There is currently a revolution in health informatics, which will move clinicians from recording patients' medical records in a written format to recording them in electronic format. This transformation is not unique to the UK or the NHS. An internet search for 'electronic health record' will identify work being carried out by the governments of Australia, Canada and the USA, to name but a few.
An electronic patient record (EPR) is a longitudinal record of periodic care provided mainly by one institution. Typically this relates to the healthcare provided by an acute hospital or a GP.
An electronic health record (EHR) is a longitudinal record of a patient's health and healthcare from cradle to grave. It combines information about the patient's contacts with the primary healthcare team and subsets of information associated with the outcomes of periodic care in the EPR, e.g. mental health, acute hospital and the community medical teams.
Many GPs are unclear about how the EHR will work in practice and what will be included in this record. This article will explore some of these issues and discuss possible options for the future.
The transformation from written patient clinical records to EPRs started in the early 1980s. Initially, EPRs were used for specific tasks such as repeat prescribing and call/recall for cervical smears.
During the 1990s some practices decided that it was not possible to keep adequate electronic and written patient records, so they decided to opt for a single record, mainly the EPR. This technically breached GPs' terms of service, but no action was taken to stop GPs doing this.
In October 2001, agreement was finally reached between the General Practitioners Committee of the BMA and the DoH to legitimise the EPR, replacing the written record. At the time this agreement was reached it was estimated that 15% of practices had abandoned written clinical records. It is currently estimated that 30% of practices are primarily using an EPR.
One of the unique qualities of general practice in the UK is a 'cradle-to-grave' clinical record. This is a strength that is envied in many other healthcare systems, and it will remain an important aspect of general practice in the future. The DoH document Information for Health1 proposed that a cradle-to-grave EHR should reside in primary care.
GPs could see this as a clear statement that the prime record would be held within a practice, as it is now. Some primary care organisations, such as PCTs, have a different view: they envisage the PCT holding all the EHRs of their patient population, with GPs and other healthcare professionals accessing the patient records held remotely. EHRs would then replace the clinical records held in a practice and hospital.
Several PCTs and health authorities are exploring the possibilities of what an EHR would look like. Examples can be found on the National Health Service Information Authorities (NHSIA) website. The pilot sites are called ERDIP (electronic record development and implementation programme) sites and can be located at http://www.nhsia.nhs.uk/erdip/).
Primary functions of the EHR
The primary functions of the EHR are:
- To help with patient care
- No provide the clinician with 24-hour access to relevant patient information
- To ensure confidentiality and secure access
- To ensure the appropriate use of clinical data for healthcare administration, clinical audit and research.
What is required to produce an EHR?
- A comprehensive clinical record for a patient
- Information collected and stored in a format that is consistent across all users
- Some GPs consider it desirable to have clinical decision support to assist with patient care. This is not universally popular among clinicians, but has great support in the DoH. PRODIGY is one example.2
- Controlled access to appropriate patient information by relevant healthcare workers
- Access by hospitals, GPs, out-of-hours cooperatives, walk-in centres, NHS Direct, community staff and social services.
Models of EHRs
Two models of an EHR have been proposed:
A central model
In this model, a central repository would hold all the information that comprises the EHR. All users – the hospital, GP, community staff and social services – would have controlled access to the data.
There are two alternatives to this general model:
- All data on individual patients would be held on the central repository. This would include the full GP records, full hospital records, full community records and full social services records. Technically this may appear to be the simplest model, but it has many drawbacks, not least the sheer volume of information that may need to be searched to find a specific item. It may also prove difficult to ensure restricted access to different parts of the EHR.
- A variation of this model would be for each organisation to hold its own EPR, and make specific data available to other NHS organisations. For example, there would be an EPR for GPs, hospital, mental health and social services. If a GP in an out-of-hours centre or a casualty office required access to information about a specific patient, the EHR of that patient would be available.
A distributed model
This is a variation of the second model described above. In this model each organisation would hold its version of the EPR, and defined data would be shared in a centrally held EHR.
A timetable of staged development has been laid out in the document Building the Information Core – Implementing the NHS Plan.3 These stages are essential to the establishment of an effective EHR.
By March 2003:
- All radiology reports, and discharge summaries to be transmitted electronically between hospital and GPs
- The change from Read Codes to SNOMED Clinical Terms to be started.
- All practices to have disease registers in place
By April 2004:
- Electronic prescribing to be available.
- A vibrant networked NHS
- All bookings from GPs to outpatients to be electronic
- Electronic transfer of records in primary care
- All Trusts to have level 3 EPRs
- The first generation of EHRs to be in place
- All local health services to have telemedicine, allowing patients to connect with staff electronically for advice.
Proposed EPR levels are shown in Figure 1 (below).
|Figure 1: Proposed EPR levels|
Advanced multimedia and telematics
Level 5 plus telemedicine, other multimedia applications (e.g. picture archiving and communications systems)
|Level 5||Specialty specific support
Level 4 plus special clinical modules, document imaging
|Level 4||Clinical knowledge and decision support
Level 3 plus electronic access to knowledge bases, embedded guidelines, rules, electronic alerts, expert support systems
|Level 3||Clinical activity support
Level 2 plus electronic clinical orders, results, reporting, prescribing, multi-professional pathways
Integrated clinical diagnosis and treatment support
|Clinical administrative data
Patient administration and independent department systems
A personal view
It is essential that a comprehensive 'cradle-to-grave' medical record remains the cornerstone of general practice.
It will become increasingly important for the EHR in general practice to be a primary care EHR: community nurses, health visitors and other members of the primary healthcare team should therefore start using the practice EHR as their prime records.
Integration of these records has much to offer all healthcare professionals in the care of their patients. There are some well-rehearsed arguments why integration is not possible, but if the primary healthcare team is to be effective, then integration is important. It is also important to maintain a comprehensive EPR at the hospital and in the community for mental health and childcare.
It is unnecessary for primary care, the hospital and the community to share all the information that each holds on a patient with the others. What is required is a central database held on each patient that would contain all the important information, with controlled access.
Each provider would need to agree what information would be shared, for example:
- Summary of medical history – major diagnosis only
- Current medication
- Summary of medical history – major diagnosis only
- Laboratory tests performed in the past 5 years
- X-ray results in the past 5 years
- Outpatient letters and discharge information in the past 12 months.
- Major diagnosis
- Any action taken under the Mental Health Act
- Whether currently under the care of the mental health team.
- Details of social services current input to patient.
- If a child – details of the at-risk register
- Details of carers.
For the information to be stored in a central repository, consent of the patient would be required. If a patient decided that he/she was unwilling to have this information held, a mechanism would be needed to stop the information being shared.
If social services were a contributor to this information, agreement would need to be reached as to the extent of health data that would be available to social services.
A central data repository would prove invaluable in the examples shown in Figure 2, below. These are all situations that have been experienced recently.
|Figure 2: Examples of situations where a central data repository would be invaluable|
Consideration also needs to be given to sharing of health information between the NHS and the providers of private healthcare.
I believe that the only workable solution is to have a separate EHR, which is used in separate parts of the health service, all of which contribute to a central EHR that is essentially a summary of all the others.
- The views expressed in this article are personal views and do not necessarily reflect the views of the BMA.
- Information for Health: An information strategy for the modern NHS 1998-2005. NHS Executive 1998. Also available at www.nhsia.nhs.uk/text/pages/info4health/contents.asp
- Watson N. Improved PRODIGY will include chronic disease management. Guidelines in Practice September 2001, 4(9): 96-101.
- Building the Information Core – Implementing the NHS Plan. NHS Executive January 2001. http://www.doh.gov.uk/ipu