Over the past few years, throughout the country, millions of pounds have been invested in computer equipment for GPs. Despite this, many practitioners use only a very small proportion of the functions available to them.
If they are to achieve the targets and milestones set out in the Information for Health1 strategy, they will need to rethink the way they use their clinical systems and abandon paper records.
In addition, as the Government imposes more National Service Framework standards and the requirement for audit increases, electronic records will be the only way GPs will be able to monitor the delivery of these targets.
Electronic records in practice
The Bishopgate Medical Centre in Bishop Auckland has been a Beacon Practice for electronic records for 2 years.
We have held monthly half-day events for practices keen to make better use of their IT systems. I have been very encouraged by the enthusiasm of the doctors and their staff who have attended. I hope that, following their visit, many had the courage to abandon their paper records.
The events were also a learning process for us and we benefited from many of the questions and comments received. They gave us the opportunity to rethink some of our procedures and to make sure that systems put in place many years ago were still valid and being implemented.
Our practice of 13 000 patients is centred in a small town in County Durham with high levels of deprivation.
We have six partners, four practice nurses and the usual complement of attached district nurses and health visitors. We also have in-house clinics offering physiotherapy, acupuncture, dietetics, chiropody and counselling. Everyone attached to the practice is expected to enter data onto our clinical system.
We first obtained a computer in 1985 – a free system from a drug company to run a trial. It had no hard drive and although we used it to generate recall letters for immunisations, it was probably more trouble than it was worth.
It did, however, allow us to see the potential benefits of computerisation and this encouraged us to buy our first 'real' system. This was the Ciba Geigy Practice Management System, which later became AMC, and later still Meditel.
At this stage, and despite being very non-technical as a practice, we became hooked on IT and invested a great deal of our own money in computers.
However, progress was slow in the early years and it was only the benefits offered by fundholding that allowed us to make rapid progress in the 1990s. This gave us computers on every GP's desk and we began to use them for our acute prescribing.
We also took part in the RCGP weekly returns service which involved us in Read coding every consultation and submitting the data at the end of each week. We still do this and the data are used, among other things, to give early warning of flu epidemics as data flows in electronically from spotter practices across the country.
As a practice we became disciplined in coding every consultation on the computer; however, duplicating the data in our Lloyd George notes took up valuable time in the consultation.
The move to abandon paper records became an obvious necessity and the changeover to electronic records was easily and quickly achieved by all the GPs, who were then in a position to impose this change on everyone else working in or attached to the practice.
What does it mean to be paperless?
We have tried to get rid of paper as much as possible in our surgery. Unfortunately, secondary care is at least a decade behind general practice with regard to IT, and at present all communication to and from hospitals is on paper, the only exception being laboratory results.
The first point of contact for patients is the receptionist. The appointments system is completely computerised, efficient and allows audit of consultations and waiting times.
The arrival time of the patient in the surgery is noted on screen. The patient is called by the GP using a JAYEX (electronic display) board in the waiting room, which shows their name and the name of the doctor they are to see.
The appointments are backed up on a floppy disk every evening so that even if our system crashes we have a copy of the day's appointments that can be run on any stand-alone PC.
In the consultation the GP relies entirely on the computerised record. There is therefore no need for the receptionists to waste time getting notes out for surgeries or filing them afterwards.
The GPs are expected to Read code anything that is important and will need to be recorded at a later date. Obviously any diagnosis made must be coded, but we also code such things as blood pressure, peak flow rate, family history, height, weight and smoking habit.
The GP is also expected to enter details of item-of-service claims such as immunisations, FP1001s, and minor surgery. This ensures that the claim is made at the time, so there is less chance it will be forgotten and the staff workload is reduced.
Details of the patient's history and examination are entered as free text and their medication is entered as part of the prescribing module.
Once GPs become reliant on the computer it is possible to add prompts to guide them through certain consultations. We do this by offering protocols and templates when certain diagnoses are entered.
We also prompt them to refer under certain conditions – for example to the dietitian if the patient's BMI is high. The computer will also warn if a drug the GP is attempting to prescribe will affect our prescribing incentive scheme and offer an alternative.
GPs have access to online help in the form of either Mentor or PRODIGY and there is also an electronic BNF as part of the package on our system. For more detailed help we have a CD-ROM server in the practice with access to the Oxford Textbook of Medicine and The Merck Manual of Diagnosis and Therapy.
Now that we have access to NHSnet and the internet, a huge range of online information services including the National electronic Library for Health, the SIGN guidelines and eGuidelines, is available to us.
Communication with others outside the practice
Pathology results and X-ray reports are downloaded from our local hospital. We have instructed our local laboratory not to send us paper results and have relied solely on Laboratory Links for many years now.
We feel that this has improved our efficiency, as all results are checked online by the GP, comments are entered and the result is filed in the patient's electronic record. When the patient phones in for the result the receptionist simply has to look it up on the computer and relay the doctor's comments.
As all laboratory results are entered in the patient's notes, it takes no extra effort on our part to demonstrate, for example, that the majority of our CHD patients have had their cholesterol measured within the past year.
One problem we have encountered is that without paper records it is difficult to retrieve 24-hour blood pressure readings and ECGs done in-house.
We have solved the problem with ECGs to some extent, in that they are now recorded directly onto computer and we have access to the readings over our intranet.
The next version of our clinical system will allow us to attach those files directly to the patient record and anyone considering the purchase of an electrocardiograph, spirometer, 24-hour blood pressure monitor etc. should ensure that they record directly onto a PC and that the files are compatible with the clinical system.
Hospital letters remain a problem. We have been trying to persuade our local hospital to email us discharge summaries for nearly 10 years, and they seem no nearer to doing this now than they were a decade ago.
We therefore scan all our hospital letters into our clinical system. Our data entry clerks Read code the main diagnosis, highlight any action that needs to be taken by the doctor and pass the letter to the GP to read. The GP takes the appropriate action and then shreds the letter.
As all our attached staff input data directly into our clinical system, they have access to all relevant data on the patient and we can see which of our attached staff are involved and what they have done.
We have therefore delivered the Government's vision of an integrated primary and community electronic record and have seen the benefits.
Support from our PCG
Since the demise of fundholding, GPs have been dependent on their PCG for IT support and funding. Fortunately, in the Durham Dales, our PCG has invested around £1 million in IT across all of our practices and has encouraged a move towards completely electronic records.
It has moved all practices to a single standard clinical system and has funded all new IT investment at 100%. As a result the majority of practices in the Dales are now virtually paperless.
Our clinical governance standards depend on IT audits and there is even an incentive scheme related to the extent to which practices use IT (see Figure 1, below). This tries to reward GPs who achieve the Government's milestones, and reimburses them 100% for maintenance of their system if they succeed.
|Figure 1: Electronic patient records – levels for primary care|
The move towards electronic records is inevitable. It can dramatically improve the efficiency of general practice, it saves GP time in the consultation and has the support of the Government.
GPs should involve their primary care organisations and demand 100% funding for their computers. If we are to deliver the Government's agenda, and realistically we have no choice but to do so, we need to put our trust in IT and abandon our obsolete paper records.
- Further information can be obtained from Dr Stewart Findlay, Bishopgate Medical Centre,178 Newgate Street, Bishop Auckland, Co. Durham, and from the website at http://www.dalespcg.co.uk
- Information for Health – An Information Strategy for the Modern NHS 1998–2005. NHS Executive, 1998.