PATIENT RECORDS
Report after report has detailed the problems in implementing electronic patient records. Dr Henry Potts, who has studied the issue in detail, discusses the theory and the practice.
T
he National Programme for IT’s mul- tiple failures have been exhaustively
chronicled – not least in National Health Executive. Most recently, the NAO has reported that the ongoing effort to create electronic care records for every patient has proved very poor value for money and will not be completed in the project’s life- time, while Parliament’s Public Accounts Committee also blasted the programme for security flaws, and the BMA has attacked linked plans to store the records in the NHS Information Centre.
It was thus hardly reassuring for health professionals to hear that, as with un-can- cellable aircraft carriers, it could be more expensive for the NHS to scrap some of its hugely expensive IT supplier contracts than just stick with them despite the delays, missed deadlines and increasing costs.
Dr Henry Potts, senior lecturer at UCL’s Centre for Health Informatics & Multi- professional Education (CHIME), and the former principal investigator on the NHS Service Delivery and Organisation-funded LOUIS programme - learning from organi- sations using information systems – spoke to NHE about the philosophy that has un- derpinned the quest for centralised elec- tronic patient records.
He told us: “There is, of course, a presump- tion behind the electronic patient record that you can have one agreed, shared re- cord. That implies that the patient record is a description of everything that’s happened to the patient – that it’s in some sense an objective summary of their medical history – but it’s clear that’s not what any patient records do, whether electronic, paper or papyrus.”
A tool, not a silver bullet
He continued: “A patient record is fre- quently a tool used by a healthcare pro- fessional to support them doing their job. They’re trying to do something, often an- swer the question, ‘what do I do next?’, and the record is a tool to support them doing that. That’s simply not the same thing as a precise record of everything that’s ever happened to that patient.
“Different health professionals doing 26 | national health executive May/Jun 11
different things will be focused on different issues. They may define a particular condition in a different way; so, take asthma, or autism. For a GP, asthma might mean one thing; for a chest specialist in a hospital, it might mean another, or asthma may be much too broad a diagnosis for them, and they will need to use much more specific terms. But a GP doesn’t want that level of detail; they want ‘asthma’.
“Or autism; it can be a label that is deliber- ately attached to a child who might be on the borderline of the formal diagnostic cri- teria, in order that they get additional help in a school context. It’s not that there’s a ‘truth’ – this child is ‘this’ or ‘that’ – but rather that healthcare professionals use di- agnoses to achieve ends.”
Terminology
“In that context, if I was an adolescent psy- chiatrist needing to describe a child, I might use a more specific term than ‘autism’, but know that if I ‘tick that box’ I know I will get this kid x help. If I’m a GP trying to get my patient into hospital, I might say x be- cause I want to help them. When we have internal markets, or a private system like the US, the most useful category when you’re treating a patient might not neces- sarily be the most useful category when you then have to bill for it. Again, it’s not that one is right and one is a lie; both are right; patients do not always fit into neat boxes. We have research evidence of these things happening. People use terms differ- ently, and change terminology to suit their purposes.”
So does Dr Potts believe the entire princi- ple underpinning the quest to centralise, digitise and standardise patient is mis- placed?
He would not go that far, he says.
“I think the practice, not the principle is wrong. It doesn’t mean there isn’t or can’t be a useful patient record that everyone looks at. But the presumption that you’ll get away with not needing any other records is a utopian fantasy – it’s like the paperless office. That didn’t happen. You can have a centralised record, but as people like Mark Berg say, you’ll still get
fragmentation elsewhere. The GP needs one thing, the hospital specialist another, A&E staff something else again.”
Oversold
Dr Potts is clear: “The promises of the electronic patient record were grossly oversold: it was a techno-utopian dream. Tony Blair stood up and said ‘if you fall over while walking in the Pennines, the A&E doctor will be able to see your records’; but that doesn’t happen, and it’s only 1% of medicine.
“There is clearly value in electronic and centralised records, but let’s not presume you can have one record that everyone agrees on and can feed into.
“One key question is whether the record can present different things to different people. In France, it does – it presents one thing to the nurse, one thing to the doctor. Smaller countries have been better at in- troducing electronic patient records: New Zealand, Denmark, maybe Scotland, the US Department of Veterans Affairs – there’s a scaling issue here. Or is it just pure chance, which systems have worked? We can look at how other places have done it better, but there’s clearly all sorts of issues that aren’t about scale that went wrong here; the lack of clinical consultation in the UK, this very top-down system, and I could go on.”
Security
In late May, the BMA again raised its con- cerns about the security of electronic pa- tient records.
Dr Potts acknowledged the debate, but said we must realise that it is possible to strike a balance.
He said: “My mum had a minor eye prob- lem recently, which we didn’t know was minor at the time, so we were sat at 8am at Moorfields A&E, hearing about how they protect privacy and confidentiality. My mum said, ‘I don’t care. I don’t mind who sees my health records’.
“Professor Trish Greenhalgh did some work on this. You have a very vocal minor- ity saying that it’s a really big problem and
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