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INFORMATION IN PRACTICE: Julia Hippisley-Cox, Mike Pringle, Ruth Cater, Alison Wynn, Vicky Hammersley, Carol Coupland, Rhydian Hapgood, Peter Horsfield, Sheila Teasdale, and Christine Johnson The electronic patient record in primary care—regression or progression? A cross sectional study BMJ 2003; 326: 1439-1443 [Abstract] [Full text]

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Downtime?

Robert D Swallow   (29 June 2003)

Paperless and Organised

Nandalal J Gunaratne   (3 July 2003)

The National Programme for IT

Rino Coladangelo, Michael F Smith   (3 July 2003)

always another way...

Adrian K Midgley   (3 July 2003)

Serious Flaw

Nicola T Shaw   (3 July 2003)

Politically correct?

P Millares Martin   (4 July 2003)

Downtime? 29 June 2003
Robert D Swallow, Senior Pharmacist, Pharmaceutical Care Mid Yorkshire Hospitals NHS Trust, Pontefract General Infirmary, WF8 1PL Send response to journal: Re: Downtime?	I wholly concur with the authors findings regarding the superiority of electronic records; indeed I and a few colleagues are exploring the use of electronic pharmaceutical care plans within our Trust. However, I was significantly stymied the other week when I needed to check a dose of an important medication prescribed by a patient's GP prior to admission. The dose (and form) of the drug were unclear from the patient (and the admission notes) but it did need resolving swiftly. As the authors point out, and is borne out in practice in my experience, drug details are usually accurately recorded in the electronic practice records. I duly contacted the patient's GP by telephone. He was rather shamefaced when he had to admit that the practice computer was 'down' for the weekend due the relocating of premises, and that he had absolutely no way of giving me the information I needed. However, I don't raise this point in a Luddite way. Rather the reverse: I think we need to address the knotty problem of adequate and reliable backup when the technology 'fails' - or in this instance, was being moved! Competing interests:   None declared
Paperless and Organised 3 July 2003
Nandalal J Gunaratne, Urological surgeon Teaching Hospital, Colombo South, Sri Lanka Send response to journal: Re: Paperless and Organised	It is an interesting study. However the fact that the paperless records had the same detail as the paper records is not necessarily a cause for joy. Electronic Medical Records are obviously going to be more legible and more detailed due to the fact that they include a proforma to collect data. If the paper records were also collected in the same manner, the two would have been equal. The advantages of electronic medical records go way beyond that fo mere paperlessness. The structured, refernced pattern of collection and the portability and speed of transfer to distance places where the patient could be needing them, the ability to search and analyse, the ability to prevent errors and clinical decision support make the real difference. To get this we must collect data in a manner quite different to the way it is being done. The computer works different to the brain. To get their benefit we must understand how they handle data. Competing interests:   None declared
The National Programme for IT 3 July 2003
Rino Coladangelo, Chief, Medix UK 17 Braganza Street, London SE17 3RD, Michael F Smith Send response to journal: Re: The National Programme for IT	We are pleased to see evidence of the benefits of electronic patient records. Integrated electronic patient care records (IRCS) is one of the main projects of the National Programme for IT (NPfIT). This programme will involve £2.3bn capital investment in information and technology infrastructure within the NHS over the next 3 years. Selection of suppliers for the programme is scheduled for this calendar year. We conducted a survey of 1115 medical doctors in England in June 2003 about their views of the programme; 1001 responded. The survey was carried out via the internet from a pre-recruited panel of doctors registered with the GMC. We make no claims as to how representative the panel is for this particular subject, but 501 GPs drawn from the panel predicted a 76% “yes” vote for the General Practice contract election (19 June 2003) against an actual 79% “yes” vote (20 June 2003). Key findings of the survey The majority of respondents appear favourably disposed towards the programme in terms of its expected effect on clinical care: What effect is the NPfIT likely to have on clinical care? All GP Non-GP N % N % N % Significant improvement 257 26% 105 21% 152 30% Slight improvement 338 34% 159 32% 179 36% No difference 122 12% 82 17% 40 8% Slight worsening 20 2% 12 2% 8 2% Significant worsening 14 1% 10 2% 4 1% Unsure 241 24% 125 25% 116 23%   Respondents feel that consultation with individual clinicians is an important aspect of the programme: How important is consultation about the NPfIT with individual practicing clinicians? All GP nonGP N % N % N % Very important 421 42% 197 40% 224 45% Important 431 43% 225 46% 206 41% Neither important nor unimportant 55 6% 30 6% 25 5% Unimportant 24 2% 8 2% 16 3% Very unimportant 18 2% 8 2% 10 2% Unsure 43 4% 25 5% 18 4% None 1 0% 0 0% 1 0%   Most respondents, however, claim to know little or nothing about the programme: How much information have you had about the NPfIT? All GP Non-GP N % N % N % Fully adequate information 6 1% 4 1% 2 0% Reasonably adequate information 52 5% 32 6% 20 4% Inadequate information 146 15% 82 17% 64 13% No information but I know something about it 173 17% 96 19% 77 15% No information but I have heard of it 245 25% 113 23% 132 26% This is the first I have heard of it 339 34% 150 30% 189 38% Only via earlier surveys from Medix 36 4% 18 4% 18 4%   And consultation appears not to have commenced: What consultation has there been with you about the NPfIT? All GP Non-GP N % N % N % More than adequate 4 0% 2 0% 2 0% Adequate 13 1% 7 1% 6 1% Barely adequate 62 6% 29 6% 33 7% Inadequate 99 10% 53 11% 46 9% None 806 81% 399 81% 407 82% Unsure 10 1% 5 1% 5 1%   Comments From these tables and the complete survey (available at http://www.medix-uk.com), we observe that respondents expect positive benefits from the programme in terms of clinical practice and working conditions for doctors. Respondents generally view the programme as a responsible investment and one of suitably high priority. Consultation with clinicians is seen as an important aspect, but consultation and communication about the programme appear not to have made a significant impact on the responding doctors at this time.   Competing interests:   The authors have material financial interests in Medix UK.
always another way... 3 July 2003
Adrian K Midgley, GP Exeter EX1 2QS Send response to journal: Re: always another way...	Assuming the previous prescription referred to above had been dispensed, asking the local Pharmacy to look at their computer record would have been an alternate approach to finding the information required. We rarely move our major systems, but for insurance against various causes of embarrassment, having a backup of the live system made and running on a separate machine is sometimes handy. It also demonstrates that the backup actually works - something we hate to find out by loading it back onto a broken server's replacement! I am amazed by the assumption - the hypothesis - that typed notes on a computer system would be terser or less good than those on Lloyd George cards. it is exactly the opposite I would make, and I am pleased to see the demonstration that this is so. In the UK general practice systems range from moderate use of templates and pro formas to very little use of them, a large proportion of the entered record is commonly free-form narrative, including from time to time items that might usefully be added in a codified form. The extensive use of forms whether as paper or as screens is more typical of the secondary sector, and I assert that it does not of itself improve usability of the machine, quality, uptake, job-satisfaction, later re-usability of the record or anything much else that doctors do to anything like the extent that some people think. In particular, the use of extensive templating and coding does not improve the robustness of the medical record against later changes of system, supplier, coding library or any of the undesirable interruptions to the permanence of the record which are encouraged by commercial considerations and closed source code programs. Legibility and retrievability are huge advantages easily obtained with simple approaches to electronic records, there are many others, but the effort to procure all of them should not ignore the merit of the easy ones. Competing interests:   None declared
Serious Flaw 3 July 2003
Nicola T Shaw, Research Scientist Centre for health Innovation & Improvement, Vancouver. Canada. Send response to journal: Re: Serious Flaw	It appears from the report presented here that there is a serious flaw in the design of this study that is actually noted by the authors and then, unfortunately, ignored. The authors commence their ‘Participants and Methods’ section with the statement that they had originally intended to differentiate between “manual (all records kept on paper) and combination (part electronic and part paper record keeping), but piloting made it clear that the appropriate comparison was between paperless records, where all patients’ clinical notes were entered on to and stored on computer, and paper based records, where either a combination of manual electronic records or only manual records were kept.” This change in comparative groups is significant. The authors’ claims as to the differences observed between the two groups are therefore questionable. Given that the majority of all English GPs routinely use electronic systems for prescribing (both repeat and acute) it is extremely hard to believe that “paperless records were significantly more likely to specify the drug dose” unless the authors were only reviewing the paper- based components of their ‘paper-based group’ as opposed to the full record. Assuming therefore, that the authors were comparing the printout from the electronic record for their paperless group and a copy of the paper- based record for the paper-based groups they were not comparing like with like. By designing the study in this way, they ignored the fact that many practitioners use a combination of methods to record the consultation. Most commonly, paper-based GPs will record symptoms, diagnosis and observations on paper but prescribe using their electronic system. Therefore, a fair comparison would have required that the full record for both groups be reviewed. This would have meant that the paper-based group would have included the electronic record printouts as well as the copy of the paper record. Giving the authors the benefit of the doubt for the moment and assuming that this is indeed what they did do, and that for some unknown reason their paper-based GPs did not use their electronic systems to prescribe, there are two further issues of concern: The first is that the authors conclude “paperless records compare favourably with manual records”. This is an interesting and very positive conclusion given that they actually specify one of the main reasons as to why GPs may prefer to use manual records during the consultation – diagrams. Whilst only 7 drawings were observed in their study the lack of drawings in the electronic systems is surely due to the inability of such systems to facilitate such recording rather than that their value was not important? Admittedly, the increase in legibility and understanding gained from using paperless systems from a medico-legal perspective is great. However, from a patient perspective I wonder how much more valuable that little drawing is? Can such drawings be disregarded as having such little value so easily? Secondly, the authors suggest that the “doctor-patient relationship may not be as personal as many suppose” based on a textual analysis of references to specific patients. I would be interested in seeing what would happen if those same doctors had been presented with a picture of the patients in question. I suspect that their recall and specific reference would substantially increase, as like many of us, doctors are known to respond very heavily to visual cues as opposed to verbal recall. Competing interests:   None declared
Politically correct? 4 July 2003
P Millares Martin, GP Leeds LS12 5AZ Send response to journal: Re: Politically correct?	Is there a point in comparing whether you write more information on stone compared to a papyrus? At the end of the day, this article reflects just the same principle that could have instigated research to Egyptians 4000 years ago to please the pharaohs. Perhaps nowadays the journal, which is forced to decline thousands of articles every year due to lack of space, is forced by the political class to show to the general public the radical change the NHS is under is evidence based and provide us with such irrelevant piece of work. Is it possible to believe that in the present litigation-prone society we live GPs are going to provide less information by using new technologies? Very doubtful. On the other hand, how can you question whether information is more accessible with a computer? What is the whole purpose of IT but to allow handling of large quantities of data quickly and efficiently. We are aiming to move to new millenium technologies, many practices are setting up web sites (over half of the practices in England) [1] and some of them are already exploring the issue of e-prescribing [2]. It is irrelevant if computer records at present are better or worse compared to old records. There is no way back. The force behind good record keeping is not where and how you write them, but whether it will be good enough in litigation. More interesting to me is to read how GPs are dealing with the imposed changes because new generations of GPs will do nothing but work in paperless practices, whether they like computers or not. And it does not even matter whether you are in any other business. Can you imagine any successful business renouncing to process their data in the fastest computers? _________________________________________ Bibliography: [1]. Millares-Martin P, Bobet-Reyes R. "Putting primary care on the web" GP, 31/03/03, page 46. [2] Millares-Martin P, Bobet-Reyes R. "Repeat Prescribing online", GP, 17/02/03, page 63. Competing interests:   None declared