Significant computerisation of general practice started in the late 1980s with the advent of the free computer system. Several companies provided practices with hardware and clinical software at no cost, and in return anonymised patient data were transmitted. This information had a commercial value and was then sold to third-party organisations. This scheme rapidly increased the use of computers in general practice.
In the past, development in practice computing has largely been led by organisations external to the NHS. Developments have occurred in response to new technologies and what the independent clinical computer suppliers thought were the needs of the market.
To enable electronic patient records (EPRs), transmission of clinical data and integration of primary, secondary and community care, a global view of strategy and implementation is required. Information management and technology (IM&T) development is nowbeing driven by the NHS management to ensure that the Health Service can deliver the NHS Plan.
Why is a practice computer development plan needed?
Practices have traditionally funded their computer development through GMS Cash Limited (GMSCL) budgets, often only receiving 50% reimbursement, and through fundholding savings; more recently, funding has come from Project Connect, at last reimbursing 100% of the costs.
In future, all developments that are reimbursed will need to be detailed in a PCG/PCT primary care investment plan (PCIP). It would therefore benefit both the practice and the PCG/T if each practice had a clear idea of where it is now and where it wishes to get to.
A possible primary care computer development plan
A brief description of the practice, structure and ways of working:
- Number of GPs
- List size
- Number of employed staff
- Number of attached staff.
Current uses of the computer: EPR
- Clinical records
- Items of service links
- Pathology links
- Acute and repeat prescribing
- Cervical smear call/recall system
- Immunisation records
- Basic biometrics
- All investigations
- Some or part of the consultation
- All consultations
- External text information
- Appointments system
- Health promotion
- Chronic disease management
Does the practice use any additional computer software?
Review of current computer system
- System supplier and version of software, e.g. Torex, Emis or In-Practice systems.
- How many 'dumb terminals' are still being used? How many PCs/ workstations are being used?
- The server is probably the most important piece of hardware you have. How big is the hard disk and what is the speed of the processor? Some practices have more than one server, i.e. one for the clinical system and a separate one for a windows network.
- What is the current system for daily back-up of all data?
- Which word processing or spreadsheet software is used? The NHS appears to be moving universally to Microsoft Office, Word and Excel.
- By March 2002, all practices should be connected to NHSnet and have desktop access to external email and web browsing. To achieve this a practice will need workstations/PCs on the desktop, a local area network (LAN) and a server. Practices should use the information that was needed for NHSnet connection, in the form of a Practice survey, to help with this section.
Over the next 4 years the following developments will take place and an understanding of this is necessary to ensure that the practice plan is compatible with these developments.
A few examples are given below. For a fuller account, see the previous article in this series (Guidelines in Practice March 2001, Vol. 4(3): 77):
- The move from paper-based records to EPRs and electronic health records (EHRs)
- Electronic transmission of:
- Pathology results
- X-ray results
- Discharge summaries
- Referral and out-patient letters
- GP to GP transfer of electronic records
- Electronic booking of outpatient appointments from primary care
Specific areas to cover in the plan
Workstations/PCs: Each member of staff will need access to a PC/ workstation. The average life of these will be about 3 years. Remember that those that utilise the most recent software packages will require the highest specification of hardware. The older, lower specification workstations can probably last more than 3 years if they are moved to areas where the computing demands are less.
Aim to upgrade workstations about every 3 years.
Servers: The server is essential to enable the sharing of information across a network. The server needs a fast processor, a large hard disk with a large amount of RAM. It is also important that an automated back-up occurs every day.
There is much discussion about whether a server needs to be based in the practice or whether this could be managed better 'off site' with the potential drawbacks of security and confidentiality.
A LAN will be installed in the practice to enable the use of NHSnet. The LAN allows the internal sharing of documents via an intranet.
An intranet is a series of documents held on a server and linked electronically. When navigating the intranet, you will see that it looks much as it would if you were 'surfing the net'. A full account of practice-based intranets will appear in a future issue of Guidelines in Practice.
All GPs will soon gain access to web browsing and email via NHSnet. The practice plan should include instructions as to how individuals will use their unique email address. Some of the issues to consider about email include:
- Do not transmit patient-identifiable data until encryption is available to ensure secure transmission.
- Are patients going to be given email addresses and encouraged to access GPs via email? Currently, GPs are advised not to conduct emailBconsultations, as there are many well-publicised dangers to this.
- A local address book of GPs, practices, hospitals, consultants and PCGs/PCTs will become increasingly useful. Ask the PCG/PCT who is going to produce such a book.
NHSnet provides access to a large amount of patient information, some of which may be usefully printed out to be given to patients.
Prescriptions: Most practices currently use dot matrix printers for prescriptions, but these are no longer being manufactured. The NHS has recently introduced prescription paper that can be used with an inkjet or laser printer.
The practice plan should allow for the gradual replacement of the older dot matrix printers. Consider having a printer with two paper drawers – one for prescription paper and one for plain paper. If space is available, a cheaper alternative may be to have two printers with a simple switch that allows either printer to be used.
Also bear in mind that electronic prescribing will commence in 2004. It may take some time to become universal, but this will effectively dispense with prescription printers.
Plain paper: With greater use of word processing and NHSnet, it is now becoming essential to have better access to plain paper printers.
Since the cost of laser printers is decreasing, consider whether a black and white laser or a colour inkjet printer will meet the practice needs. Look at the cost per sheet printed: laser printers are more expensive to purchase but the cost per sheet printed is often lower.
Also consider whether it is necessary to have a dedicated printer or whether it is feasible to network a printer and thereby share this resource between several people.
Does the practice have a scanner? If not, consider getting one. They are now relatively cheap and easy to use. Practices are using scanners to scan hospital letters into the patient's EHR as well as scanning documents to store them electronically and linking them to an intranet. When electronic transmission of discharge summaries and outpatient letters begins, it will decrease the use of scanners, but is still some way off yet!
- Mobile computing
As more practices become 'paperless', the patient's EHR will need to be downloaded to a laptop or hand-held computer for home visits.
Clinical: Some of the smaller GP system suppliers are disappearing, often being aquired by the larger suppliers. It seems likely that in the future the number of suppliers will decrease. A practice needs to think about their current system and their supplier's development plan.
Recently, there has been a vogue for moving to a different supplier, following poor service from an existing one. This is a really important issue, as changing your supplier is expensive and may not deliver the improvements in service you are seeking. If you are unhappy with the service received, talk to the supplier, inform the suppliers' 'user group' and talk to the PCG/ PCT's IT lead.
The website addresses of some national user groups are shown in Table 1 (below).
Table 1: Website addresses of some national user groups
Non-clinical: Plan for the widespread use of word processing. Ensure that the practice has the most up-to-date software package, plan to upgrade the software regularly, and ensure that you have an adequate number of licences.
Some health authorities are using IT modernisation funds to ensure that all practices are using Microsoft Office 2000. This is important to ensure document compatibility, as more information is transmitted electronically.
- Each user must have a unique user identity and password.
- Passwords must be confidential and not shared.
- Passwords must be changed regularly.
- Users must log out of workstations when finished.
Damage to data: Fire, floods and theft do occur. Ensure that data are backed up and there is an agreed system of storage of back-up data. This should be 'off-site' or in a fireproof safe 'on site'.
- Computer virus detection software must be installed and regularly updated.
- Disks received from outside the practice should be checked for viruses.
- Files received from outside the practice should be checked for viruses.
Uninterruptible power supplies (UPS): These need to be used for the main processing unit and any terminals where significant additional processing occurs.
Data Protection Act: All practices must be registered. In 1998 it was estimated that 30% of practices were not registered.
Cost: Computer hardware and software are not a luxury for practices, but a necessity. Over the years the costs of practice-based computer systems have risen substantially. Average-size practices are paying £8 000–10 000 per year in maintenance and only getting 50% of this reimbursed. Upgrading a practice system can cost between £40 000 and £50 000.
GP computing has been fully funded via 50% reimbursement from GMS, and some via indirect reimbursement. If all GPs spent the same amount on a given item in a year, this would be reflected in the indirect expenses element of the Doctors and Dentists Pay Review Body (DDRB) report each year. This is called the 'cost plus contract'. This has served the profession well in the past, but with such large sums of money this is no longer the case.
The NHS needs GPs to have modern IT systems in place. For this reason, as with Project Connect (formerly GPnet), the purchase and maintenance needs to be fully funded.
There is not much use in having the latest gadgets on GPs' desks if they do not know how to use them. As part of their IT plan, practices should look at the training needs of the GPs and staff.
- Is there a locally based user group?
- If not, ask the clinical supplier for the nearest one.
- Ask the PCG/T to look at the training needs for all practices. Locality-based training is essential.
- Most GP software suppliers have websites with discussion groups; these may be a source of help.
- Most GPs and staff would benefit from training in Word and Excel.
- This may already be available through the training department of a local trust.
- Pharmaceutical companies are very willing to provide such training.
A computer development plan provides a focus for the development of IT within a practice, and provides all partners with some form of ownership. It should clarify the gaps in development and then provide a 1-, 3- and 5-year plan as to how those issues will be addressed.
The PCG/T will be clear as to what funding will need to be made available. There may be common agendas in practices, such as training, and the PCG/T can address these.
If you would like to share your experience of drawing up a computer development plan for your practice or PCG/T, please contact us by:
Post: Guidelines in Practice, The Chapel, Park View Road, Berkhamsted, Herts HP4 3EY
Fax: 01442 862650
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