Continuity & Personal Service

No additions/comments/updates over the summer - pretty typical of the 'behaviour' in GP practices. With more staff on holiday, those who remain are busy with the routine work and NOT with making heroic plans to deal with the expected winter pressures, the next rush of central developments and demands, and the ongoing barrage of NHS criticism.

So what has been happening in our quiet attempts to improve the range of options for digital interaction with patients?

Firstly there is a slow, steady and sustained trickle of new registrations for Online service registration. No great demand for Record Access, but significant interest in appointment and repeat medication ordering. And we believe that some basic publicity has helped!

Second observation is the realisation that my system provider had failed to repair SMS appointment reminders to patients AND continues to report in the record that an SMS reminder has been sent!
Does not inspire confidence that future digital interaction (upon which we plan to increasingly rely), is yet robust enough?

But my most important reminder of priorities happened during a seemingly ordinary 10 minute consultation yesterday, and it has lifted my spirits at the end of the summer holiday.
The consultation in question was with a patient I have known for most of my 25 years as a GP. I was reminded that 22 years previously to the day, I had attended urgently at his home to discover a classical presentation of a 'heart attack'. At the time I carried a wide range of emergency drugs (before Paramedics existed in my area) including morphine (now rarely carried thanks to a former colleague in Hyde) which relieved the urgent situation before departure to hospital.  The intervening years have seen a range of interventions, surgical and pharmacological, but have probably all contributed to a long and active retirement.
I was thanked gracefully and politely, for myself and my surgery continuing to 'care' and provide a service that is appreciated daily.

So for me this is a reminder that care, compassion, responsibility and continuity of care have not started because of recent 'scandals' and 'painstaking reports', or arrived by computerised protocol. They have existed throughout my working life, in all care locations and from all members of the caring and support teams I have worked with. The failures remain the minority exceptions - often when the 'needs of the system' are allowed to override the judgement of those at the point of care.
I must remember that in ANY of my attempts to open up more digital communication and interaction opportunity, compassion is not delivered by a computer, or 'care' by an algorithm alone. It is those who run the systems that must introduce technology that supports rather than detracts from these qualities. Quite a challenge ahead!

Peter S.

Memories

Time flies - and medical students grow into doctors who (sometimes) grow into respectable senior members of the profession.

I look back with rose-tinted spectacles, as on this day 30 years ago, I am reminded that I stepped out onto the ward in a starched white hospital coat as a 'proper' junior doctor.

The unsuspecting patients in Birmingham were not warned or prepared as I assumed responsibility for decision making on a whole new level.There will clearly be differences with the new generation, who may start better prepared, better supervised, less tired and better trained to interact with fellow human beings, but I suspect much of the excitement and trepidation is undiminished.

The 'digital' junior doctor may well not be burdened with pockets full of reference material, may 'clock-off' without a 24 hour duty shift, but will still need to practice and refine what they have started to learn over 5 years about interaction with patients, relatives and colleagues in healthcare. No amount of 'virtual' practice can match real life in remaining a steep learning curve.

So my advice to them is to listen, and engage the brain and heart when dealing with people.

Technology is fun, and essential to use, but can only compliment the essential care, compassion and personal touches that nurses, doctors and all our colleagues provide.

Good luck, and learn quickly. I need you to be looking after me sooner than you think!

Peter S

Expectation v Capacity

It is very hard sometimes being part of such a negative, defensive, pessimistic and cautious profession - or so the 'media' currently paints us in General Practice.

For those with an interest, there is an additional thought provoking publication from the 'Medical Protection Society' over on-line interaction and relationships between doctors and patients - worth consideration.

MPS Guidance

In particular I am concerned of the mis-match between patient expectation on routine response to e-mail enquiries, and the attitudes and capacity in General Practice.

Simply put - more communication channels from the public to General Practice will add to demand and workload unless other work, communications and processes are discontinued. I believe most practices are currently working at or beyond safe capacity, so yes, we are cautious with good reason.

Peter S.

What to do with the 'Information'......

I am going to attend a meeting this week to learn more about 'Information for Commissioning'.

What can Commissioners ask for or expect, what can they do with it and how will it change things?

It should be very interesting and relevant as we glide smoothly (?) into the era of CCGs.

But perhaps I have been living in a different universe from other Healthcare providers for the past 10 years or more. We have no end of data available already, we have 'grown-up' with local comparisons and 'bench-marking', we look in detail at prescribing, referrals, length of stay, urgent admissions, 'frequent-flyers' etc etc. What is so new in the ambitions now being expressed and the expectation?

Well - being the grey-haired sceptic I am, a few observations flow:

• The availability of data to the NHS is far from new - we have always had lots, but seem to be short of time and resource (and sometimes the will) to analyse & understand it, to identify areas of unwarranted variation and to act upon these.
• The data alone does not drive change - despite all the political ambition and rhetoric. 
• The commitment and resource to continually collate, analyse and reflect upon collected data and the information it reveals needs to be embedded within every care AND Commissioning organisation.
• When finances get tighter - we tend to cut resource to analytical staff & processes and 'assume' wrongly that the work can be absorbed into daily activity.

SO the message from a small healthcare organisation with a track record of reflection and action on comparative data is simple:

• Priorities what you look at and start small
• Be prepared to learn by comparison with peers
• Commit resource to data analysis as an administrative and clinical function
• Make changes as a team AFTER analysis
• Review future performance to check desired outcomes

In Commissioning  'learning' Healthcare Organisations at all levels, NHS England and CCGs are not just asking for delivery, they must resource practitioner and organisational level reflective analysis.

In my 'bubble' of digital Primary Care I am nervous that there will be a strong Top Down temptation to 'name-and-shame' those who are slower to embrace policy aims at the front-line, as revealed by National reporting. In a forward looking 'learning organisation' we would help each other to understand the data and the opportunities for change and improvement these reveal. To turn the sticks into carrots... the real power of data......

Peter S.

Well done EMIS

I am not normally known to sign the praises of computer system suppliers - even the one I have used for many years. But this week the company released a small upgrade to the search and audit function that means I can find out much more about how many patients on my list are registered and using the on-line interaction services.

So why is this so important to me?

Well, very simply, without looking at the statistics of patient interaction I may be complacent assuming we have done all we need to meet the demands for on-line interaction, or that such a function is only used by a tiny minority.

So this month my surgery has a registered list of 9,277 patients. Of these 1,329 have an activated account with the theoretical ability to access on-line services such as medication and appointment ordering - accounting to about 14% of the surgery list.
A further 1,630 have had a PIN issued giving them the opportunity to complete registration, but have not yet chosen to complete the process (a further 18%), leaving 6,318 using only traditional services.

There are a few interesting features in the 'activated user' group. 114 accounts are for children under 10, so clearly some parents see advantages of registering their children. In general more females are registered for the service, except in the 60-69 and 70-79 age ranges.

So overall 2 cheers for EMIS who have responded to my request to add search functionality - but they could do much more...

I need to have regular reports produced, without having to devise and build and run hem myself, and I suspect all other practices will want the same with 2013-14 DES targets. More importantly to make an impact on demand at the desk and on the phone I need a more detailed breakdown of how many appointments are booked on-line and repeat scripts ordered on a monthly basis - and who are users of Medical Record Access and messaging.
This information will help the practice to manage workload AND give a better understanding how our services are used and could be developed.

And all GP IT system suppliers are in the same boat. The systems contain highly useful information - just help us as users to get at it please in a way that makes sense.

PS

Bad memories...

One of my cheerful patients on Friday was just off on holiday to Morzine in France, for a family snowboarding trip. All excitement and a precautionary 'check-up' for snuffly offspring before departing.

I remarked that the same location marked my last ever skiing trip location 4 years ago, a fall seriously fracturing my leg, and a painful ten month rehabilitation period before returning to work. Perhaps the 'health promotion' message to take care and wear a helmet will sink in!

But last night for me marked again by unpleasant dreams re-living the event, asking myself 'what if'... to change the outcome.

I have not yet been faced by patients who have experienced harm, of even just mentioned uncomfortable reminders of past events and experiences after reviewing past records and events - but it will happen sometime.

Not a reason to ban the prospect of retrospective access in my eyes, but important to have human sensitivity in dealing with the lingering consequences of past event for our patients.

Peter S

Mobile Apps.....

I go away on holiday for a week, and come back to a 'storm' of news and innovation!

Several companies announced innovations that are increasingly focused on patient interaction and convenience, combined with an increasing focus on what a patient may want and need.

My own system supplier has quietly announced the launch of an 'App' available for android and apple devices allowing booking of appointment, repeat medication requesting and secure communication.

I have tested this out on a 'dummy' record, and it looks like a promising start.

So yet again, exciting times ahead as we see what the market can offer to invigorate and open up opportunity. I very much hope that the direction of development will be towards functionality that enables patients and families to access, understand and use information to make healthy and safe choices with confidence. Like most colleagues in Primary Care, the relentless 'shift' away from Secondary Care without any resource re-allocation is pushing us close to breaking point, and technology on its own is only part of the solution...

Appy Easter

Peter S.

Life as a Hedgehog

It can be uncomfortable and dangerous, living ones life in the 'middle-of-the-road'.

But am I in the foolhardy, spiky minority, am I taking risks?

The debate I follow, and the related ongoing subject of these postings, is the progress in GP practice on-line interaction with patients. And it seems to have been a noisey week in the press and social media!

On one side of the carriage-way are the articulate 'nay-sayers', expounding the risks of a free-for-all with sensitive information, mushrooming workload and a security nightmare. On the opposite side are  the proponents of progress at any cost, predicting doom, gloom and revolution if all the barriers to information access are not unceremoniously torn down immediately....

And so, I 'dither' in the middle of the road, looking both ways, but not really drawn to, or convinced by either camp of the rights and wrongs.
Like many of my GP colleagues, I have rapidly become a user of IT to access services and information that make my life easier and more convenient. I expect to check balances and transfer money on-line, to browse and shop in the evening for presents I have forgotten,  to communicate with friends and colleagues and to plan my family schedule.
But also recognise that I wish to be private and secure with my information, I shred documents and take care of passwords, I update anti-virus software and try to remain alert for security threats and 'scams'. I have been caught out before, and will be again, but on balance I still choose to 'take the risk'.

So am I on my own, in the middle-of-the-road'?

It would appear not! The majority of my colleagues, and quite probably of my patients, can see benefits and risks, but will increasingly try out on-line interaction in health as they do in other areas of their lives. Every practice and every patient will have different reasons and experience - all equally valid.

So it turns out that MOST of us are 'in the road', those shouting from the sides may well be the oddities with entrenched views and less grasp of reality. There really are NO cars or lorries bearing down on us, threatening instant oblivion - there are challenges to face, mistakes to make, evidence be gathered and lessons to be learnt, but not by sitting on the edge lecturing to others.

Being in the 'middle-of-the-road' may turn out to be the cool place to be!

Peter S.

Missed the boat with Records Access?

There are 'delights' of being behind the times with 'IT'. But that is followed by the pain, challenge and frustration of trying to 'catch-up'.

And the NHS is always 'catching-up'!

In a reflective mood I am considering what I need to offer patients this year to make their lives (and mine) easier, safer and healthier. What can I do with the information I hold in trust, with the relationships I have spent so long developing and the clever opportunities that an 'on-line' world opens up?

The easy answer is to follow the innovators and evangelists on opening up records to patients - 'do what I am doing and your problems will be solved'. Or I could follow the bulk of my professional colleagues - 'I am far too busy doing the basic work 11 hours a day in General Practice to take on anything else'.

But perhaps there is a 'third-way' (with apologies to multi-millionaire Tony Blair)? To follow my instincts, trust my knowledge of my patients and my record system and pursue a local pathway to improve little bits of my Health Service provision and interaction - irrespective of National policy, perceived wisdom and the next wave of 'targets'....

And my area for attention may just 'leap-frog' the interest and expectation in Records Access for this year. E-mail is 'old' hat, social media is inappropriate, PCs are dated technology - but 'bite-sized' direct secure messaging may hit the spot!
So how and why have I come round to this view? Observing some of the trends and expectation across all age groups - our society is advancing using smaller and smaller 'parcels' of relevant but fleeting 'information' to make decisions and manage life, often through mobile devices. Who has the time, interest or inclination to 'wade' through long and complex documents to find a 'nub' of crucial information? Ask yourself, when did you last read through the T&C of a software update - or do you just press the 'accept' button and proceed?

In my world THIS is the way forward to share clinical data, recommendations, communication and interaction 'on-line' with an increasing proportion of my patients. It could be done via a medium of their choice (for inclusivity), text, e-mail, letter secure messaging - who knows. It will involve small discrete 'parcels' that are of immediate relevance - the patients can do what they want with it - dismiss in seconds, store or collate - the choice is open and free. Results, advice, updates, reminders, letters, prompts, warnings from the practice - and as we develop functionality comments, suggestions, status reports, questions, values and observations from patients and carers back to us.

Am I on the 'right' lines - who knows?

But I suspect I am not the only one thinking beyond Records Access...

PS

A year of on-line GP practice services for patients

My surgery has been offering ‘on-line’ interaction with patients since 2006. We started with medication requesting and appointment booking, and more recently added access to medical records in November 2011. What follows is a summary of the activity during 2012.

Successful logins	8745
New patients registered for service	227
Appointments booked	2018
Appointments cancelled	591
Repeat medication requests	2468
Address detail change	226
Medical record viewed	115

So what are my conclusions at the end of a year that has seen a significant rise in political interest over ‘on-line’ GP services for patients?

• With a practice list size of 9000 and 6 years of on-line service behind us, we still have an average of less than one on-line interaction per registered patient.
• ‘Transactions’ at the convenience of patients dominate the activity.
• Medical record viewing remains at a very low level without active clinician promotion.
• There is significant potential to increase on-line activity and relieve telephone and front desk pressure with routine tasks such as repeat medication requests and GP appointment booking.

We do not know the age/sex breakdown of service users – this could be informative.

We are uncertain how we compare with other practices

We have not researched the barriers to use by patients

Medical record viewing has not been a major challenge or workload in the previous year.

So – ‘more of the same’, or ‘must do better’?

For serious consideration in 2013:

• Offering nursing and ‘task specific’ appointments
• Advertise the appointment and medication services more actively
• Target specific individuals for Record Access and test result notification
• Press for better activity reporting from system supplier

Happy New (Patient on-line) Year!

PS