Nothing about me without me?....

Christmas over, 'sales' in full swing, New Year rushing towards us, and the prospect of a damp and bleak January ahead...

Bah humbug!

Thankfully the end of the world proved another false alarm and no reprieve from a full surgery, but NHS services in Primary Care we will see a gathering pace towards the changes that accompany Clinically Led Commissioning under the NHS Commissioning Board.
The end of March will also see the formal end of 'Connecting for Health', and reading many commentaries you could easily surmise that few will mourn the passing. But hidden under headlines of inefficiency and misguided strategy are considerable nuggets of success. Of course I am biased - but most of the successful elements had significant clinical influence and 'buy-in' leading to useful and USED developments. I hope this lesson is retained in future structures and plans.

Only two predictions for 2013 in the field of Primary Care informatics:

1) Patient 'on-line' interaction with primary care will increase significantly, with politicians claiming vindication of patient power and clinicians claiming a victory for common sense and professional responsiveness, but primary care services remaining under ever increasing strain to deal with basic reactive healthcare, rising demand and expectation, let alone aspirations for proactive and preventative work.

2) 'Open Data' as an agenda for change using the immense and hitherto lightly utilised primary care database will become a heated high profile debate, polarising opinion and distracting from worthy aims. As a clinician I am struck by the challenge from the single 'headline' within the 'Power of Information' documentation - 'Nothing about me without me'. In terms of individual access to our own GP records this is translated into a right of easy on-line access to our electronic records, but what is the converse implication for central collation and use of 'our' data for secondary purposes as demanded by the 'Patients and Information' directorate of NHS CB? In particular what restrictions do I as a citizen and patient want to see applied to MY identifiable health data?


I do not have the answers to the last question, but add the observation that electronic clinical records usually reflect a private and very personal patient - carer relationship that is appropriate to share  between those parties, but indiscriminate wider sharing (and in particular publication) carries significant risks for this fundamental relationship of trust.

So more interesting times ahead

Happy New Year!

Peter S.

The Good, the Bad, and the Different

Lots on my plate in the last few weeks, so I have taken my eye off Records Access at the surgery. And when you take your eye off - things happen!

My surgery has undergone a system migration this week - never an easy transition, and the first time for us in 19 years. As part of the process there is disruption to Patient Access. Neither of my test patients now have the ability access to Medical Records - I probably need a training refresher here! Not heard if this issue is the same for my patients - but I do expect it to be the same.

The patient interface has also undergone a change - and the Patient Access ID number has changed to a new (longer) one including a practice identifier code. Will probably turn out to be easier, but NOT a memorable number - so patients will have to write it down (as I do), perhaps making it a bit less secure.

On the bright side there is an opportunity to enter a number of security questions - I am assuming these are needed for password re-set remotely. That WILL be an improvement that I must check out!

And last irritation is that the patient information links are not currently working. The experience of enthusiasts and innovators in that patient support and educational information is vitally important to make use of the record. Must do better....

PS

Who will benefit most?

A big question with "Records Access", who stands to gain the most?

The patient, with or without a chronic illness?
The 'digital' surgery?
The affluent with modern technology and smartphones?
Advertisers and the IT industry?
Politicians claiming vindication?

No clear answer(s) at the moment.

Attending and contributing to an evening talk in Lewisham on Record Access sponsored by The Health Foundation has contributed to my knowledge and made me consider the potential to support citizens with diabetes more effectively. It is always good to have a mixed audience of patients, health care providers and local managers, polarisation of opinion is reversed, and some real progress can be made in awareness of mutual opportunity. The 'myRecord' project in this locality will be well worth watching as a locally owned and driven initiative to use technology to support care better.
Perhaps those present have shown/reminded me that the technology use is not just to improve care, rather to enable and encourage better SELF-care.

My second 'lightbulb' moment around 'on-line' services for patients comes from consideration of how patients may get access to test results, using new technology. A much repeated and topical government and policy aspiration.
For me, there are still significant barriers for many of the population to bother to search records and review results - it is likely to be a minority activity EVEN with enthusiasts. But to mis-quote many historical figures - perhaps there is 'a third way'!

My inspiration is to use technology to assist the current process, not to invent new pathways or generate more work for General Practice. We already have swift return of results through electronic laboratory links, and in most surgeries these are rapidly reviewed, commented upon, actioned where necessary, then filed into GP records. There are already very efficient mechanisms to confirm results belong to the correct patients, despite the 'distrust' of some senior officials, and trusted processes to deal with important results! What is missing is a way to convey the result and clinical interpretation/advice directly to the patient. Currently most GPs write, telephone or instruct patients to contact the surgery to check results - an inefficient process for all of us, patients particularly.
The solution? Immediate 'one button' option to copy the result AND the clinical advice/comment via the channel chosen by the patient - an SMS message to mobile phone or e-mail are equally possible. (US Blue Button' concept). And before there are too many complaints - we already pay for NHS mail and SMS text messages through N3. There are some issues around such a proposal - but all are simply soluble IF we have a will to do so. Perhaps such a solution makes getting test results and supportive advice a lot easier and quicker than the cry for 'full record access' can deliver? It could then easily extend to other 'bite-sized' bits of information - Immunisation status, hospital letters, consultation notes....

So lots to ponder - but a solution to message my patients securely would save me an hour or two a week.... and probably more than that for my patients.

Are you paying attention GP system suppliers?

Peter S.

Hearts & Minds

I have just returned from a GP system user groups conference, filled with enthusiasm, new ideas and ambition - that is what these events are about. But through the buzz of new announcements and promises there were three distinct 'threads' that relate to 'Records Access', and my small scale experiment in opening records.

The first, and probably the most important is that the general professional resistance to this proposal has significantly reduced, with a shift to apathy or even interest in how it may be done! I suspect the clear policy message in the Information Strategy has had an impact - but there were still practical concerns voiced, and scepticism as to the true demand from patients.

The second was a clear recognition by the company that 'Information' is the clear thrust of their future strategy. Making the record available when, and where needed, information to support clinicians, practices and organisations, and very clearly integrated with high quality information for patient use.

The third more practical promise was of forthcoming improvements to the system functionality, enabling easier administration and delivery by practices, and easier patient use.

All three of these are needed to win the 'hearts & minds' of clinicians, patients and organisations in order to deliver so much more than the simple transaction and viewing services we have now. It cannot be long before all the providers of IT systems to Health & Social care services start to take similar steps - or are required to follow. This is not a race, but an exciting time of opportunity, leaning and innovation! I believe the NHS has the spirit and ideas to innovate using technology, and in partnership with industry - I just hope it is given the freedom rather than constrained by targets and red-tape.

Peter S.

Control....

In the British Medical Journal this week, the lead theme is 'patient control of records', with an editorial comment, main article and personal view.

I have spent a significant amount of time pondering the meaning of 'control'. There does seem to be a wide variety of views and, surprise surprise, no easy answer.

For the most determined advocates, control has been explained in terms of patients 'holding or posessing' the records, determining who and and when the records are accessed and being the central 'hub' for all who request access. The most negative sceptics articulate a very different vision, where the existing organisational medical records are maintained and shared for patient view only with strict technical controls and information governance procedures, in order to ensure confidentiality.

Perhaps most are missing the point - what is it we as patients and 'citizens' expect as control?

For very many of us this elusive ‘control’ is not ‘posession or ownership’ of the record or about asserting our ‘rights’ to  see all the notes about us, but rather a ‘confidence’ and trust in those who care for us – confirmed through the routine ability to see and understand plans and records, should we wish to do so. Most of this is focused on the relationship between clinician and patient and ‘shared decision making’ over all aspects of health and care.

As a clinican in a professional relationship with my patients, I want them to feel comfortable, informed and valued in all our contacts – in other words, ‘in-control’. I cannot always make this happen, but I feel that control is NOT about asserting rights, but rather having the confidence that they are being respected.

Peter S

Packing for holiday? What have you forgotten?

If, like me, you are a 'mere mortal' and did not pursue athletics to an International standard, now is the time to venture abroad for sunshine.

So we will pack clothes for all conditions, enough suncream to cover a medium sized boat, 12 pairs of shoes (ladies), a small library and a bottle opener/cork-screw. If well prepared we will pack our medication and a few days spare, insect repellant and a few plasters. We will splash out on an annual travel insurance policy and even find our E111 at the bottom of the 'swimwear' drawer.

So what have we forgotten? Well how many people will 'pack' their medical record to take with them? I suspect very few, at present, but things may be changing. On a smart-phone, tablet or laptop it is very easy to travel with a copy of our medical record - if made available by the GP surgery. We will have to protect it with security passwords (and this requires discipline for most of us) but it could come in useful after the yearly cycle hire disaster, or attempting a spectacular beach volley-ball recovery.

Perhaps I am over ambitious - but if we bother with travel insurance, is it equally important to take our information to support safe care in an emergency when away from home?

Peter S.

Practical Matters.....

Just setting up 'Records Access' is not a complicated task - but continuing to manage and administer it is proving to be!

Despite a lack of 'overwhelming demand' there is the on-going challenge of basic administration. As soon as anyone is active with a surgery 'transaction' facility there is the burden of managing forgotten passwords, and even worse - 'technical questions' that relate more to internet problems and the layers of security.

For a practice like mine, this generates more work for the 'team', and in my case - for myself as the key system administrator and manager. But I am increasingly nervous that this will rapidly become unmanageable as the pool of patients with RA slowly grows.  I cannot be available daily to address individual questions, or to provide an evening and weekend service when away from the surgery building. I certainly am NOT the one to ask computer and software questions of - or to provide an informal 'support-line'.

Anecdotal comments from other surgeries and enthusiasts echo this concern. A whole new 'system' of working and support is required - and for such aspirations to become widespread in General Practice, patients, clinicians and surgeries are going to need a whole new level of support and back-up - or we let patients down. It is pretty obvious that there are resource implications in the pipeline.

Doing it right is a significant and enduring challenge......

Peter S.

Technical irritations!

No postings for a while... Why? Too busy doing the day jobs...

The leaflets continue to disappear from the waiting room, and a trickle of interest is maintained. Annoyingly I have spent a significant about of time trying to sort out technical difficulties for one patient to access the Medical Record. This raises another challenge for practices - and supplier companies - how do we 'support' this activity when patients find technical, software and IT problems? This is complex and time consuming (and un-resourced). Here I just do not have the answer - but we will all need one if Records Access is to be a success and benefit.

Activity at my surgery in May as follows:
615 total log-ins and 197 failures
107 appointments booked
29 appointments cancelled
16 new accounts
182 repeat items ordered
9 address changes
5 medical record viewings

So less than 1% of log-ons at present are for Records Access - but it is a start.

Still a bit unhappy about failed log-ins, and unsure how to explore this further. A failure rate of nearly 1 in 4 suggests to me an unreliable system or over complicated process. Not sure Amazon would stay in business with this - or RBS/Nat West!

Peter S

The Power of Information

The Government Information Strategy has been published, and comments and analysis started to circulate.

While the high level strategy attracts general support, it will be the detail of delivering the reality at the sharp end of the NHS where we all be ultimately judged. Will it make a difference to me as a patient or me as a health professional?

I very much hope so!

My lessons in providing access for patients at my surgery are changing my views about what I would like for myself and my family.

My wish list:

• Easy registration for on-line services
• Electronic booking and cancellation of appointments
• Checking and updating my address and contact details
• Order my repeat medications
• Appointment reminders (if I choose)
• See and print my test results and recommendation from my GP
• A simple 'routine' message service to show that I have seen results and recommendations
• See my future agreed test or review schedule
• See my current Summary Care Record
• See and check my GP summary as kept by the Practice
• See the latest hospital letters about me
• See where I am in 'the system' when referred to a specialist

I would like the reminders and appointment functions to work on a standard 'Smart-phone' - the others can be from a PC or tablet device.

I have though rather more about other information such as older letter, the full record, an audit trail of who has seen my record, e-consultations etc, but these are not currently things high on my priority list. A significant reason is that I trust the GP surgery that looks after me, and the clinicians and staff who work there. They are not perfect, but I am not intending to use 'Records Access' to check up on them, rather to make their job of looking after me easier, and reminding me what I need to do to look after myself and stay healthy - from the convenience of my desktop or mobile phone, 24/7.

Perhaps I will change my mind when I get a regular reminders to get off the computer, to walk a bit more, to reduce my intake of wine and to attend for my scheduled 'health-check'....

Peter S.

Feedback from patients starts...

Last week marked another milestone in the experience of Records Access at my surgery, direct feedback from a couple of my patients.

While I have had copies of my initial survey returned, this is the first time I have had the chance to learn directly who is using the facility, and a bit about their experience.

One patient had clearly been having problems accessing the record, and then later been blocked altogether with password problems requiring a re-set. While this is only a technical issue, it is perhaps a warning that this may become a frequent event. For patients who only look at part of the records occasionally, or who rarely need to book appointments or request medication, forgotten passwords will become a barrier to use. For the practice we are very reluctant to take on additional work with re-setting, particularly when there appear to be efficient and safe mechanisms deployed in the commercial world. Clearly an area where we need to do better to make access smoother.

A second patient had far more success, and had been looking through the record with interest. The questions brought about the presentation of the record from a patient perspective has alerted me to some of the anomalies that I take for granted. This includes the absence of values when they are low or high and 'out of the laboratory range', and instead they arrive from the laboratory as text. Then they no longer appear as a 'value' - which can be very confusing for a patient who knows they had a test on a specific date, but cannot see a result! Also very useful was the observation that a previous significant diagnosis was not listed in the significant problems section of the record. Checking back revealed it was noted in the past record, but not correctly flagged as a 'significant event' due to subsequent improvements and standardisation of our 'summarisation' arrangements. This is now corrected, and gives me an immediate example of where a record summary, jointly managed by patient and clinician, is more accurate and relevant for future care.

So the message of the week - the GP record summary holds important and useful information to support the safe care of the patient, but its value and accuracy is increased when jointly managed by the GP & patient in partnership.

Peter S.

Could do SO MUCH BETTER!

Fascinating statistics available on how my practice population currently use electronic access, and the picture nationally from the EMIS system provider.

At my surgery in March 8 people accessed their medical records electronically, with 17 viewings in total between them. We had 28 new people sign up for access to basic transaction services. 198 appointments booked and 69 cancelled in addition to 180 patients requesting repeat medication. Not exceptional - but a steady flow of activity.

Now if that activity were translated into all GP practices in England (adjusting for list size) every month there could easily be:
1 million appointments booked on-line
356,000 appointments cancelled on-line
930,000 repeat medication requests on-line

And a lot of the activity from patients using on-line services IS during the working day - so surgery staff can attend to other priority patient care and quality service related work.

Below is a graph that shows the EMIS average on-line access activity hour by hour.



More than 70% of the activity is during the routine working hours - very similar to my surgery experience.

So although I am exploring access to GP records electronically, it would seem that any effort to encourage more use of the basic transaction services at my surgery - or any others, is a clear winner as a priority! And when we take the next steps with FAR MORE interested on-line customers?

Peter S.

Shared ambition - but double standards....

In between the joys and pain of routine General Practice I have been spending rather more time on the work 'behind the scenes' with the sharing of clinical information to benefit clinical care.

Whatever the care setting, whoever the clinician and (almost) whoever the citizen or patient, all seem to agree that better sharing of information is essential to improve care and efficiency. We all claim to share this ambition.

In our real world however it is all too easy to sit back and wait in vain for leadership and directives to 'share' informations, drop our barriers and 'open up' the data. And here I must point to the lessons of the last few years. When there are central/national efforts to begin sharing, create opportunity and aspire to a new way of working WE ALL have a tendency to be defensive. We express concern over the lack of ambition - or the excessive scope, we argue over complex security processes - or the difficulty of access, we demand detailed information governance scrutiny - but trust Tesco with intimate details. So though an unpopular message, I believe all of us are at fault for the painfully slow progress of some National projects with amazing potential. The Summary Care Record best exemplifies this problem.

But amid the public and sometimes vitriolic criticism of perceived 'top-down' initiatives, we are witnessing significant progress with local schemes. Sometimes in small or discrete communities, sometimes based around organisations and sometimes around IT systems. One of the common features linking success is 'local ownership', with understanding and drive for local benefit. Within such local schemes it is possible to take control of the sharing agenda, and choose to blur the rules and guidance on security, governance and consent, for a clear and shared aim to improve care and safety. And this IS reaping local benefit - for patients and communities.

So what does this mean for National initiatives? Well, I hope that we can all learn from local success, without developing new and isolated islands of sharing with no ambition to engage with a wider community. 'I've solved my problem' is not a strategy for success in a National Health Service.

I hope that the 'Information Governance Review' under Dame Fiona Caldicott will help to re-establish a level playing field for information governance, that we can use what is left of the shrinking National Informatics resource to share innovative practice. I also still hope that clinicians and commissioners will re-look at National products NOT as a problem to be tolerated, but as an opportunity to use as part of a bespoke 'local solution' to information sharing - between organisations and with citizens.

And for citizens and patients viewing their own records? To learn quickly how to make best use of this opportunity, not telling citizens what to do, but responding to their suggestions, the requests for interaction and a new level of trust and shared control. The 'cutting-edge' enthusiasts, the reluctant followers and the 'sceptical laggards' all have a role to play. Access to GP records is a tiny element in the change we are all witnessing, that we cannot control, and that threatens the 'comfort zone' of care providers like myself. I think I am learning that although we share ambition this will not be a comfortable ride!

Peter S.

LIES - Damm lies & STATISTICS!

Yes - I know - statistics can prove or disprove anything, yet we (?) in the scientific and medical community are constantly pouring over and analysing them to seek out 'evidence' of where we do well, and where we need to improve.

SO for me another confession - the result of running an audit of activity 'on-line' at my surgery in the last year. The 'audit tool' we are provided with is very basic, producing a single massive file - too big to fit into excel! So first note to self (and suppliers):

1)  Provide us some basic tools to report on activity - please.

So for the last year from April 2011 to March 2012:

Activity	Count
Repeat Medication Items ordered	5135
Stop Access	5
Make appointment	2254
Log-in	9141
File Change of Address	106
Failed log-on	799
Change Address	109
Cancel Change Address requests	1
Cancel Appointment	711
Archive change of Address	3
	18264

It appears I vastly under assessed the number of patients who use our 'on-line' facility, based on information from another part of my surgery IT system reporting (confusing!!!). We have had 808 individual patients access the surgery system at least once in the last year, which means almost 9% of my surgery list.
So, second note:

2)  Ensure reporting 'on-line' activity is consistent in all modules of IT system.

Before I sit back in bask in the 'warm-glow' of self satisfaction I have to point out there are some wide variations in usage by individuals - evident only by detailed filtering and sorting of the combined report (almost beyond the skill of an ageing, non-technical GP).
The range of 'on-line' usage is from 1 to 857 log-ins per year! There are a number of 'high users' who access our system 100-175 times in a year - using many of the transactional options, however a single user stands out as 'atypical' with 857 successful log-ins in the year and an additional 13 failed attempts. Maximum number of log-ins for that individual is 28 in one day.
Clearly there are other reasons and issues that need addressing separately for this individual, and questions about the benefits and disadvantages for them, the surgery and the wider population and care services.
So third and fourth note (to self and future guidance):

3)  What will be the 'accepted' reasons for withdrawal of Records Access privileges, and the mechanism for appeal?
4)  Can we  have individual reports on usage from the clinical system?

SO totting up the activity I come to an average of 11.3 log-ins per year for active users (or 10.3 discounting our practice enthusiast). So WHEN patients are registered for transactional activity it IS well used - and I am confident it provides a valued additional service AND saves time and money for my surgery.

Last (wishful) note:

5)  Please can I have working reports on patient access to the full GP records that I have enabled? How often are they viewed, and what in particular are patients looking at?

Peter S

21 and counting....

It may not be a landmark in terms of activity, but we have 21 patient requesting access to medical records at the surgery so far. This may be around 0.23% of my practice list, but it is still considerably more than most practices in England. Leaflets advertising the service are prominently place on the main reception desk, and disappear regularly!

Now perhaps where this gets interesting is in comparison to the number of patients who are active users of  'on-line' transactions. Contrary to my previous publications and claims, it turns out we only have 272 active users out of a practice list of more than 9,000. This is despite ACTIVE encouragement, and offering leaflets about on-line access to all who newly register at the surgery, So:

• 3% of my practice list are enabled users of on-line service
• 7.7% of those registered for 'transactional services' have asked for full Records Access

Perhaps the figures are starting to make some sense?

If I had 25% of my surgery list registered for 'transactional services' then I could expect around 170 people asking for Records Access - if all the trends continue.

SO - priority of work at the surgery is to get as many people as possible registered for, and using, transactional services. RA may well follow-on naturally. This is likely to bring the most immediate benefit for patients in terms of convenience and 24 hour access to appointment booking and medication requesting, AND for the surgery in terms of efficiency and reducing front-desk and telephone contacts.

The other question to address is how difficult do patients find it to register for simple transactional services, let alone full records access. I wonder if the RCGP, BMA and System Suppliers can come up with ways to make this easier - and if the Information Governance review being led by Dame Fiona Caldicott will give any direction to remove barriers?

Peter S

Technically challenged.......

Well the leaflets continue to disappear from my waiting room - so some of my customers clearly find the subject of records access interesting!

But my next challenge is far more technical. Before we can reliably enable our patients to view their own records we have to have an efficient, and reliable, process to register them. And here we have challenges. Having established a reliable process to register patients for appointments and repeat medication, there are additional 'back-office' tasks to generate an additional password, set permission and text viewing dates. And after these are circulated to patients they have an additional password to remember, and to navigate through a brand new Practice Website.

Complicated? No-wonder at least one person has locked themselves out of On-Line access altogether! So we will be creating some understandable frustration for the enthusiastic patients before we are confident and reliable in managing this transition.

The software suppliers also have some work to do, to make management and administration of Records Access easy at the GP surgery end. They will also have to consider more useful reports on activity - so we can better understand when it is useful and what patients look at.

SO firmly on my wish list:

• Make it easier to administer
• Improve the reports
• Consider a 'tab' to show the current uploaded 'Summary Care Record'

You never know - it might get more popular with the practices...

Peter S.

Learning from others....

We are never too old to learn!


But the NHS as a 'learning organisation' does not always make the most of opportunities.....
In the UK, the most impressive success with patients becoming involved and engaged with a section of their record through an electronic medium is almost certainly 'Renal Patient View'. This had been developed to enable patients with kidney disease to take a full and active part in managing their condition. And crucially it is useful to both patients and clinicians alike, with positive impact on self care motivation, and enabling improvements in quality of patient care and care planning.
If like me you want to learn more have a look at the site below:
http://www.kidneycare.nhs.uk/_Aboutus.aspx

For more detailed information they have two excellent recent publications, firstly the final evaluation report on Renal Patient View
http://www.kidneycare.nhs.uk/Library/RPV_Final_Evaluation_Report.pdf

Secondly a short guide on how to encourage patients to use the service:
http://www.kidneycare.nhs.uk/Library/HowtoguideRPVuptakeTJKGii.pdf

So - involve the clinicians, sort out the administration, value and use the facility and encourage patients to use it - Simples! Pointing the way ahead for GP record access......

Peter S

Up and moving...

Things are starting to move - with the 'prominent' placement of leaflets to introduce 'Records Access' as an option on the main reception desk at the surgery. We are having a few requests for detailed information each week, and 10 people now have RA passwords.

I am starting to recognise more clearly the challenge of managing another 'active list', creating and distributing passwords, activating access and planning the transition to a 'business as usual' plan. Not always straight forward with the priority being secure handling of this critical access information.

There is a significant workload that will need to be absorbed into routine working practices, but we aim to minimise printing costs by e-mail distribution of detailed leaflets and instructions.

The RCGP have been invited to lead a work stream that will determine the path and delivery of widespread RA across England. I hope they will be taking into account the ability and experience of all practices, not just the firm and established advocates. The very practical 'front end' administration at practice level needs to be deliverable by hard pressed staff with minimal resource implications. I suspect that many will be looking for a 'template' they can follow to enable RA with minimal effort, utilising literature that is trusted and building on early success with more straightforward transactional services.

Perhaps the close involvement of suppliers will help us to understand better how GP core or third party software needs to develop rapidly to smooth the administration of the process, and to generate easy automated reports.

Not feeling brave enough to 'actively recruit' patients as we are are likely to raise expectation beyond the capacity to manage the process yet!

Peter S

Oh so slow.....

Confession time - too busy to actively promote the service at present.

Result - nine requests for Records Access to date, and only one fully processed.

Main blocker - me, the staffing and administration of the process!

Action - pursue current interested parties to fully implement RA for them.

Constraints - staff sickness limits my current ambition and expectation.

Concern - what would we do if this became a 'target'?

Requirement - GP system software that makes RA administration easy.


Conclusion - Snow Patrol are excellent in concert.......


Peter S.

Lessons from Kaiser in USA on Records Access

Fascinating Webinar on wednesday with the US team leading Records Access for patients in the Kaiser Permanente organisation.

In 2010 they had 2.5 million appointments booked on-line, 12 million e-mails, 10 million prescription repeats and almost 30 million laboratory tests - covering 8.8 million patients.

Points I particularly noted:

• KP developments have been transaction led, and activity increased year on year
• Significant investment in integrated support information for patients through the portal
• Appointment/medication transaction activity does NOT shame UK
• On-line record access is ‘Results’ focussed and basic non-urgent communication
• Communication is via controlled, not 'open', e-mail
• UK advocates have already gone WAY beyond the Kaiser Physician comfort zone with consultation details etc
• Listen to, respect and address concerns of the (many) professional ‘Nay sayers’
• They do not have specialist appointment booking – we DO (C&B)
• E-mail contact workload does build, and is clearly causing increasing concerns
• 3 e-mail contacts/year per on-line patient, 800 per year per physician in 2010
• Need to integrate RA with daily workflow tasks
• They share concerns over release of ‘harmful’ test results
• KP wrote all the content (much exists for us in NHS Choices and other accredited resources etc)
• Webex attendees tend to represent those already keen on Records Access...

So we can learn things from them - but our Heath Economies are slightly different, perhaps they can also learn from us!

So my personal 'learning points':

• Support Records Access with information patients can use to make a difference to health
• Be very cautious about opening an additional communication channel without clear aims and spare resource
• Listen and respect the views of nervous and sceptical colleagues, and learn together
• Build on the fantastic UK availability of electronic GP records to offer appointment, tests results and medication ordering as widely and quickly as possible

Why not have a look at what KP offer below?

https://healthy.kaiserpermanente.org/html/kaiser/index.shtml

And lastly...

From the cost and activity figures given by KP compared to NHS public data I have compiled the table below from 2010, to give me a rough idea how the NHS is in comparison... (Shoot me down if I am wrong)

	Patients (million)	Spend (£ billion)	Spend per patient (£)
Kaiser	8.8	27.9	£3,170.45
England	52.2	97.1	£1,860.15

I have always thought the NHS gives value for money, no matter how hard people knock it. It remains a 'National Treasure'.

Peter Short

Another perception-reality gap?

Some weeks I read medical magazines & journals and wonder at the effort we put in to the accumulation of 'irrelevant' knowledge. But this week I have been stimulated  and challenged by a number of articles in the BMJ, if you are fortunate enough to have access, links are provided below.

Shared decision making - BMJ 2012;344:e256

Where will Records Access fit in to enhance shared decision making, and help to close the 'perception-reality gap?

Matters of Life & death and quality of life - BMJ 2012;344:e775

Will it just be the 'major' items in Health records that interest patients, or are there things that to clinicians appear trivial, that patients will consider important to understand and address?

Stop the medicalisation of old age - BMJ 2012;344:e803

Will patient and advocate scrutiny of records suggests that we (clinicians) often pursue targets/protocols and guidelines rather than the informed best interests of the older people we treat?

More questions to ponder......

Then again - I could spend all my time debating the issues and questions and be to busy to change anything or try for myself.....

Peter Short

On a more POSITIVE note!

Sometimes the 'conservative' attitude of GPs in England attracts negative publicity, but this approach can shift in a relatively short space of time.

I am very encouraged that the GPs political body has had a recent debate on 'Records Access', reported in the medical press, but perhaps not fully reflecting the new willingness to be involved in resolving the challenges to make Record Access beneficial for patients and the Health Service.

They do point out some of the issues to address before they would be able to support a widespread rollout, these include:

• Third party information - conforming to Data Protection Act requirements
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• Record understanding - assistance for patients to understand and use a clinical record
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• Security & confidentiality - confidence in getting the balance right
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• Control - understanding risks and benefits
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• Patient recorded entries - learning about how this will become possible and safe
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• Cost benefits - how will we show that the benefits are worth the effort of patients & clinicians

In the 'Information Revolution' consultation all of the same issues were raised from different parties, so perhaps my professional group are not so 'conservative' after all?

A more positive way to move towards friday - which will end with a Snow Patrol gig!

Perfect end to a challenging week?

Days when 'Access' in bottom of my agenda....

There is no doubt in my mind that there is NOTHING like a full day of front-line clinical practice to put in perspective the challenge that we face in allowing new and innovative ways for patients and citizens to interact with their Health advisors.
After eleven and a half hours at the sharp end of 'undifferentiated illness, uncertainty and discontent' with hardly a break, I am shattered and drained of sympathy and enthusiasm. The benefit of 28 years of experience, grey hairs and a generally mild manner has not protected me from the pressure of 'trying to do the right thing', non-stop on the conveyor belt of General Practice.
And all-round the country tomorrow, my colleague GPs and Nurses will start again with the same routine.

Am I really very inefficient?
Should I 'free up time' to analyse what I should be doing differently?
Why do I find it so difficult to adopt a 'low appeasement strategy' advocated recently by  a respected mentor?
Is this sort of experience and combination of feelings the reason why so many of us are reluctant to consider the combination of Records Access, virtual consultations and expanding communication channels?
We just have difficulty imagining how we can fit it all in........

Answers on a post-card.

Peter Short

Records Access & 'The Big Picture'

Well the Christmas & New Year 'disturbance' is over - and life in the land of General Practice returns to normal (chaos) - amid the wind and rain, heated public debates over health, and ongoing economic gloom.

And will 'Records Access' solve the dilemma for the NHS of increasing demand, tighter financial limits and ever closer scrutiny? Probably not.... No DEFINITELY NOT.

So where does it 'fit in' to future healthcare evolution? Well there are interesting debates going on in many circles, and perhaps that is in itself a sign of change to come, a willingness to consider a more mature and interactive relationship, utilising new media and information sharing opportunities. And as ever there will be polarised views, those who resist 'risky and unsound change without an overwhelming evidence base', and on the opposite side the evangelists who find it hard to understand and sympathise with an often conservative profession that has real concerns about the risks and implications of radical change. So in the middle ground sit the majority of practices, interested to learn more at their own pace, nervous that they have no spare capacity for new 'innovations', and uncertain when and how to proceed and how access fits into the big picture of health and social care.

On top of the list of questions seems to be 'will Records Access' deliver benefits? And here the answer may at the moment be 'not on its own'.
So if not in isolation - what role may it play and why should we consider it?

Well the evidence so far in the UK and Internationally seems to suggest to me it may have an important role to play when combined with actions, transactions and communication. With the record, if we just 'look at it' little changes, the lesson of digital expansion and the internet is that the ability to 'do things' could radically move the agenda forward. GPs have learnt this lesson painfully over 25 years, moving from paper to electronic records - the exciting bits are when we 'do thing's with records - exchange information, audit, decision support and many other 'digitally enabled' functions. So perhaps I should worry less about 'Records Access' as a subject or target and start to think about the opportunities for efficiency and innovation, how this first step enables self-care, healthy choice awareness and to have the data to populate their own 'healthcare management' system and do other thing beyond my current experience and imagination.

So as I work to stimulate interest from selected patients in my surgery I do so with a realistic expectation that 'Records Access' is not my goal, but more likely to be a step in the right direction to patients taking back some of the burden, responsibility and interest in their own health, and in doing so to help me look after them better.

It's good to have ambition!

Peter Short (glass-half-full)