Integrated record keeping as an essential aspect of a primary care led health service
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7158.579 (Published 29 August 1998) Cite this as: BMJ 1998;317:579
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For some time our community based psychiatric service has used
consecutive and multidisciplinary case notes for psychiatric inpatients.
This has been paper based rather than using I.T. as in Rigby et
al.Advantages include improved communication and sharing of information,a
reduction in duplication and repetition of information,a
reduction in the requirement for multi disciplinary meetings,the amount of
paper required and the patients' files are no longer as chaotic as they
used to be.
Ref. Rigby M ,Roberts R,Williams J, Clark J,Savill A ,Lervy B,Mooney
G. Integrated Record Keeping as an essential aspect of primary care lead
health service.British Medical Journal 1998,317 579-582(29th August)
Christine M Tyrie
Consultant Community Psychiatrist
Penrith Hospital
Cumbria CA11 8HX
Competing interests: No competing interests
I read the article in question and was highly impressed with it's content. However, as a final year student reading Dentistry and soon to be a full member of the profession I wondered if the authors had given any thought to the inclusion of dentists amongst those able to use this database of records.
There are benefits to both the patient and dentist, as the dentist can input information regarding patient treatment, while accesing data on medical records and drugs the patient may be prescribed that may be contra-indicated to dental treatment.
The rise in oral cancer has raised interest in screening programmes which can be implemented by both medical and dental professons as the oral cavity is readily available for examination. If oral cancer is suspected, then this record system can be used as a tool for better communication and liaison between those involved in the care of such patients. This will ultimately raise the levels of patient care, which is the desire of every healthcare professional is it not?
Competing interests: No competing interests
EDITOR - Rigby et al (1) do well to raise the need for integrated records in the primary care services. This need
has been apparent for most of my professional life and seems no nearer solution. The question of integrating primary with secondary care records is it seems not even on the horizon.
The paper makes many positive and helpful points, but I was surprised to read that 'Whenever an important change to a record was made .. information about the change would be sent .. to all the professionals involved in the care of the patient. It would require a structured list of health professionals currently involved with each patient ..'.
This makes me wonder if the Authors are fully acquainted with the principles and potential of database management. One of the fundamental principles is that data is only stored once, and in one place. The database is a single entity (actually or virtually) but specific views of the data suited to their requirements are made available to all those with a right to access it. Ease of access at multiple terminals is of course important. I see no need to maintain lists of staff currently involved, or to send updated
records to anybody. Staff access the system, not vice versa. If staff need to draw a colleague's attention to a case, this should occasion a message from staff to colleague.
The technology to allow this is well developed in relational database software such as Oracle (Oracle UK) or Access (Microsoft). The advantages of these seem to be so great that the question of acceptability needs to be addressed. These database systems are secure, reliable and flexible, and can allow for subsequent changes and developments which are inevitable in medical work. I think the main barrier is the psychological one of achieving acceptance of one system by all the staff who
would use it.
Alan Sheard Retired consultant in public health medicine
1 Rigby M et al. Integrated record keeping as an essential aspect of a primary care led health service. BMJ 1998;317:579-582.(29 August.)
Competing interests: No competing interests
Developmental data in primary care records
EDITOR - Rigby and colleagues (1) argue that without adequately
shared clinical information integrated patient focused care is difficult
to achieve, undermining the effective functioning of extended primary care
teams (however constituted) upon which the NHS will increasingly depend.
Their review placed emphasis upon integrated record keeping and various
methods to achieve this. Our recent experience of adolescents’ primary
care health records reviewed during the course of an Edinburgh study
suggests that attention should be paid to health professionals’ skills and
behaviour and to organisational factors.
We found that antenatal and birth data were generally absent from
these patients’ records, perhaps lodged instead with their mothers’
casenotes. In a survey of 60 randomly selected records from three
practices, only three contained Apgar scores and birth weight was absent
in 60% of records. Health visitor developmental data was similarly
grossly under-represented. In theory six different developmental checkups
ought to have been available, but this was true for only one child and in
more than half it was missing altogether. This situation may not apply to
the records of children with clear cut disorders or disability but subtle
motor, perceptual, and cognitive problems can have equally profound
effects on later development (2), affecting social adjustment, school
performance, and behaviour. Only ongoing developmental screening may
reveal their presence, yet once a child is five such accumulative data
becomes lodged within community child health records i.e. school medical
records (notably overlooked in the authors’ review), impracticably located
to assist general practitioners’ clinical decision making. Experienced
parents may pick up their child’s difficulty and report this,
inexperienced or unobservant parents will not. The recently introduced
computerised patient (i.e. parents’) held developmental records are not
always well designed for data review.
If these findings are an accurate reflection of a more general
picture the problems they highlight are likely to constitute important
obstacles to appropriately responding to parental concerns about a child’s
behavioural problems. The importance of their resolution has been
increased by the findings of recent gene-environment studies (3), which
demonstrate that genetic or other early constitutional factors can
decisively influence a child’s social experience and that this effect may
increase rather than decrease in magnitude over time (4). However, those
responsible for managing the school environment of vulnerable youngsters -
school guidance staff and educational psychologists - also have no direct
access to health and developmental data, nor in general the skills to
interpret it. Developing the means to ensure that relevant information is
available for primary care consultations must include an examination of
the role of community child health services.
S Hume Specialist registrar in child and adolescent psychiatry
P Robinson Research fellow
RM Wrate Consultant psychiatrist
A Gowans Research assistant
Young People’s Unit, Royal Edinburgh Hospital, Edinburgh EH10 5HF
D Manders Consultant psychiatrist
Department of Child and Family Mental Health Services, Royal Hospital for
Sick Children, Edinburgh
1. Rigby M, Roberts R, Williams J, Clark J, Savill A, Lervy B,
Mooney G. Integrated record keeping as an essential aspect of a primary
care led health service. British Medical Journal 1998; 317: 579-582.
2. Hellgren L, Gillberg IC, Bagenholm A, Gillberg C. Children with
deficits in attention, motor control and perception (DAMP) grown up:
psychiatric and personality disorders at age 16 years. Journal of Child
Psychology and Psychiatry 1994; 35: 1255-1271.
3. Rutter M, Plomin R. Opportunities for psychiatry from genetic
findings. British Journal of Psychiatry 1997; 171: 209-219.
4. Thapur A, McGuffin P. Genetic influences on life events in
childhood. Psychological Medicine 1996; 26: 813-820.
5. Gosbee J (editorial). Communication among health professional.
British Medical Journal 1998; 316: 642.
Conflict of interest: none
Competing interests: No competing interests