Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Chianti or Cabernet Sauvignon?
- Tony M Penney (8 August 2005)
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‘Connecting for Health’ using the past medical history
- Huw Llewelyn (9 August 2005)
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Front Line electronic Booking
- Peter Banks (11 August 2005)
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The peasants are revolting!
- Steven Ford (11 August 2005)
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Problems are inevitable. The goal is still worth striving for.
- Robert J Young (12 August 2005)
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Tony M Penney, General Practitioner Linden Medical Group, Kettering NN15 7NX
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Sirs You state that “persuading people that "it will all be worthwhile" is at least as great a challenge as the technical one” and that “senior managers responsible for the NPfIT need to ensure that NHS staff see the glass as half full” … but half full of what? In the East of England we are working hard to make sure that the glass contains a Cabernet Sauvignon rather than a Chianti. We recognise that future end-users of the system must be intimately involved at the earliest stages of design so that not only does the software function well, it also facilitates best working practices in order to deliver benefits for patients. I am currently devising a process that will enable a broad input from NHS staff into the design of new systems in conjunction with our Local Service Provider. In this way we will have real influence in tailoring new systems. This approach may take a little longer, and it will certainly require more effort, but the end product should be high quality and therefore more easily “sold” to a sceptical profession. This is just one example of a change in NPfIT policy, also illustrated by the recent appointment of national clinical champions, whereby clinicians are becoming increasingly more influential upon the whole Programme. All is not lost. Competing interests: Currently seconded part time to the East of England NPfIT Cluster team |
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Huw Llewelyn, NHS Physician Whittington Hospital, Highgate Hill, London, N19 5NF
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Jane Hendy and her colleagues suggest that before ‘Connecting for Health’ can work, its national programme managers will have to improve communication with front line staff [1]. But there also needs to be an improved approach to communication that 'connects' us, as front line staff, with each other and also with our patients. This can be achieved by producing a past medical history (PMH) on a computer (e.g. on Microsoft Word). A computerised PMH has interesting advantages. It can be updated by the last doctor to see the patient in order to help the next doctor (or any member of the team), who can also update it. It can be created initially from prepared PMH guidelines by ‘pasting’ them into the structured PMH, a process which is quick and also allows the clinical management to be checked for errors [2]. The PMH can also be produced automatically in Microsoft Word from GP computer systems by designing the appropriate data base report forms. A full evidence-based PMH outlines the ‘particular’ diagnostic evidence about the particular patient (e.g. the presenting complaint, the confirmatory findings and the latest result of the marker(s) of progress), followed by an outline of the management, with dates and times [2, 3]. In future, the 'particular' evidence in the patient’s elecronic patient record and the 'general' scientific evidence in the literature could be accessed from the PMH or its guidelines by using 'hypertext' or other links provided by ‘Connecting for Health’. The patient and members of the multi-disciplinary team (e.g. nurses, radiologists and pharmacists) can see clearly in the PMH the diagnostic indication for the various treatments and the evidence for the diagnosis. It can be given to patients and used help to explain diagnoses and decisions in a transparent and reassuring way [3]. It can also empower those who wish to be an ‘Expert Patient’. It can reduce the amount of paperwork for doctors and secretaries [2]. It would be a useful source of information for audit data bases and hospital coders. Updating it on the ward appears to reduce significantly the length of in-patient stay [3]. The evidence-based PMH can also be used to teach diagnostic problem solving [4]. The computerised PMH can be introduced now on existing networks without much disruption. It can be attached to the NHS 'spine' and the individual patient’s ‘Health-Space’ record in future [5]. If this approach were introduced, it would form a bridge between traditional medical records and the culture of logical clarity needed before IT systems such as those provided by ‘Connecting for Health’ can work. References 1. Hendy J, Reeves BC, Fulop N, Hutchings A, Masseria C. Challenges to implementing the national programme for information technology (NPfIT): a qualitative study. BMJ, 2005; 331: 331-336. 2. Llewelyn D E H, Ewins D L, Horn Jackie, Evans T G R, and McGregor. A M. Computerised updating of clinical summaries: new opportunities for clinical practice and research? BMJ, 1988, 297, 1504- 1506. 3. Llewelyn H, Chaudhry A, McGibbon V. Professional performance, transparency and the GMC. http://bmj.bmjjournals.com/cgi/eletters/330/7481/1#100104, 7th and 14th April 2005. 4. Llewelyn DEH, Ang HA, Lewis K, Al-Abdullah A. The Oxford Handbook of Clinical Diagnosis. Oxford University Press, 2005 in press. 5. Llewelyn H. NHS culture, data protection and freedom of information. http://bmj.bmjjournals.com/cgi/eletters/330/7490/490#104264, 18 April 2005. Competing interests: None declared |
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Peter Banks, GP The Leeds Road Practice HG2 8AY
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My understanding is that I am one of the few GPs in England to be making fully integrated electronic referrals using the EMIS GP computer system. My first “live” electronic referral was in February this year. You would think therefore that Richard Granger “The man ultimately responsible..” (BMJ 6.8.05 page 310) would be my best friend or would know my email address or would have sent me a questionnaire at least. A few people in suits came to “see it done” in the first couple of weeks and certainly technical problems are dealt with by the help desk reasonably well, BUT where is the user input in all this. I have commented on basic design problems with the system noted when I did my first referral but no one is listening. Technology needs to make things easier or we need to be paid to do extra! Don’t ask us to fit a round peg in a square hole ask us what shape to make the peg. Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice
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Sir The clue to the difficulties being encountered in implementing the NPfIT is given in this paper's Abstract's Participants - no mention of the actual users of the system, just assorted panjandrums of greater and lesser degrees of titular magnificence. The whole edifice teeters on the usability/acceptability of the user interface. The users have got to want to use the system because it’s easy and helpful. The grandness of the vision, the vastness of the expenditure, the shininess of the machines, the detail of the planning, the complexity of the systems, the rightness of the cause, the necessity of modernisation, the 'face' of the sponsoring politicians - none of these things signify if the users requirements are not met ahead of all other considerations. Existing paper records are no longer ideal for many reasons but they did evolve into their present broad form for sound reasons. Heed should be taken of that evolutionary process when devising a digital replacement The end product should, in appearance and functionality, generally mimic the old familiar systems. Amongst the first changes that need to be wrought to NPfIT is the ability to operate the whole system without keyboards. Many clinicians are one or two finger typists, myself amongst them, and the time taken correcting the spelling, punctuation, grammar and capitalisation of notes occupy precious minutes. I shudder to think what a court would make of some of the primary school level 'texting' gibberish that passes for computer notes that I have encountered. Secondly, clinicians need to be able to access several data fields simultaneously - not in sequence. Nothing counts except what is in front of the clinician in the thick of the action and what can be done with it. Yours sincerely Steven Ford Competing interests: Subject to daily foaming frustration with the IT systems foisted upon us. |
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Robert J Young, Consultant Physician Hope Hospital, Salford, M6 8HD
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As part of the North West and West Midlands Connecting for Health Cluster I am closely involved with design, implementation and planning at Cluster, SHA and local levels. Within this Cluster commendable efforts have been made to involve IT Staff, Managers and representative Clinicians. So I would like to comment on the many anxieties and frustrations identified in the small but perceptive study carried out by Hendy et al. I believe the situation to be less problematic in Primary Care where there has been a 15 year programme of investment in generic EPR (electronic patient record) systems orientated to multidisciplinary clinical needs. In Acute and Community Care, however, very few organisations have invested in generic clinical IT applications. In consequence, the rays of hope generated by NPfIT have given rise to expectations which, because they are undeliverable in the short term, are beginning to sap morale. By the same token, however, I disagree with Hendy et al when they conclude that staff may not embrace clinical IT with enthusiasm. Frustration has arisen because staff are enthusiastic to use Electronic Records. Indeed experience in the few places where generic enterprise wide EPR systems have been implemented confirms that clinical staff are hungry for this change. In my opinion the present disquiet derives predominantly from this long desired development remaining tantalisingly beyond their current reach. And while I do not disagree with Hendry's conclusions that it will be difficult to persuade those who have built up highly customised departmental systems to move to a generic product our local experience in moving from such systems to an enterprise wide EPR suggests that the benefits of integration and connectivity are quickly seen to outweigh the initially perceived disadvantages of adaptation to a generic format. Because of the dismal starting point this will no doubt be a long hard road. But as clearly identified by the Institute of Medicine (http://www.nap.edu/execsumm/0309072808.html) it remains the most long overdue health care system reform likely to deliver significant and widespread improvements in patient care. Connecting for Health needs to hold its nerve but never underestimate the need to communicate with all the NHS staff through the difficult, but I hope ultimately rewarding, times ahead. Competing interests: None declared |
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