Paperlight Practice

1
Paper-light Practice

• Why and How?

2
Kepier Medical Practice
What shall we do with the paper?
3
Where are we?
Hewlett
Lloyd
A-F
4
Why Electronic Record

• Information for Health (1998)
• EPR
• EHR
• electronic lab results by 2002
• 24 hour access to records and GP to GP transfer
  by 2005
• Building the Information Core- Implementing the
  NHS plan
• Validation of GP records on computer.

5
Information for Health
Local Implementation Timescale

• _at_ 2000-2002
• Substantial progress in implementing integrated
  primary care and
• community EPRs in 25 of Health
  Authorities.
• Beacon EHRs to have initial first generation
  EHRs in operation

• _at_ 2002-2005
• Full implementation at Primary care level of
  first generation
• person based Electronic Health Records.
• The electronic transfer of patient records
  between GPs
• 24 hour emergency care access to patient records

.
6
GPs reasons for EHR

• Clinical Quality
• Clinical Governance/Audit
• Miquest
• Easy access to full record from
• Surgery, Home and on Visits
• NSF data sets and templates (IHD etc.)
• Computer guidance on screen
• Mentor / Prodigy/ Local Guideline

7
Our Reasons

• Lack of space for paper filing
• Lack of availability of notes for team
• Dual entry of searchable information
• Illegibility
• Notes frequently missing

8
History 89-97

• 10/89 First computer
• cytology/ hysterectomy/ imms. / repeats 91gt
• 9/92 New Computer System (EMIS)
• In each consulting room
• Large staff workload transfer repeat scripts etc
• 1994/5 Pilot GP links (Reg IOS)
• 1996 Fundholding, logging referrals
• 6/97 NHS Net (email/ internet)

9
History 94-7 (Clinical)

• 1994 Increasing use templates (GPs)
• AG pilots consultation on computer (prints LG-95)
• Sticky label templates
• 1994 Sunderland morbidity group
• 8 code morbidity register and health status
• 1996? Health Promotion reports
• 1996 Stop using yellow repeat cards
  (an
  example of our resistance to change)
• 8/97 Appointments

10
Yellow Repeat Card
Kepier Medical Practice Repeat
Prescriptions Name D.O.B Address
No. Medicine Dose Number
Date
12/10/95
Drug 1
11
History 97-8

• 1-7/97 Explore A4 records
• 8/97 Decision to go for the burn
• 9/97 All GPs/Nurses consult on computer only.
  Gradual less use cards.
• 1/98 Summary(F12) only on visits
• 3/98 Too many changes-esp. staff roles. Need to
  rethink and communicate better.

12
History (up to date)

• 4/98 Summaries
• 10/98 Scanning letters(filing protocols)
• 10/98 Printout for patients moving
• 3/99 Laptops purchased.
• 7/99 Lab Links
• 12/00 Scan letters as images.
• 1/01 Shredding of imaged letters.
• 1/02 Electronic letters (ENT)

13
(No Transcript)
14
ELECTRONIC PATIENT MEDICAL RECORDS IN PRIMARY
CARE Changes to the GP Terms of Service
15
What Paper?

• Paper In
• Non paper data
• New Paper
• Surgery
• Visits
• Phone Calls
• Paper Out

16
(No Transcript)
17
Hospital Letters

• Typed (250-300 a week)
• and 10 FTA letters/5 mammography forms
• Handwritten (60 a week)
• AE
• Discharge
• Physiotherapist
• CPN
• Optician

18
Other Paper In

• Case Conference reports
• Laboratory Results
• Local Guidelines
• DOH papers (HSC)
• Data sheets
• Meeting agendas/minutes
• Advertising

19
Typed Letters
20
Typed Letters
Hospital Letters 600/week
21
Typed Letters
Hospital Letters 600/week
Date-Stamped Scanned
22
Typed Letters
Hospital Letters 600/week
Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
23
Typed Letters
Hospital Letters 600/week
Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
24
Typed Letters
Hospital Letters 600/week

• Alternatives
• Staff code the problems, BP, Bloods, ECG etc.
• Drs see post before staff and highlight

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
25
Handwritten Letters
26
Handwritten Letters
Letters (handwritten/provisional/non-scannable)
27
Handwritten Letters
Letters (handwritten/provisional/non-scannable)
Date stamped Logged on computer
28
Handwritten Letters
Letters (handwritten/provisional/non-scannable)
Date stamped Logged on computer
Visit Book (Discharges only)
29
Handwritten Letters
Letters (handwritten/provisional/non-scannable)
Doctor Reading Coding Action (themselves or
highlight for secretary)
Date stamped Logged on computer
Visit Book (Discharges only)
30
Handwritten Letters
Letters (handwritten/provisional/non-scannable)
Doctor Reading Coding Action (themselves or
highlight for secretary)
Kept till Full discharge letter or review at
2months.
Date stamped Logged on computer
Visit Book (Discharges only)
31
Handwritten Letters
Letters (handwritten/provisional/non-scannable)
SHREDDED
Doctor Reading Coding Action (themselves or
highlight for secretary)
Kept till Full discharge letter or review at
2months.
Date stamped Logged on computer
Visit Book (Discharges only)
? Keep some limited types (under review)
32
2002 Electronic Letters(started with referrals
to ENT 1/2002)
33
2002 Electronic Letters(startedwith referrals
to ENT 1/2002)
Incoming Electronic Letters ?spring 2002
34
2002 Electronic Letters(started with referrals
to ENT 1/2002)
Incoming Electronic Letters ?spring 2002
Doctor Read, Code file on PC
35
2002 Electronic Letters(started with referrals
to ENT 1/2002)
Incoming Electronic Letters ?spring 2002
Doctor Read, Code file on PC
Computer note to PN or receptionist re any action
36
2002 Electronic Letters(started with referrals
to ENT 1/2002)
Incoming Electronic Letters ?spring 2002
Doctor Read, Code file on PC
Computer note to PN or receptionist re any action
SHREDDER SCANNER
Almost Obsolete
37
Non Paper Data In

• Phone call from
• Hospital
• Pharmacist
• Relative
• Patient
• Request for script on on repeat list
• Report re hospital appointment
• Report re reaction to treatment

38
Consultations

• Surgery
• Doctor
• Practice Nurse
• District Nurse/Health Visitor/Midwife
• CPN/ Social Worker/ Counsellor
• Telephone calls
• Visits

39
Visits

• Summary Printout (whoops thats paper!)
• Dr to transfer notes back to computer
• Doctor dictates for secretary
• Palmtop Computer
• Laptop Computer gtgt

40
Paper Out

• Prescriptions
• Certificates (paper so far)
• Insurance report automatically generated
  edited printed. (Will be encrypted email)
• DSS reports (still paper.why?)
• Note request from solicitor printout of notes
  (photocopy pre 1997)
• Patient leaving practice

41
? 2005
42
? 2005
43
? 2005
http//www.nhsia.nhs.uk/gp2gp/docs/GP2GP_PID101.pd
f
11/2001
2005 Paper a thing of the past ?
44
Dangers

• Power Failure
• Down Time
• Unexpected Crash
• Hard Disk Failure
• Computer Virus

45
General Protection

• UPS to avoid loss of data if power cut
• Nightly backup to protect stored data
• Protocols for staff
• In anticipation of shutdown
• In event of loss of clinical computer
• Backed up appointments lists (paper/disk)
• Backed up Summaries for next 1-2 sessions

46
Hard Disk Failure

• Loss of data
• ?Loss of network
• Loss of software
• Loss of configuration

• Maintenance contract
• Backup
• 2 servers
• RAID/hot swappable disks
• 2 Mirrored disks
• DAT Tape Backup
• Backup storage and verification

47
Computer Virus

• Anti-virus software
• on server
• on PCs
• regularly updated
• Policy re
• 3rd party software
• downloads
• disks

• Sudden
• Corruption of past tapes

48
Has it worked?

• Getting there, still some paper
• Painful lessons re
• Time
• communication
• insecurity of new roles
• regular update protocols and need for everyone to
  know
• Need to keep on top software updates etc.

49
Has it worked(Problems)

• What is going on? Barbara says you told her to
  cut and paste.
• Id rather file the letters in L-G again
• What are these new printed physio forms?
• The scanning is still tedious. (BUT)
• Laptops not rolled out yet...
• Lab results still need checking, improving.

50
Lessons for us

• Plan out stages in advance (Incremental)
• Involve everyone. ? A bulletin/news board
• Know who will do what (and write it down)
• Know who will troubleshoot (pref. not Dr.)
• Practical/ Technical/ Very technical/ Emotional
• Regularly take time to review TOGETHER

51
Lessons for us

• Be bold to discard duplicates. But think.
• Build in safeguards but review these too.
• Admit your mistakes.
• BUT
• Remember all we can do now that we could not do
  before computers.
• Easy to forget the hassle and ignorance.

52
Help from the Trusts

• Readiness to allow community staff to enter
  clinical data on our EHR
• Move to electronic letters. Until then where
  possible white, typed AE forms
• Pressure suppliers where hospital software unable
  to cope with output automatically.
• Training and explicit confidentiality policy now
  wider team accessing records.

53
Help from PCT

• Training courses for staff / protected time.
• Enough local technical support to install, update
  and troubleshoot. Address books, antiviral,
  intranet. (CS approved)
• Facilitation of projects
• Summarisation and archiving
• electronic prescribing
• practice web sites and intranets/ extranets
• Financial backing of progress

54
Help from the centre

• Realistic legislation and support.
• Early definitive advice re retaining letters.
• Funding at 100 modernisation maintenance
• Real live GP input into coding issues and any
  attempt to direct clinical recording
• Support for initiative
• Recognition of the extra work changed roles

55
Into the Future

• The biggest step is behind us
• Advantages clinically and in audit Now
• Promises in Info for Health
• Plans for eLetters, DN record, web site
• Investigation eScripts, common templates
• Hopefully doctor to doctor transfer
• And 24 hour access to notes

56
Conclusions

• There is light at the end of the tunnel
• The change has been hard but rewarding
• The staff are wonderful and still with us
• Lets keep on shredding sharing as a team