PRIMIS

1. PRIMIS 23rd April 2002 Metropole Birmingham

2. Making the right choices – using the computer in the Consultation Dr Nick Booth Sowerby Centre for Health Informatics University of Newcastle 23rd April 2002 Birmingham Second National Conference PRIMIS

3. SCHIN Research • Decision support / EBHC/ Knowledge management • Electronic Health Care Records • Web based Appraisal • Electronic prescribing • GP-GP record transfer • Terminology and Classification

4. My Projects • Information in the Consulting Room • NHS RDD • Durham and Darlington EHR (DuDEHR) • NHSIA / Durham and Darlington Health Care Community • SNOMED Clinical Terms

5. Making the right choices • Preamble • Setting • What drives the process? • Information in the consulting room • Data collection in the consultation • What are the choices? • Joining up organisations • An agenda for progress 23rd April 2002 Birmingham Second National Conference PRIMIS

6. Setting is changing • Moving toward an era of multidisciplinary care across traditional boundaries • Fewer boundaries • Reduced effort to cross boundaries • Not just GPs • Not just PHCTs • Now PCT wide teams And… • NSFs mean unit of analysis of quality is across all the traditional silos of information

7. Policy, co-ordination, and funding “Silo” service support environments – each organisation has its own information service. Information outside of a single organisational system is hard to get. Integration rarely happens The practitioner and the patient The traditional approach to service provision

8. Policy, co-ordination, and funding Integrate legacy systems using brokerage technologies EHR is the consequence of joining together organisational systems Brokerage environment The practitioner and the patient

9. What drives the process of computerisation? • Information for Health • Modernisation • Patient care • Clinical governance • Policy/targets • Performance management • Money

10. Who drives the process of computerisation? • Teams • Clinicians • Doctors • Management • Government

11. The iiCR projectObserving use of the computer in the consultation Nick Booth Paul Robinson Judy Kohannejad

12. Project aims • Identify the skills that help the GP to maintain rapport with patient and use the computer during the consultation. • Develop and pilot a teaching package that supports the training of GPs and the development of these skills. (Cambridge-Calgary Guide)

13. Background Drivers to use the computer in consultation • Changes in clinical practice • Clinical governance Problems with using the computer

14. Clinical Practice • Team work • Changing roles • Population management, quality, equality • Medical science gets more complicated and changes more rapidly • Public expectations • Accountability

15. Clinical Governance • Electronic clinical records • Narrative and clinical history • Templates and data entry • On-line decision support • Care pathways / NSF

16. Problems with using computer • Lose rapport (phase 2 evaluation) • Habit (Douglas) • Patient does not understand computer use (Als) • Attitudes to sharing knowledge

17. Effects of using computers 1 • Dr. spends more time looking at screen than at paper (Herzmark) • Reduces time spent interacting with patient (Warshawsky) • Increases length of consultation • Increases Dr initiated content (vs. patient) • Increases medical content (vs. social) (Sullivan and Mitchell) • Computer as enforcer

18. Effects of using computers 2 • Computer use does interfere with doctors’ communication behaviour • This can be minimised by practice and experience, which allows a back-grounding of the computer use (Greatbach et al)

19. Computers in the consulting roomKey issues: • Good rapport improves outcomes • Silence invites confession • Think of new ways of keeping the patient quiet • Practitioners need to concentrate on the screen • at some points in the consultation • Some clinicians seem more skilful with triadic • consultations than others

20. Research Questions • Can these skills be identified? • What are they? • Can people divide their attention?

21. iiCR Project: sample • GP Trainers (purposive sample) • Self selected • Familiar with using computer in the consultation

22. iiCR Project: method • GPs taped a surgery and collected CSQ forms • Looked at all consultations on tape • One or two consultations selected and transcribed by JK (CA transcription) • 2 columns (Dr – Pt interaction: interpretation) added to transcript (PJR)

23. Why this method? • Computer use is part of the choreography of the consultation • What is the data?

24. iiCR: what we saw • A lot of use of paper! • Most GPs do the minimum of typing/ data entry while the patient is present

25. 4 types of behaviour: Controlling Responsive Opportunistic Ignoring iiCR: what we saw

26. iiCR: what we saw 3 strategies: • Signpost • Blather • Respond (every time)

27. iiCR: what we saw Variation in sharing of: • Screen • Knowledge sources

28. iiCR: what we saw Failures to respond to speech-act • When in prescribing or template filling modes • Were they deliberate??

29. Multi-tasking • Can GPs do it? • Can researchers do it?

30. iiCR project: current state • Initial research complete • Supplementary section of Calgary Cambridge guide completed and approved by authors • Outline teaching package drafted • Testing in trainers’ groups ongoing • Research findings incorporated in Prodigy training

31. iiCR: the final stages • Teaching package • Refine • Use • Evaluate • Research • Consultations with simulated patients • Immediate review with researcher

32. Control in the consultation • iiCR helps clinicians take control • Patients need a guide to help them cope with clinicians in the consultation • The computer as a control agent? • Senior partner • PCT • Government

33. Using the Computer in the Consulting Room

34. What are the choices: 1? • Do you let the computer in to the consultation? • Go paperless • Narrative or codes • Before during or after • What about decision support • Collect data in real time? • Or use a data entry clerk • Or use a nurse

35. What are the choices: 2? • Structured care needs high quality data entry • Move it to the practice nurse?

36. The computer as enforcer? • Puts structure on the consultation • Takes attention away from problem solving • “The feeling of exploring the unknown is the essence of general practice” • “This feels like a practice nurse consultation”

37. More choices • Do we share records with others? • Openly • Comprehensively • Across boundaries • Who do you trust? • Who trusts you?

38. Joining up organisations • Not just a technological problem • Not just an infrastructure problem

39. Why is IT hard to deploy in the NHS? • Health information is hard • Technology needs to work within an organisation • It must match the way people work • It will not transfer from a dissimilar organisation

40. Example 1 • Health Information systems in UTAH • Intermountain health care • Integrated multi-hospital system including primary care • 1 CEO • University Hospital owns all the feeder hospitals and the primary care organisations in the health care pyramid • Clinicians must use the system • The organisation defines the system • HL7 is just an interface standard

41. Intermountain Health Care (IHC) • Not for profit corporation • 22 Hospitals • 500->25 beds • 24 Clinics • 14 Urgent Care Centers • Health Plans (Insurance) • Physician’s Division (~400 employed physicians)

42. Sunquest Lab AGFA Radiology Tamtron Anatomic Pathology McKesson Pharmacy ARUP Blood Bank MIMIR Blood Gas Machines Dictaphone Varis Oncology MRS Mammography Logicare ER Computrition Dietary Clinical Integration! HELP (Inpatient HIS) 3M IDX (Outpatient) IDX Systems HDM & Medrec 3M ADT, Orders, Results, Billing Registration, Scheduling ADT, Billing Health Data Dictionary 3M DataGate Interface Engine STC Tuxedo ADT, Orders, Results, Billing ADT, Billing, Case Mix Billing & Financial IHC ADT, Results, Orders Registration, Scheduling Tuxedo DataStage CIS EMMI/LDR Database (HEMS) 3M Clinical Workstation 3M Tuxedo Data Warehouse IHC

43. Example 2 • Durham and Tees Valley • New StHA 3 weeks old • 6 acute hospitals • 10 PCTs • Tertiary centres in Teesside and Newcastle • 2nd major reorganisation happens in the middle of the project! • Typical of one sort of diversity in the UK

44. X

46. 60% 10% 30%

47. Agenda for Progress • Clinical point of care computing needs more research • Especially in acute sector • Consultation is a site of special scientific interest • Tamper at your peril • Computer use is an acquirable skill • We need education for this clinical skill

48. Agenda for Progress 2 • Ruthless standardisation is not enough • Organisations define the system - not vice-versa • When we join up organisations we need a shareable infrastructure • Organisational as well as technical • We need a clinical forum to discuss infrastructure • We need the right organisation • With the right technology

49. Acknowledgements • SCHIN staff • NHS Research and Development Directorate • NHS Information Authority • GPs and Practices in Northumberland, Durham and North Yorks • …

50. SCHIN www.schin.ncl.ac.uk/iicr www.schin.ncl.ac.uk/durhamehr N.S.Booth@ncl.ac.uk