My practice was an early adopter of online services, and we promote them heavily.

For prescriptions, we prefer this route to manual ordering or community pharmacist ordering, since pharmacists appear to over order, wasting money, and online takes away the paper.

At the moment, if pharmacists or patients hand in a repeat slip with items ticked, then there will often be messages hand-written on there as well. Our admin girls have to translate these slips and messages for a GP.

Online its much smoother; a patient just ticks what they need and it just appears in an ‘authorise’ box.

A change is not always a rest

That’s not to say we couldn’t improve the process. At the moment, everything comes into one box, so repeat prescription authorisations end up in the same place as a lot of other stuff.

We would like the prescription requests separated out, so our practice team could review them before a doctor sees them.

I think this is an example of our clinical system still ‘thinking’ it is running a small old surgery and not ‘thinking’ about how things should work for a 20-30 GP surgery with an entire pharmacy team in house.

A lot of processes differ in a big and in a small practice, an I’m not convinced the system is flexible enough for big practices.

Indeed, change can sometimes get in our way. We used to have the option to limit the GPs that a patient could choose when they booked an online appointment. We limited this to their usual GP. Now this option has been taken away from us.

The problem is that patients often like the next available appointment. So I could give you endless examples of patients who now come into see me, saying: “I was asked to come in and discuss my results.”

“Yes,” I reply, “but with your usual doctor not me. Your usual doctor knows why s/he did the test and what they thought the results would mean.

“I don’t; and am now going to have to go through it all with you again.” Also, it makes it harder for my patients to see me if I’m seeing other people’s patients because I had an earlier appointment at the point that they booked.

We need triage

Another issue is that our current online service platform has no triage built in. For ages now we have been encouraging our receptionists to ask what is wrong with patients.

Not to be nosey, but to direct them to the right person/service. We have instant access physio, pharmacists and other clinics, for example, that don’t need a GP appointment.

We need the online system to do the triaging that the receptionists can do. Interestingly, there are several solutions cropping up. The Hurley Group and Harry Longman have options.

These seem to filter the appointment request. They take a history from the patient and present it to the GP, which might save time. They aim to pick up trigger words red flags, while diverting trivial things to alternative services.

I believe Harry’s system is an extension of his system (GP Access) to enable GPs to vet their appointment requests – that’s not actually what I’m after, although I gather others have had good results with it.

I would like something that can do most of the triaging without me. For the moment, though, I’ve not tried these newer options. I worry they are expensive and aren’t flexible enough for my local needs; but perhaps I’m wrong, or it’s just early days, and I need to bite the bullet, have a go, and feedback on any issues that come up.

Meanwhile, around the time that Emis took away the ability to limit appointment requests to specific GPs, I noticed that it also allowed third parties to produce alternative booking options. PAERS seems to have been authorised as an alternative supplier; though I can’t find anything about it on their website.

This is interesting, as it might open up the whole system. I’d love to see what PAERS and others are thinking of in terms of online services.

I hope they’re thinking bigger than just displaying medical records to patients and inputting blood pressure readings from iWatches. I hope they’re thinking about making appointment booking better.

Electronic communications: nearly but not quite with us

Joe McDonald’s latest column talked about the cost of mailing people. This is something we have picked up in GP land for a while. Our annual 5000+ letters re our flu clinics are quite a cost, even with a franking machine.

There are several companies who offer an interesting service to take off some of the pressure. They install a printer driver onto your system that, when you hit print, sends the letter to them. They print it, fold it, put it in an envelope and post it for you.

Alas, while it’s cheaper when you take into account the paper, the envelopes, and then time taken to get one into another, it never seems that much cheaper in direct costs. A lot of practices are now using these services for one-off letters as well as bulk mails; but as Joe says there are significantly cheaper ways of messaging people.

Why not use electronic mail? Well, there are several companies having a go. MJog and iPlato are text messaging companies. Their default product is appointment reminders – automated SMS messages remind people about appointments to reduce ‘did not attends’.

Their two-way product allows people to confirm/cancel appointments; which is great. You can use them to invite people to things like smears, from which they can actively opt out – not just ‘non respond’.

But it would be interesting to be able to send more complex messages (as with Twitter, 140 characters sometimes isn’t enough).

Both mail companies and SMS companies seem to be working on either apps or websites that allow practices to communicate with patients. One appears to recognise whether a patient is known to the practice and emails them if it has an email address and posts if they don’t.

However, I’ve looked at the products and I don’t think one of them is clearly ahead at the moment. The problem they all have is that the security and information governance isn’t quite right.

Remember: the confidentially rules are very tight. A scenario from IG training is: ‘a police officer comes to reception, and asks for a list of patients in the waiting room, as somebody has been attacked outside; can you hand it over?’ You can’t.

The fact that a person has/d an appointment is confidential. I worry about practices that put patient names on call boards or call out their names.

A husband picking up their wife’s phone shouldn’t be able to accidentally read a message about her contraception or lack of it – or, worse, her HIV. In theory, he shouldn’t even know she is in communication with her GP.

Secure app suppliers – try the NHS!

Interestingly, some apps exist that allow secure, encrypted, end-to-end messaging that only display the messages when you are in the app – Threema, for example. These aren’t in the health arena, yet, but perhaps there is a syngergy.

I think we are on the cusp of a revolution. Opening up the interface between the patient and the practice will allow for some innovations. The ability to securely message a patient from the practice efficiently and cost effectively will be a huge productivity gain.

 About the author: Dr Neil Paul is a full time partner at Sandbach GPs; a large (23,000 patient) practice in semi-rural Cheshire. He is also one of the directors of Howbeck Healthcare Ltd, which helps support several GP Federations.

Dr Paul has been involved in primary care IT and health service management for more than ten years in various roles, including PEC member. In his spare time, he writes medical iPhone software and is a keen photographer.