Going Paperlight

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Going Paperlight

• Planning
• Real Practice
• Accreditation
• Dr Angus Goudie, Kepier Medical Practice,
  Houghton le Spring

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Where are you now?

• Do you have any patient data JUST on the
  computer?
• Do you use the computer for repeat prescribing?
• Do your GPs and Nurses record all their
  consultations JUST on the computer?
• Are your incoming and outgoing patients letters
  stored on the computer?
• Are messages and telephone contacts recorded on
  the computer?
• Are you accredited for any data JUST on computer?
• Is your office still awash with sheets of paper?

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IMT DES

• Level 1,
• Leads appointed ,assessment, IT Plan
• Training assement
• Information Governance
• Level 2 Data accreditation/ Paperlight
• Notes summarisation for Spine upload
• Requires we are paperlight - in theory accredited
  now.
• In practice linked to paperlight accreditation by
  PCT
• Address updates and ePS
• Data hosted on CfH approved server

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Key features for the paperlight

• Evidence that Adhere to Good Practice
• Sheet to fill in for the PCT
• Protocols for everything see below
• Data Accreditation queries (This morning)
• Assessment Visit
• Patient consent for their notes to be checked
• OK given for DES component 2
• OK for record to be held all/partly on computer
• This is for 3 years for the modules we use
• Can be for 1year, pending evidence
• Can be appealed against (LMC role etc.)

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Where are we coming from?

• Kepier Medical Practice
• 9300 patients.
• 5 FTE GPs, nurse practitioner and GP reg
• Until 2002 in very overcrowded Health C.
• Short of filing space
• Short of rooms
• Keen to do the best job for our patients

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Why Electronic Record

• Information for Health (1998)
• electronic lab results by 2002
• promise of 24 hour access to records and GP to
  GP transfer by 2005
• Planned local electronic discharges 2002
• Promises and frustration
• 2000 Validation GP computer records.

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GPs reasons for EHR

• Clinical Quality
• Clinical Governance/Audit
• Miquest
• Easy access to full record from
• Surgery, Home and ? on Visits
• NSF data sets and templates (IHD etc.)
• Computer guidance on screen
• Mentor / Prodigy/ Local Guideline

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Our Reasons

• Lack of space for paper filing
• Lack of availability of notes for team
• Dual entry of searchable information
• Illegibility
• Notes frequently missing

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Practice History

• 10/89 First computer
• 9/92 New System (EMIS) every GPs desk
• 1994-5 GP links (Reg IOS) and Fundholding
• 1994gtgt Increasing use of templates
• 6/97 NHS Net (email/ internet)
• 9/97 GPs/Nurses consult on computer only
• 3/98 Too many changes-staff roles.
• 1998 Summaries, Scanning and Printouts
• Now For accreditation Full documentation
• Who is responsible?
• What is the procedure?

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What Paper?

• Paper In
• Non paper data
• New Paper
• Surgery
• Visits
• Phone Calls
• Paper Out

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Incoming Paper

• Hospital Letters
• Laboratory Results
• Case Conference reports (see child protection)
• Local Guidelines
• DOH papers (HSC)
• Data sheets
• Meeting agendas/minutes
• Advertising
• Notes from last practice (see later)

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Typed Letters
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Typed Letters
Hospital Letters 600/week
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Typed Letters
Hospital Letters 600/week
Date-Stamped Scanned
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Typed Letters
Hospital Letters 600/week
Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
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Typed Letters
Hospital Letters 600/week
Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week

• Alternatives
• Staff code the problems, BP, Bloods, ECG, XR etc.
• Can use templates
• Drs see post before staff and highlight

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week
Types of Scanning
Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week

• Types of Scanning
• Cut, OCR and paste

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week

• Types of Scanning
• Cut, OCR and paste
• Attach image files

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week

• Draw-backs

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week

• Drawbacks
• Slow

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Typed Letters
Hospital Letters 600/week

• Drawbacks
• Slow
• Stupid when already a computer file at the
  hospital

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Handwritten Letters
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Handwritten Letters
Letters (handwritten/provisional/non-scan-able)
Doctor Reading Coding Action (themselves or
highlight for secretary)
Kept till Full discharge letter or review at
2months.
Date stamped Logged on computer
Computer Visit List (Discharges only)
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Handwritten Letters
Letters (handwritten/provisional/non-scannable)
SHREDDED
Doctor Reading Coding Action (themselves or
highlight for secretary)
Kept till Full discharge letter or review at
2months.
Date stamped Logged on computer
Visit Book (Discharges only)
? Keep some limited types (under review)
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Electronic LettersHoped for in 2002 from
Sunderland ENT
Incoming Electronic Letters
Doctor Read, Code file on PC
Computer note to PN or receptionist re any action
SHREDDER SCANNER
Almost Obsolete
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Electronic Letters Achieved

• Hospital ENT and Diabetic Clinic on hospital
  computer with web access and could be cut and
  pasted
• OOH service using Adastra send text document that
  will import like lab links into EMIS. (ugly but
  better than fax and scan)
• Minor injuries unit send to windows for us to
  action. (Graphnet/ GePMail)
• Pilot 6months, part coded
• Needs snagging

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Non Paper Data In

• Phone call from
• Hospital
• Pharmacist
• Relative
• Patient
• Request for script on on repeat list
• Report re hospital appointment
• Report re reaction to treatment
• Patient related messaging between team

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Consultations

• Surgery
• Doctor
• Practice Nurse
• District Nurse/Health Visitor/Midwife
• CPN/ Social Worker/ Counsellor
• Use of templates for data quality etc.
• Telephone calls
• Visits

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LV Template
From Northern network of cardiac care Primary
Prevention Toolkit www.nncc.nhs.uk/toolkit

• (next 5 slides)

• Template includes all data needed for
  Hypertension
• (including QOF exclusions etc.)
• Smoking, alcohol, exercise, weight and linked
  advice
• ECG, bloods etc.
• Calculated CVD risk and allocated JBS2 risk band

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Child Protection Template
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LV Template

• (next 5 slides)

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Visits

• Summary Printout (whoops thats paper!)
• Dr to transfer notes back to computer
• Doctor dictates for secretary
• Palmtop Computer
• Laptop Computer gtgt
• Telephone card in laptop- wireless link to
  practice.

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Paper Out

• Prescriptions (ePS on the horizon)
• Lab requests Forms/labels. ?electronic
• Referrals
• Certificates (paper so far)
• Insurance report automatically generated
  edited printed. (Secure Web transit)
• DSS reports (still paper.why?)
• Note request from solicitor printout of notes
• Patient leaving practice

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Insurance Report

• Timesaving
• Legible
• Very acceptable to Insurance companies
• Set up to National eGPR standards
• But
• Relies on data being entered onto system
• Summaries being updated

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Farewell to the patient

• Note transfer to their next GP

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How we pass on the computer record

• Farewell patient print out
• Active problems
• Medication
• Allergies, family history, immunisations
• Latest of each type of value/ test result
• All consultations since September 1997
• Printout of patient letters (since mid 1998)
• Case conference reports
• A copy if relates to more than one family member
• Computer record tagged as reminder to do this.

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Article and template on patient data page
of www.sunderland.nhs.uk/beacon
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GP2GP and CD transfer 2007/8
Image Files Recent scanned letters
Text letter/ Word documents

• Text File
• Practice details
• Confidentiality statement
• File types and how to use

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GP2GP and CD transfer 2007/8

• GP2GP over 500 practices using it for EMIS to
  EMIS.
• First EMIS to Vision piloted
• Will be some time before universal
• Coding issues?
• CD transfer requires PCT approval of the practice
  and method security/Info Governance
• Slow to import and not coded
• http//www.tinyurl.com/pubac

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Incoming patient notes

• Need to summarise
• Data is more than unsearchable text
• Summary Contents
• Diagnoses
• Immunisations
• Allergies
• Test results for chronic disease (QOF e.g.)
• Who to do it?
• Updating summaries and recording updated
• Who? How often? Where?
• Ideal is clinicians with patientsBUT
• 3 per surgery per GP/ Nurse to keep most
  lt24months
• Lists of overdue summary updates

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Sunderland NoteBusters list www.sunderland.nhs.uk/
templates Page marked Coding and templates Word
and Excel
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Dangers

• Power Failure
• Down Time
• Unexpected Crash
• Hard Disk Failure
• Computer Virus
• DES Physical security policy, Disaster
  Recovery Plans

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General Protection (DES)

• UPS to avoid loss of data if power cut
• Nightly backup to protect stored data
• Protocols for staff
• In anticipation of shutdown
• In event of loss of clinical computer
• Other backup appointment lists.
• Antivirus
• Hosted service Supplier/ PCT

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Confidentiality/ Security (DES)

• Individual allocated security role
• Fully implemented security policy
• Passwords/ smart cards/ third party users
• Lockdown/ log-out
• Any home working risks/ agreements
• Paper shredding/
• Use internet/ discs/ downloading
• Awareness of Good Practice Guidelines
• Data protection registration
• Patient notice of policies data/ sharing
• Security of information transmitted
• Fax/ verbal/ email/ mobile/ voicemail/ enquiries

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Has it worked?

• Getting there, still some paper
• Painful lessons re
• Time
• communication
• insecurity of new roles
• regular update protocols and need for everyone to
  know
• Need to keep on top software updates etc.

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Has it worked(Problems)

• What is going on? Barbara says you told her to
  cut and paste.
• Id rather file the letters in L-G again
• What are these new printed physio forms?
• The scanning is still tedious. (BUT)
• Laptops not rolled out yet...
• Lab results still need checking, improving.

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Lessons for us

• Plan out stages in advance (Incremental)
• Involve everyone. ? A bulletin/news board/
  meetings.
• Know who will do what (and write it down)
• Know who will troubleshoot (pref. not Dr.)
• Practical/ Technical/ Very technical/ Emotional
• Regularly take time to review TOGETHER

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Lessons for us

• Be bold to discard duplicates. But think.
• Build in safeguards but review these too.
• Admit your mistakes.
• BUT
• Remember all we can do now that we could not do
  before computers.
• Easy to forget the hassle and ignorance.

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Help from the Trusts

• Readiness to allow community staff to enter
  clinical data on our EHR
• Move to electronic letters. Until then where
  possible white, typed AE forms
• Pressure suppliers where hospital software unable
  to cope with output automatically.
• Training and explicit confidentiality policy now
  wider team accessing records.

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Help from PCT and CfH/NHS

• Training courses for staff / protected time.
• Enough local technical support to install, update
  and troubleshoot. Address books, antiviral,
  intranet.
• Facilitation of projects
• DES accreditation procedures
• Summarisation and archiving
• electronic prescribing
• practice web sites and intranets/ extranets
• Financial backing of progress
• Clinical input into new solutions

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Into the Future

• The biggest step is behind us
• Advantages clinically and in audit/QOF/
• A summary/record worth sharing
• The Spine or locally
• Plans for eLetters, DN record, web site
• More work on common templates/data quality
• GP2GP and ePS

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Who do our systems serve?

• Dont forget the Patient