Dr Colin Mitchell is a consultant geriatrician and divisional IT lead for medicine at Imperial College NHS Healthcare Trust. He is also a retired video-game reviewer from the halcyon days of 1996 and had a Twitter account @drcolinmitchell before most of you had heard of it. Credentials. He will be speaking at BGS Spring Meeting in Gateshead.
If you want to know what NHS hospital records looked like in 1985, take a look at NHS hospital records today. Unlike almost every other large scale organisation or industry, or even our GP colleagues, most hospital doctors in the UK still largely use paper records as part of the daily routine. But finally that seems to be changing. A bit.
The move towards Electronic Health Records is often described as inevitable, but that’s what they said 10 years ago! Remember the National Program for IT? That went well. Unfortunately this attitude also reinforces a feeling of lack of control – that these systems will be (eventually) forced on us without our say or involvement. In my opinion it’s this attitude that makes clinician engagement with electronic records so difficult to achieve, and that in turn makes the implementation of electronic records substantially less good than it should be. It seems that fear of change, concerns about information governance, and up-front costs lead to paralysis rather than progress.
Although electronic systems have infiltrated NHS hospitals into some clinical areas, often these are specific, separate systems, for pathology or x-ray reports, or specialty procedure results. Some of these systems are powerful and user friendly, like most PACS (Picture Archiving and Communication System) for x-rays, and I rarely hear people pining for the good old days of digging out films and physically chasing (or finding) reports. However many other systems are old or clunky, and few are connected to other systems or easily accessible. It is this (embarrassing) reality and the potential for improvements in efficiency and quality that have led both the Dept of Health and the 5 Year Forward view to commit to significant advancement in the use of clinical IT in the NHS. The King’s Fund report on digital IT concluded that better awareness and understanding generally, and clinician engagement particularly, was key to harnessing these benefits (1).
Geriatricians are in a strong position to be involved in the development and rollout of electronic documentation. We work in multiple settings and specialties, we access the full range of documentation, from nursing notes to specialist letters to community rehab referrals, and the aggregation of data and maintenance of active issue lists are part of our everyday work. By engaging early and often, and bringing a holistic mindset, we not only ensure that the records are fit for purpose but that they actually help us work better. For example, organisations are often keen to use the electronic record to police or enforce behaviour. Usually this is achieved by blocking access to functionality until certain conditions are met (eg completion of an admission Venous Thromboembolism risk assessment). Unfortunately the unintended consequences of this can be disastrous, including blocking of legitimate access, encouraging people to reflexively override blocks or enter junk data to make the reminder go away, and the alienation of professionals by making the record obstruct rather than assist.
Interestingly one of the side effects of the lack of clinician engagement is that patient engagement with electronic records is potentially a more powerful force for improvement – patients or their carers/relatives are increasingly expecting to be able to access information related to their health electronically, and progressively will expect to interact digitally as well – not just making or changing appointments directly (which is still far from standard, in the age of Uber) or viewing letters and results, but using their mobile devices and apps to add health-related data or interact with health professionals.
The current NHS Global Digital Excellence program has lofty goals to kickstart electronic implementation and innovation in the NHS by investing in trusts that are already relatively digitally ‘mature’, to allow them to move even further ahead. The idea is that these pathfinder organisations can learn the lessons and develop/customise the solutions and pathways that the rest of the NHS can use quickly and cheaply in their wake. Time will tell how this effects (or affects) progress, but at the very least it seems to be more likely to allow more local, flexible and agile use of resources than a ponderous national program. Certainly it seems to be a good time to declare an interest in Health IT and electronic records – it’s already allowed me to co-design a post-fall review form with junior doctors to guide their assessments and record data in useful places for quality assurance and audit, and a colleague (she’s non-IT literate, which is even better as it ensures the IT people explain things properly) is currently working on a tool and workflow document that flags patients up in any area as needing a Comprehensive Geriatric Assessment, aggregates frailty information, and helps to initiate further assessments and care plans.
At least in my trust, this is one area where us geriatricians are way ahead of our colleagues in terms of adopting new technologies and advances, and there’s no reason why this can’t be replicated all over the country. So get involved, or get dragged along anyway!
- Kings Fund Report: https://www.kingsfund.org.uk/publications/digital-nhs?gclid=CjwKEAjw5M3GBRCTvpK4osqj4X4SJAABRJNCoPhwHePnNeIcNkb-HEVfHF1rWCQF953pf78lv9OJdhoCQ7Hw_wcB