Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case studyBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c3111 (Published 16 June 2010) Cite this as: BMJ 2010;340:c3111
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We were disappointed that this evaluation did not spend more time
comparing the Summary Care record during its early rollout phase with
Scotland’s established Emergency Care Summary (ECS). The ECS has been
active in Scotland since 2006, and 100% of Scottish practices are now
sending updates of all prescribing and adverse reactions to a central
database automatically twice daily. Over 200,000 records are accessed
every month by users who are limited to clinicians working in NHS24,
Accident and Emergency Departments and Out of Hours teams. In total there
have been over 5.1 million accesses to date with a 37% year on year
increase from 2008 to 2009. Feedback from users has been overwhelmingly
positive, with quotes from clinicians such as “One of the best tools we
have for improving patient safety”, “ECS information can help the most
vulnerable patients, e.g. those who are admitted over the weekend who have
no one to bring in their meds”, and “Before ECS we often had to ‘work
blind’ with no information at all.”
An evaluation using a survey was carried out in three Acute Receiving
Units where ECS is routinely used: NHS Forth Valley, NHS Lothian and NHS
Ayrshire & Arran. This found that:
• Clinical decisions can be more timely, more accurate and patient
• Hospital pharmacists are using it increasingly for medicines
• All the 24 pharmacists surveyed rated access to the information on ECS
as ‘useful’ or ‘extremely useful’
From hundreds of reports of clinical scenarios in which ECS was used,
these show direct clinical benefit:
• A relative phoned NHS24 on behalf of her elderly mother to ask which of
her mother’s medicines was the new one which had caused an adverse
reaction so that the correct one could be discontinued;
• An elderly man was an emergency admission with acute renal failure.
He had altered consciousness and no details of his drug history but his
ECS showed a new nephrotoxic drug. He was safely monitored off all drugs
instead of undergoing renal biopsy.
• A patient with mental health problems would have been admitted for an
overnight stay but this was avoided by using ECS which clearly showed his
Scotland’s program was mentioned four times in the full 230-page
final report, but dismissed apparently because its success was due to
Scotland’s population being below 5 million people. We do not think this a
relevant objection. Distinctive features of the ECS include:
• The ECS Program started with a clear purpose: to improve care by
providing only key medical details for clinicians directly providing
unplanned care, which defined its limits.
• It was led from the start by the clinical groups that agreed this
• Any proposed extension to other purposes or clinical users is controlled
by the Program Board with full consultation.
• The views of patients, including those with potential stigmatising
conditions such as HIV or mental health problems, were established early
by focus groups led by the Scottish Consumer Council.
• the two stage consent model has 2 features giving patients control of
their ECS record: “Consent to View” is asked from the patient at the
point of care, and patients can opt out completely by directly notifying
their GP practice Although SCR adopted the “Consent to View” feature
there was no simplification of the opt-out process.
• The shared record is more accurate, due to automatic twice-daily update
that is independent of user activity such as Smartcard use.
We have recently completed a critical incident study of the use of
ECS in NHS24 and this confirms that it improves patient care by making
decisions safer, as so many people cannot detail what medication they are
taking, especially in an emergency when they are ill or confused.
We therefore urge professional bodies, all Departments for Health and
other stakeholders to carefully consider experiences with all the
electronic record-sharing systems across the UK, in addition to the
Summary Care Record evaluation recently published in BMJ.
Competing interests: No competing interests
What has not been examined to date are the alternatives to pushing
data into a single database. The most accurate and complete records kept
on a patient are those held by the GPs. The move of all the clinical
system suppliers to enterprise systems and storage makes records
potentially available 24/7 from anywhere with an N3 connection. Patient
access to their own GP held records is already available to 70% of the
population, with the other two clinical system suppliers working on
providing the same. Patients could give access to any clinician needing
to treat them outside their home practice. Data would include their past
history, allergies, alerts and medication and could be viewable in out of
hours, extended hours and urgent and emergency care.
Why create a vast database of extracted excerpts, which will be next
to impossible to keep accurately synchronised, when direct access to the
full record (or the necessary parts of it) will achieve the goal of
providing the right data at the right time at the point of care. This
also removes the concern over the State having access to patient records,
since records would remain under the control of those entering the data;
system suppliers would look after storage; and patients would give consent
before any viewing.
Secondary care data gets fed into GP records to add to their
completeness. With the forthcoming 48 hour electronic discharge summary
this should cover most needs. For special cases such as renal patients
needing instant results, access to a portal web page pulling in both
secondary and primary care data would suffice. in such cases, data are
not extracted and stored, merely viewed, that viewing is recorded, and
then switched off.
The SCR was based on an unresearched and unverified need. The two
Greenhalgh reviews have revealed the errors in this approach. The public
by and large do not see the need for this and are concerned about
security. That is if the information campaign had reached them at all –
for most of them are still unaware of its existence or proposed roll out.
If there is to be yet another review, then it needs to research what
is already out there and working, and to identify savings that could be
made by using existing technology. It must be completely objective,
rather than being used to justify current policy.
Competing interests: No competing interests