Patient records fit for modern health care

1. Patient records fit for modern health care Professor Mayur Lakhani FRCGP Chairman of UK Council CONFERENCE ON THE DATA ACCREDITATION STANDARD FOR THE IM&T DES, Leicester 4th July 2006

2. 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

4. 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

5. What causes medical errors? Hellebek, Ejdrup

6. The headlines!

7. IM&T DES Welcome it! good news for patients • It is about Better Patient Care • >Quality 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!

8. 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

9. Modern Health Care

10. Modern Health Care • Practices do not work in isolation – part of a complex network of health care providers and virtual teams

11. 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 Interfaces in Health Care

12. 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

13. 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

14. 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 patient’s changing needs. • 3. Relational continuity – an ongoing therapeutic relationship between a patient and one or more providers (Haggerty et al, 2003)

15. 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]

16. 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

17. Results out of hours and delay in managing complications • High INR (>10) • Abnormal FBC (myeloproliferation) • High potassium level • Anaemia • Methotrexate level • Systems to deal with results OOH: • Communication arrangements

18. 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?

19. 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

20. 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.

21. The case for standards and accreditation

22. 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?

23. 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)

24. 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

25. 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

26. 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

27. 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

28. Skill mix and different ways of working – recording all contacts

29. 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.

30. 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!

31. Take home messages

32. 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

33. Assessment: Local Panel Evaluation of Portfolio including lay members: Can the doctor be recommended for revalidation? Doctor’s Portfolio Criteria/standards/ evidence Clinical Governance Local Certification How is the doctor doing? Appraisal How am I doing? Revalidation Good record keeping –essential part of being a doctor

34. 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 IM&T 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