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It’s time for physios to get involved with the design of electronic care records, says Daloni Carlisle.

Imagine a health service without paper records, where you can sit down at a computer or open your mobile device, call up a patient’s notes including the history and all the reports and x-rays that you need and then write your notes, fill in charts, make referrals and generate reports for commissioners. That’s the vision of the national electronic care record being developed in England as part of the National Programme for IT and in the rest of the UK under different arrangements. Its development has become a protracted process and remains the subject of fierce debate. Nevertheless it has reached a crucial stage where clinical involvement will make a difference and ensure that what is implemented will enhance modern healthcare delivery and management. That is why, Andrea Peace, CSP head of professional policy and information, says, ‘The important message is to ensure our members take up the opportunity to work with system developers, to design, trial and refine the templates to record clinical information before systems are launched. Freeing up time for these discussions is critical. Otherwise you may find the system does not meet your service needs.’ The national care record was part of the original specification for NPfIT when it was launched in 2002. The reasoning ran like this: patients have records all over the place. There is the GP record, the entry in the hospital Patient Administration System, paper records of clinical episodes, in maternity services, mental health, in sexual health clinics and so on. This creates an inherent risk as health professionals in urgent care settings do not always have access to important information such as adverse drug reactions. It is deeply frustrating for patients who have to give their details and clinical history again and again and again.

Ending the paperchase

So, how about an electronic record to bring everything together? It would mean:
  • no more asking patients to repeat their history
  • instant access to critical clinical information wherever the patient might be
  • the opportunity to share information across the multidisciplinary team and along the length of a patient pathway
  • access to accurate and timely data for commissioners or planners, and
  • the chance to create anonymised data for audit and research.
Fast forward to 2009 and the national care record is still, well, a vision. It took several years to resolve ethical issues such as confidentiality and informed consent, and the argument is not over yet. In addition, there have been technical delays and changes in contracts with the software companies charged with developing this clinically rich electronic record. The situation today is a mixed picture. Nationally the full electronic care record is not expected until 2014-15 at the earliest. In the acute sector, hospitals are waiting for companies to develop the computer systems that are eventually expected to deliver the electronic records: the firm Cerner with its Millennium product, and CSC with Lorenzo. In the meantime, trusts may be given the freedom to move away from the national products and develop more local systems. Ms Peace notes: ‘It is a complicated picture for our members as healthcare organisations are at different points in the journey towards making the electronic care record available.’ In community services, a number of providers have begun to implement computerised records using the systems RIO and System One. Each has modules for physiotherapists to record their clinical notes. In each case, clinical input is vital for these computer systems to develop in a way that means they can capture meaningful clinical information. That’s the challenge for physiotherapists: get involved in the design and implementation of electronic care records – then you’ll have the best system possible for patients and practitioners alike. FL

Benefits and challenges

‘The benefits are potentially huge,’ enthuses Margaret Hastings, chair of the CSP information management and technology forum. ‘Electronic care records would mean real time information about clinical decisions and clinical care. From the recorded datasets, we would then be able to use the structured data to provide information on case complexity, clinical activity, throughput, audit and effectiveness. Pull all these together as anonymised data into a secondary usage service, and we could have a massive database for researchers to access, proving beneficial to physiotherapy.’ Ms Hastings is realistic about the challenges of switching to electronic records, citing physiotherapists’ apathy or fear; the failure by hierarchy to engage clinicians fully; skills gaps in IT; lack of access to computers; and sheer technical difficulties. One hurdle is that the main system providers have not yet met physiotherapy reporting needs. At present Ms Hastings says: ‘Many of the current hospital or community wide systems record physiotherapy information in free text notes fields, which are impossible to use for any form of clinical analysis but are just an electronic version of a paper note.’ She adds that some physios have resisted early attempts to structure records, which, as they see it, will reduce clinical reasoning to tick box exercises. The CSP is working hard to resolve these issues and now sits on the national advisory group of Connecting for Health (the government agency delivering NPfIT in England) and is invited to comment on national developments. Yvonne Pettigrew, the clinical lead for allied health professionals at Connecting for Health, argues that although electronic care records will tend to standardise the practice of record-keeping, this is not necessarily a bad thing as it will be evidence based. And where it could be a problem, she says: ‘If we are involved we can be very vocal about where that is not appropriate.’ ‘I can’t imagine working without the system now’ Susan Montgomery is an extended scope practitioner physiotherapist working in Lincolnshire community health services. She started using the System One electronic care record in December 2007 and describes her experience ‘We were all a bit nervous at first and there was the usual knee jerk reaction. But there was lots of training and we were very involved in the development and things have gone very smoothly. I can’t imagine working without the system now. In my service, referrals come in to a central point. They are scanned into the system and each new patient is registered, giving us the telephone numbers and demographics. The referral letter is in there and additional information such as x-rays. The appointment system is electronic and everybody can see everybody else’s appointments so if a colleague wants me to see one of her patients, they can book them in. They can email me the notes and ask what I think too, so there is lots of peer work and mentorship. We helped to design the musculoskeletal templates and they are very similar to the paper records we filled in as juniors, except they are all typed in. Everything you would have written into the patient notes is put into this electronic patient journal. I can even dictate letters to the GP directly into the system. It has brought enormous benefits. There is no more deciphering scribbles and if I am off sick a colleague can see exactly what has happened with a patient. It records all the batch numbers of medications I prescribe, for example, and whether I have obtained informed consent. We are able to run off management reports instantly too, for example tracking the number of referrals we have made. We are now working on proper clinical outcomes although it is very early days. We want ways to measure the outcome of treatment so we can see the clinical effectiveness of what we are doing.’

Top tips for a smooth transition

  • don’t think of or explain this as a computer or IT project. It is a way of improving patient safety, quality of care and making your job easier
  • early involvement of clinical staff is crucial. Managers: make sure you involve clinical staff. Clinical staff: attend meetings and join working groups when you are invited
  • where possible involve clinicians in designing the forms they will use. Where these are already developed, make sure physios understand the potential benefits of electronic care records for clinical care, audit, information sharing and collaboration
  • involve health and safety representatives early on to avoid problems with seating and computer use
  • make sure all staff have computer access
  • system failures are inevitable at the start of implementing a new system. An efficient helpline really makes a difference

Integrating the private sector

Private practitioners have been using sophisticated computer systems to manage their business and record clinical data for many years. The concern is not how to improve current systems, but how to integrate them with the NHS. Key questions include: will private practitioners be able to get an NHS email address allowing confidential communication with GPs, and will they be able to access and provide input into patients’ NHS care records electronically?

Moving to RIO – a mixed experience

Frankie Ward is a senior physiotherapist at Surbiton hospital, part of NHS Kingston’s provider services, and moved to using the RIO system in October 2008. It has been a mixed experience, marred by a lack of computers, so not all the physiotherapists can use the system, and charts that seem poorly designed for physios. She says: ‘We had problems at the beginning navigating the system, but it is getting better now. The real problem is the musculoskeletal body chart, which is not helpful at all. It is clumsy and we are not able to use agreed national standard symbols. ’Nor is it by any means paperless, she says. ‘Physios who have computers are completing their subjective assessments on the computer, doing the objective assessment on paper, scanning it, and shredding the paper so we do not have to store it.’ It is not all bad, she stresses, as information can be shared more effectively. But problems with ergonomics and frequent system crashes have deterred physios.

Rolling out the summary care record

The summary care record, a short version of the electronic care record that contains the information needed for urgent care, is being rolled out now in England. For each patient, it includes demographic details, details of current prescriptions and drug allergies, and, with patient consent, it can be made available to urgent care providers. Andy Carr, physiotherapy adviser to the summary care record programme, says: ‘It is not going to replace the more detailed locally held information that you would use for day-to-day patient management. It is much more about making episodes of care safe.’ He adds: ‘It is a first step and over time, it will draw in information from other sources such as outpatients and A&E, and will eventually be fed by information from Cerner and Lorenzo.’

What is happening beyond England?

In practical terms, physiotherapists in Northern Ireland, Scotland and Wales may feel very disconnected from anything to do with the electronic care record. But that is not to say it is not coming, or that they should not be lobbying for involvement. Margaret Hastings, chair of the CSP IM&T committee and clinical information lead for NHS Greater Glasgow and Clyde, says: ‘There are two views on how to build a clinical system. One is to have every profession recording their notes in a single system, where the basic functionality has to cover everybody. The other is to use portal technology where clinical data is held in a variety of specialist / bespoke systems, and accessible to other clinicians who need it. ‘This second route is the direction of travel for Informing Healthcare in Wales and eHealth in Scotland. We need to be able to share information with all who need to know to deliver safe, effective and efficient clinical care. There is no one way to achieve this.’ In Northern Ireland, each health board is taking its own approach, rather than adopting a province-wide programme.


In England all strategic health authorities have Connecting for Health leads, who can help you find out what is happening locally and how to get involved.
Daloni Carlisle

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