Patient records fit for modern health care

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Patient records fit for modern health care

• Professor Mayur Lakhani FRCGP
• Chairman of UK Council
• CONFERENCE ON THE DATA ACCREDITATION STANDARD FOR
  THE IMT DES, Leicester 4th July 2006

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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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The headlines!
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IMT DES Welcome it! good news for patients

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

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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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Modern Health 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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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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Fragmentation

• multiple points of access, and increased number
  of interfaces
• Increased number of services and health care
  professionals involvement
• Technical complexity is increasing, both in
  general practice and in the NHS as a whole
• Co-morbidity
• Without (usually) a shared health record loss
  of information

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Values

• Patients do not like repeating stories
• Patients do suffer disruption of care across
  interfaces
• Value continuity and interpersonal care
• Value attempts to coordinate care
• Integration and co-ordination of care is a
  crucial requirement in a health service
• Fragmentation of Care hand offs
• Continuity is a relevant concept both in both
  primary and secondary care

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The importance of continuity

• 1. Informational continuity - the use of
  information on past events and personal
  circumstances to make current care appropriate
  for each individual.
• 2. Management continuity a consistent and
  coherent approach to the management of a health
  condition that is responsive to a patients
  changing needs.
• 3. Relational continuity an ongoing therapeutic
  relationship between a patient and one or more
  providers (Haggerty et al, 2003)

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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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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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Scenario

• A 42 y.o. man presented with a history of
  feeling generally unwell, anorexia and vague
  abdominal discomfort. Clinical evaluation did not
  give any clues and a set of initial blood
  investigations were negative. The patient
  presented again 2 months having lost some weight.
  Again there were no localising features but the
  GP was concerned about an occult malignancy. His
  sixth sense suggested something seriously wrong.
  An urgent referral was made to the hospital.
• More than 12 months later the patient presented
  with an unrelated problem ankle injury. The GP
  inquired about the above appointment the
  patient stated that he never received the
  appointment. Anyway he had felt better and did
  not need it now
• What issues does this raise?

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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
• Understanding the health needs of the population
• Supporting Commissioning

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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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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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In the NHS

• Almost one million people visit their GP every
  working day
• Almost 90 of problems are dealt with in general
  practice
• About 350 million consultations with general
  practitioners per year
• 78 of people consult their general practitioner
  at least once during the year

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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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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 Dr M initials and mine. Dr
  M. initials are JFM and mine are JKM.
• Urology versus Gastroenterology!

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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
• professional development, commissioning - need
  for measurement

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

• Good quality electronic medical records are an
  essential part of a modern professional life and
  health care system(s)
• Welcome the IMT DES - peer review of systems
  (accreditation) is a notable way of driving up
  standards
• 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