Political "Top-Trumps" and GP Record Access

No postings for more than 10 months - and no-one noticed…..

I have moved from GP partnership into the world of a 'Portfolio' GP, maintaining clinical practice at my former surgery, but working for HSCIC across a broader remit to link projects and programmes closer together, for patient and clinician benefit.

In England there has been consistent work going on 'behind the scenes' leading up to a flurry of activity in March to activate online interaction between citizens and General Practice. So with the publication of achievement figures today, there is a sense of surprise and amazement that the landscape of opportunity for citizens has changed so much.
Of course the sceptics will argue that 'only' around 5 million people are currently registered to use these types of service, and that very few yet go as far as to access the medical record elements.
While that is true, there are several markers of a 'step change' in attitude to the opportunity, approach and demand for digital interaction with Primary Healthcare services:

• General Practices themselves turned on the functionality - a positive attitude
• NHS England and GPSoC worked to educate and enable - facilitation NOT enforcement
• Improvements in Patient Facing Functionality - a market waking-up to opportunity
• BMA commitment to work with NHS England - constructive dialogue to expedite benefit
• Alignment with future strategy - Five year forward view

So I am very optimistic that General Practice IS leading the journey of discovery about how citizens and Health & Social Care services can effectively and safety interact in a virtual environment. We all need this to work, to mitigate the politically unpalatable reality of demand outstripping the resources we currently have, without radically new different ways of working.

Digital interaction, with supported self assessment and management, improved signposting and the effective delivery of a virtual service to support healthy choices and rehabilitation, is a major part of the ambition in the next 5 years. Without it the Health and Care services may well soon sink under the burden of 'wants' and 'promises'.

Health and Care services are there to deliver what citizens are assessed as needing, in a manner that is as acceptable and convenient to citizens as possible. Time to move on from Political 'Top-Trumps' to utilise digital interaction to improve the quality and safety of health and social care.

PS - Social Media Hermit…..

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.

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

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

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

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.

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

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