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.