GP computing has been one of the great success stories in patient care and the use of IT in the NHS.
Since its earnest start in the early 1980s, GP records have gone from paper based narratives held in A5 Lloyd George envelopes to fully interactive records, capable of handling the complexities of modern patient care, including the Quality and Outcome Framework (QoF) used for performance related pay and its central reporting mechanism, Quality Management and Analysis System (QMAS).
Without the universal use of electronic GP records throughout the UK, neither the targets introduced in 1990, nor the 2003 new General Medical Services contract, would have been achievable.
In the North, Midlands and East (NME), the area where Computer Sciences Corporation (CSC) is the Local Service Provider (LSP) under the National Program for IT (NPfIT), CSC is planning to introduce Lorenzo, which is understood to incorporate GP records, by 2010.
At present, CSC are supporting TPP SystmOne as their official alternative GP solution, with a view to incorporating it fully into Lorenzo by 2010.
Managing shared records
A great deal has been written about access to medical records held centrally, including the Summary Care Record (SCR) and the risks of unauthorised access. However, as far as I am aware, little or no attention has been paid to the management of the record itself. Has full consideration been given to the management of how such shared records should be arranged?
Lorenzo is planned as an early manifestation of the SSEPR (Single Shared Electronic Patient Record), defined as “a single electronic patient record for each individual patient used by, and contributed to by, all the organisations caring for that patient”, and scheduled to be introduced within two years.
Regardless of the access controls (and who controls access permissions), there are problems in managing a SSEPR which should concern everyone – and for which at present, I believe, no-one is claiming responsibility.
According to board minutes, Yorkshire and the Humber SHA is currently introducing a new shared record system to local NHS organisations, using a GP system with an integrated community module. The approach used within the TPP SystmOne SSEPR is understood to only let records be amended by whoever made the original entry.
The rationale for this is that the record also belongs to the organisations outside the general practice and only the organisation making the entry can change it: GPs can alter GP entries, community can change community entries and so on.
But using shared records that can only be amended by the service that made the original entry may present some worrying hazards.
Take the example of the patient who is sent to chiropody and returns with a diagnosis of diabetes mellitus, which the GP knows to be wrong; the entry on the records can then only be amended by the service that made the wrong diagnosis originally.
Currently Diabetes Mellitus gets picked up quickly thanks to the searches developed for QOF, and it is expected that patients with the diagnosis have the disease and should be managed appropriately.
Managing future veracity disputes
How in a future of SSEPR will disputes about the veracity of entries be resolved? How can we ensure safe patient care while such matters are being discussed? How much time should we allow to resolve queries about other practitioners’ opinions and diagnoses?
Have such data conflict and veracity problems already occurred? If they have, what is the strategy that has been developed for managing them, and does it work? What are the information governance and audit policies? Finally, who has final say when such problems occur?
I am not sure whether any community can, in a second episode of care, change the information entered in a previous episode, quite possibly in a different community trust.
If the data includes prescribing it would seem that there is a considerable risk of inaccurate information being preserved – rather than being corrected when spotted – with potential risks created to medical care, life insurance and job prospects!
Medical records need to be changeable
In a medical record, it is important that diagnoses are accurate if the record is to be used in the management of the patient, and changeable if the condition is disproved or evolves into something different over time. Most GP systems can deal with this by keeping the diagnosis originally entered in text and showing the coded diagnosis which replaces it, thus removing the mistaken diagnosis from problem lists, searches and decision support.
Has this problem been considered in the development of Lorenzo and other SSEPR systems? If so, where can the solution be found, and accessed and who is charged with dealing with the queries of future prospective users?
Lorenzo, as I understand it, is intended to provide a further development in the integration of medical records across different NHS organisations, and include hospital as well as GP and community records.
I’m a GP and my practice has been paperless since 1997: believe me, records do not take care of themselves – and Read Code is not easy to use at the best of times. I have a great deal of sympathy for those outside general practice who have different requirements for record keeping – both hospital and community deal with narrative records of episodes of care, or repeated, care for single conditions rather than the cradle-to-grave GP record – and have had no previous training in the concept of the EPR or Coding, whether Read Code or its planned replacement, SNOMED-CT.
Unanswered questions
With this being the case I find it surprising that what seem to me to be key questions surrounding the management of the record remain unanswered. Who, in this SSEPR, for instance, is the Data Controller and Caldicott Guardian?
Who is responsible for maintenance of data quality – including correction of errors and how prescribing is to be managed? Not a trivial point as the person who signs the prescription is legally liable.
Further questions include: how will data that requires action – such as abnormal blood results – be handled? Similarly, the question of what the effects will be on existing mission critical interactive GP records, does not appear not to have been considered.
If they have been considered and policies set, the agreed solutions are not readily available and have not been clearly communicated or published. Or, if they have, I’ve not been able to find them, and I’ve spent time searching for them.
In the worst case scenario, if GPs are persuaded to migrate to an LSP solution and their records are degraded, what might be the consequences? One scenario could be that GPs in NME will have their accreditation to hold electronic records withdrawn and be forced, in the interests of patient safety, to revert to the Lloyd George envelope!