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PRIMIS

PRIMIS. 23 rd April 2002 Metropole Birmingham. Towards the EHR … a view from a country practice. Dr Ralph Sullivan GP, High Bentham, Yorkshire Dales Project Board Member, PRIMIS. Some NHS IM&T targets. by 31/5/03 completion of the GP to GP project by 31/3/05

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PRIMIS

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  1. PRIMIS 23rd April 2002 Metropole Birmingham

  2. Towards the EHR… a view from a country practice Dr Ralph Sullivan GP, High Bentham, Yorkshire Dales Project Board Member, PRIMIS

  3. Some NHS IM&T targets • by 31/5/03 • completion of the GP to GP project • by 31/3/05 • integrated primary and community EPR • acute EPR level 3 • emergency care EHR

  4. Some survey findings From Concepts in Health Informatics, IN Purves, in e-Clinical Governance by L Simpson and P Robinson, Radcliffe, 2002

  5. Sharing electronic patient records ~ three key issues for Primary Care • creating and maintaining patients’ electronic records (the EPR) is going to need a cultural change among clinicians • extracting the information recorded on paper into the EPR will drain resources from Primary Care and create a huge training requirement • the ethical considerations of sharing patient records without express informed consent have not yet been agreed

  6. The information in the EHR will chiefly come from General Practice • the Secondary Care EPR is some time off • 90% of patient contacts in the NHS take place in Primary Care • the EHR will be based on the EPR for some time • to be fit for this purpose the EPR must be reliable: that means complete, accurate, and unambiguous • only “paperless” practices with very good data quality will be able to meet these criteria

  7. General Practice records were not intended for sharing • they began life as a free text aide memoire, intended to be read by the author alone

  8. General Practice records are not ready for sharing • the narrative is often incomplete, making the records alone an unreliable source of information • the record may contain third party references, or local references (e.g. initials) • it is designed to be read in context, surrounded by the recent history • important information is often entered in free text and is thereforemissing from summaries, or it is not entered at all!

  9. That’s the last time I look for a Read code … ever!

  10. Coded information in summaries can be misleading • taken out of context • ambiguous codes • qualifying free text • uncertainty of diagnosis • patient’s concerns • dates and episode structures • code conversions

  11. Step by step guide to “paperlessness” Scanning incoming documents Summarising past paper records Summarising hospital reports Laboratory results on computer Nursing teams using electronic records Using structured data entry Key non-problem coded consultation information Free text and key problems in consultations GMS IoS claims and registration Prescribing records

  12. Attaching invg. reports Scanning incoming documents Summarising past paper records Summarising hospital reports Laboratory results on computer Nursing teams using electronic records Using structured data entry Key non-problem coded consultation information Free text and key problems in consultations GMS IoS claims and registration Prescribing records

  13. Summarising and Scanning

  14. Summarising and Scanning

  15. Summarising and Scanning

  16. Summarising and Scanning

  17. Summarising and Scanning

  18. Summarising and Scanning £87,500,000 pa

  19. Summarising: GP2GP & EDI £57,500,000 pa

  20. Can we assume that we know what patients will allow the NHS to do with their records?

  21. Can we assume that we know what patients will allow the NHS to do with their records? • express and implied consent to the use of the patient’s record • what are patients giving implied consent for in consulting the NHS? • who is going to bear the burden of informing patients? • should patients be able to restrict the use of their records after anonymisation? • will patients become less forthcoming about some important facts with their doctor or nurse?

  22. Implications for data control • doctors and nurses will have responsibility for informing patients of what happens to their records in the NHS • patients will require access to their records • the software will need to be able to flag all or parts of the record as confidential and not to be shared • it may be necessary to flag restricted parts of the record • it must be clear who does control the data: the clinician that created the record or the Minister of State?

  23. The confidentiality debate • Protecting and Using Confidential Patient Information – A Strategy for the NHSInformation Policy Unit, December 2001www.nhsia.nhs.uk/def/pages/info_core/overview.asp • Health and Social Care Act, section 60www.doh.gov.uk/ipu/confiden/index15.htm • General Practitioner Committee guidance on Remote Health Recordswww.gponline.com

  24. The EHR needs the commitment of every doctor, nurse and therapist to: • obtain training in informatics • work to new priorities for data collection • provide the infrastructure for the complete EPR • explain to patients what will happen to their personal health records • inform patients of their rights to control whether their records are shared • ensure that each patient’s record is treated as the patient requires

  25. Meanwhile what happens when the EHR is exported? • first responsibility of the new user is to ensure the security and confidentiality of the data • more sharing = more opportunities for access • access should be on a “need to know basis” and of benefit the patient • the new user should appreciate the actual value of the information • not over-estimate the quality of the record • the new user should understand the structure and meaning of the record

  26. Some examples of problems that may arise • the incompleteEHR • e.g. the doctor in the Brighton A/E department with a patient in a coma after a fit • research based on disease registers • systematic errors in creating records • commissioning based on disease codes v records based on operation codes • misinterpretation caused by record structure differences or bugs • review instances in EMIS disease registers • each primary care computer supplier uses a different episode structure

  27. GP2GP electronic record transfer • technical issues need to be overcome: • structural differences between systems • Read code conversions, local codes, associated features • drug dictionaries • security of transfer • retaining unedited, read-only copy of the old practice’s record • for the sending practice it should be easy • for the receiving practice it will not be so straightforward

  28. Receiving an electronic record • view the record in a format that makes it easy to understand • in its native format or converted to my familiar format? • assess the completeness and quality of the record • against the electronic consultation records? • against the paper record? • against the hospital reports? • ask the patient at the registration medical? • import a summary into my practice record

  29. The value of the EHR and GP2GP record transfer will depend upon: • motivation and education of Primary Care clinicians to create and maintain a complete, accurate and unambiguous EPR designed for sharing • open control of the EHR, lying with the clinician • patients’ willingness to allow their records to be shared • an understanding of the strengths and weaknesses of the EHR by secondary users • provision of the required IT functionality by suppliers • willingness and ability of the NHS to fund the process

  30. Any Questions?

  31. PRIMIS 23rd April 2002 Metropole Birmingham

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