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Reflections on Rio. Dr Annette Downey Psychiatrist for older people And cognitive analytic therapy practitioner. The Old Belmont Hospital, Tiverton. Tiverton District Hospital. Experience of Implementation. Requires a large organisational cultural change
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Reflections on Rio Dr Annette Downey Psychiatrist for older people And cognitive analytic therapy practitioner
Experience of Implementation • Requires a large organisational cultural change • Early knowledge of the new computer system = the early diagnosis of dementia which provides early information to people with dementia and their families which results in reduced psychiatric morbidity and provides containment. • Early on Rio becomes a scapegoat for anything in the organisation that goes wrong
Karen Norberg #1 Knitted Brain by Karen Norberg
Typical Rio Neuroses • Fear of embarrassment – being shown up as computer illiterate • Paranoid big brother fears • Fears of breaches of confidentiality and consent • Anger that a system that was supposed to be ‘paperless’ actually resulted in more paper wastage than ever. • Passive resistance – having both Rio implemented and a paper system continuing in a unit side by side – result = twice the work for staff based on a lack of trust in the system
Why do we need Rio? • An aid to multidisciplinary patient centred care. • All health care professionals involved in the same patient, record contemporaneously their working notes and assessments in the same record • Automatic computer generated signature and time of record (never have to sign or explain your discipline or date a medical record again) • Detail can be added later with the record needing to be validated by the person entering the data.
‘ICPA’ • Single place for recording of • Mental State Examination • Personal history/life narrative • Past psychiatric history • Medical history • Social history • Forensic History • Risk assessment – dynamic and can be graphed • Physical examination – with parameters that are dynamic and can be graphed • Specialist assessments – HONOS, CORE etc – trust can decide which ones it wishes to use
Care Plans • ICD 10 diagnoses search tool • Care plan libraries for particular conditions • Used as clinic letters – able to be agreed and signed during consultation, print and give to patient at the end of consultation with all parties agreeing to the plan. Can then be sent electronically to other professionals involved in the care in place of a dictated letter to the GP.
Diary and Clinic lists • All clinics are recorded on Rio and are linked to your case load – to record a person as seen in clinic they need to be referred to you on the computer. • The Rio diary has the facility to show clinics occurring at the same time side by side. Clinics not occurring due to annual leave or other leave can be indicated electronically . • Information for inpatients who are also outpatients at the same time (ie open to more than one sub-speciality) will be available to all. No hidden specialist notes. Useful for the more complex cases, those having psychotherapy and also being care coordinated. For each patient a list of professionals currently involved is available , including those involved in the past who have closed the case. • Electronic recording of time of consultation, length of consultation and outcome ensures people are not lost to follow-up. Also enables active management of caseloads quantity and quality.
On call • Pin-cards and laptops are required • Result: In 4 years I never saw a patient (even on call) without access to the current psychiatric notes.
Teaching • Access to the complete record electronic record made providing case summaries and case presentations easier – no problems deciphering scrawled handwriting and signatures. No lost notes waiting for dictation or hidden forgotten in an office drawer. • Material for case based discussions was straight forward • Useful for mentoring and supervising work and detecting learning points/developmental issues – for example with an F1 doctor I was able to review her writing of admission records for inpatients, confidentially without needing to remove the records from the inpatient ward where they were needed for access by the nursing staff.
Research and Audit • This can suddenly be completely done at a distance from where the care is being delivered – pros and cons to this. Enabled Somerset to be able to very quickly produce Audits based on a large number of patients. • Notes are never lost
Team meetings, Wardrounds • Rio provides an information and communication bridge between the inpatient and community staff, also between specialities . • Laptop entry and case note data projection onto the wall of the meeting room of the current health care record, became the norm by most specialty teams, within 2 years of Rio starting in Somerset • Multiagency and disciplinary discussions are able to be entered at the same time. • Teams can all quickly analyse referral letters ( all projected onto the wall for all the team to see). • In the same way the team could quickly all review correspondence, mental states, physical exams, care plans and other progress notes for each case discussed.
Potential Rio Pitfalls • Underinvestment in servers (system power ) – causing logging in difficulties or slowness (Monday mornings particularly). • Can be vulnerable to viruses – can result in loss of accurate data entry – fortunately data can be entered retrospectively. • Electronic prescribing was never successfully started, although there were a few attempts and at least one pilot. • Underinvestment in office and desk space; administrative staff ; computer equipment. • Staff accessing care records through the generic record search system, rather than through caseloads results in a loss of confidentiality - all Mr Smiths are listed. • Confidentiality and consent not checked via audits of which staff have had access to the notes and why. • Any downtime during patient crises – on call at night recording of crises can save on Microsoft word for later entering on Rio the next day - data entry is not timely.
Summary • As in the beginning of therapy it is important to suspend judgement- to keep an ‘open mind’’. • A great deal of modern IT infrastructure is required – Desks, computers, printers & scanners, and phone lines.– • I recommend an expert users group to include a wide range of staff both in terms of seniority and also professional group. • Not least an investment in the IT skills of staff is required – Rio will spur on this development. • The infrastructure for successful mastery of the Rio system also requires strong administrative support • Unlike my experience in Somerset, Devon is not an ‘experimental guinea pig’ – Rio has been successfully used in many acute mental health trusts. • 5 years on NHS staff are much more familiar with electronic technology. • Many functional aspects of Rio will already be used via other IT packages in parts of Devon eg electronic care plans and EPEX – the difference is that Rio includes all aspects of mental health clinical decision making and note recording on one single computer system.
