational continuity is essential

• Patients do not like repeating stories
• Patients do suffer disruption of care across
  interfaces
• Fragmentation of Care hand offs

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Results out of hours and delay in managing
complications

• High INR (gt10)
• Abnormal FBC (myeloproliferation)
• High potassium level
• Anaemia
• Methotrexate level
• Systems to deal with results OOH
• Communication arrangements

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Good electronic patient records in primary care
are essential for

• good clinical decision making and to continue the
  care of a patient
• for medico-legal protection
• To meet contractual and payment mechanisms (QOF)
• To allows teams to deliver care
• To co-ordinate and integrate care across the
  patient journey
• Follow up, audit and research, teaching and
  training
• Public health Understanding the health needs of
  the population
• Supporting Commissioning (models of care)

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The case for standards and accreditation
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The crunch questions

• How good are electronic patient records in
  primary care?
• How can we make them even better?
• How would we make this judgement?
• How can we support improvement?

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Some current problems with electronic patient
records

• Inaccuracy of summaries patient safety issues
  e.g. MI
• Problem list management (the summary list
  containing ear wax or URTI)
• Variation in morbidity recording -
  distinctiveness of diagnosis and inconsistent
  codes
• Not all relevant data being captured
• Reams of stuff when patient sent into hospital
  
• The problem of dual records! (manual and
  electronic)

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Acting on Letters

• A practice received a letter from an optometrist
  recommending referral of patient with raised IOP
• The GP expected the patient to attend
• No referral was made
• Delayed referral for Glaucoma
• Need good systems for dealing with correspondence
  and capturing important events/action on the
  electronic patient record

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Skill mix and different ways of working
recording all contacts
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Coding of data Has the patient had an ovary
removed?

• Omentectomy versus oophorectomy
• I can only presume that the midwife who entered
  the details onto the computer has read
  omentectomy from the operation note and has
  erroneously entered this as oophorectomy.

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Abbreviations - A Case of Mistaken Identity
Extract from a letter

• Mr .was by mistake given an appointment for my
  outpatient clinic today. This resulted from the
  similarities between initials of two consultants
• Urology versus Gastroenterology!

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Studies from Keele University

• Quality of recording varies between morbidities
• High quality coding can be achieved
• A program of assessments, feedback, and training
  appears to improve data quality in a range of
  practices.
• Needs a trained support team to implement

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Standards for electronic health records

• Education and training issues what training do
  doctors get in this area and what is performance
  like?
• Clear need for standards and accreditation
• Working with patients and users
• Clinical engagement is crucial

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Take home messages
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Message for clinicians

• Leadership and commitment
• Shared responsibility
• ICT can support clinicians improve the quality
  and safety of care
• Part of CPD

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Revalidation Good record keeping essential part
of being a doctor
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Message for the conference

• Welcome the IMT DES - peer review of systems
  (accreditation) is a notable way of driving up
  standards
• Good quality electronic medical records are an
  essential part of a modern professional life and
  health care system(s)
• Leadership and commitment from doctors and
  nurses is essential as is working with patients
  and users
• We need to raise our game in completeness and
  accuracy of coding
• Training, education and support is crucial from
  PCTs