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  1. PRIMIS Piecing Together the Past Professor Martin Severs Chairman NHS Information Standards Board Fifth Annual Conference 11 – 12 May 2005 Piecing Together the Future

  2. Piecing Together the Past From the seven wonders to the seven deadly sins of primary care computing Professor Martin Severs

  3. Presentation • Perspective • Seven Wonders of primary care computing • Seven Deadly Sins of primary care computing • Conclusion • Applause or Hasty Retreat

  4. Perspective • The components of my world view [weltanschauung] • Patient and their individual care is paramount • Quality of data and its improvement is an essential component to sharing without re-recording • Care is increasingly dependent on teams often from different organisations who through geographical separation may never meet

  5. 1+. Patients First • Primary care heeded the lessons from history • “The current deficiencies in collecting medical information were the multiplicity of records and the different methods of reporting, coding and storing; there was no uniformity”. • “There was a need for a cumulative record on every person drawing relevant data from all his medical and social episodes”. • “The emphasis should be on the patients’ life history not the requirements of Health Service Records”. • Bothwell, P.W. and Bradford-Hill, A. BMJ 1963; Aug 3 : 309 - 310

  6. 1+. Patients First Note GP’s were there first! ‘Systems must be ….. primarily designed to improve the delivery of patient care rather than support finance and administration’ Audit Commission 1995: ‘For your information; a study of information management and systems in the acute hospital’

  7. 1+. Patients First • Work of Dr Richard Fitton Glossop • 10% of his patients have taken an electronic copy of their records home • 1/3 have errors or omissions • 1/3 patients say this information has changed their lifestyle • Primary Care February 2004;29

  8. 2+. You walked the walk • Most individual practices have their own IT applications and databases (98%)

  9. 2+. You walked the walk • There is no misery! • ‘If there is technological advance without social advance, there is automatically, an increase in human misery’ • Michael Harrington (1929 – 1989), American author and Democratic Socialist in ‘The Other America’ (1962)

  10. 3+. Concentrated on ‘Killer Apps’ • 3 RCT’s on computer based prescribing, which showed improved accuracy of drug dosing. • Saving on medical time 1 minute per prescription. • 38% less phoned requests from patients. • 5% less enquiries from pharmacists. • Cost savings of up to 30%. • Better completion 95% vs 42% of handwritten ones. • Wyatt J and Walton R BMJ 1995; 311:1181-1182

  11. 3+. Concentrated on ‘Killer Apps’ Applications used in computerised practices (%) Patient Registration 100 Basic repeat prescription 100 Age/sex registers 95 Immunisation/screening recall 95 Cervical screening recall 95 Word processing 73 Disease Registers 68 Defaulter Identification 64

  12. 4+. Legibility and Utility • ‘Until now we have had to put up with notes so badly written even the original author cannot interpret them. We have had to endure lost, defaced, duplicated and inaccurate records for so long anything has to be an improvement’ • Alan Stewert ex nurse Computer Weekly 23.09.03;38

  13. 4+. Legibility and Utility The cost of poor handwriting In a study in 1994 over 90,000 malpractice claims over seven years, the second most prevalent and expensive claim was due to medication errors caused by misinterpreted prescriptions. Medication misinterpretation claims cost on average $120,722 with a range of $5000 to $2.2 million per claim. Cabral DY. JAMA 1997:1116-1117

  14. 5+. Research and Audit • GP’s and other researchers use real patient data for researching and auditing their own practice • It also enables the audit of the practice of others • Most of this presentation was gleaned from published material

  15. 5+. Research and Audit • Do doctors get the information they want when they refer patients to specialists? • Most improvements can be made in: • Prognosis • Contingency Plans • Reasoning behind plans eg tests, new drugs • More use of problem lists • Internal Medicine Journal 2004;34:31-7

  16. 6+. Platform for decision and knowledge support Primary Care understand that: ‘The key tasks of managed care, from identifying best practices to co-ordinating physicians are impossible when relying on paper records’ Appleby C. Hospitals & Health Networks 1966;70(4):30-32

  17. 6+. Platform for decision and knowledge support • Systematic review; 62/97 [64%] trials showed doctors did best with decision support in diagnosis, preventative care and disease management • Automatic better than manual: 44/60 [73%] versus 17/36 [47%] • Little evidence on cost effectiveness; methodology not clear and criteria for a good one not clear • JAMA 2005;293: 1223-38

  18. 6+. Platform for decision and knowledge support • USA; 5 primary care practices • Doctors overrode: • 91% drug allergy alerts • 89% high severity drug interaction alerts • Independent review agreed with the doctors in 98% of occasions • Conclusion: ‘Identify and eliminate alerts which are not clinically credible’ & change the ‘threshold on alerts on drugs which the patient currently tolerates’ • Weingert et al Archives of Int Med 2003;163:2625-31

  19. Leo Fogarty Richard Fitton Phil Brown Nick Booth Mike Pringle Steve Bentley Grant Kelly Mike Bainbridge Steven Pill Dipak Kalra Gillian Braunold Peter Johnson Mark Smith etc 7+. Great Mentors and Teachers

  20. 1-. Perceived Isolationism

  21. 1-. Perceived isolationism • Patient records are not easily transferred to other practices or care providers (>90%) • Development and effective implementation of care pathways is inhibited • In urban areas 25% of patients change GP per year. Records transferred by Royal Mail • In a study of 317 general practitioners in Yorkshire, 17% said that lost paper records had led to wrong drugs being given. Sixty percent thought that the introduction of electronic records would improve standards of care Source: Poor record keeping leads to drug errors.Pharm J 2002;268: 421

  22. 2-. Data Quality • Work of Dr Richard Fitton Glossop • 10% of his patients have taken an electronic copy of their records home • 1/3 have errors or omissions • 1/3 patients say this information has changed their lifestyle • Primary Care February 2004;29

  23. 2-. Data Quality • Systematic review: scope and quality of data in primary care • 4589 articles; 174 classified; 52 met inclusion criteria • Lack of standardised assessment of quality of data in electronic records makes it difficult to compare results • Thiru K, et al BMJ 2003:326:1070-2

  24. 2-. Data Quality • Automated Quality Checks on Repeat Prescribing in primary care UK • 3 general practices for four months • Gold standard for knowledge; BNF all prescribing had to have an indication • 14.8% prescriptions had no indication • 62% of alerts were incorrect;44% due idiosyncratic coding; 43% because of missing mapping between indication to read code in knowledge base

  25. 2-. Data Quality • Conclusions • More consistent data collection across multiple sites • Reconciliation of clinicians willingness to infer clinical diagnoses and the machine’s inability to do the same • Rogers et al Brit J of Gen Pract 2003; 53: 838-834

  26. 2-. Data Quality • Marked variation in code groupings 9 in 17 practices • Marked variation in individual codes 25 in 17 practices • C10 DM code used in all practices but only in 14-98% of diabetics • Marked variation in detail; 45% had DM type coded; 21% retina exam coded • Gray et al BMJ 2003; 326: 1130-2

  27. 3-. No improvement in Communication • ‘Diabetics disadvantaged by poor communication says Audit Commission’ • ‘Poor communication and poor record keeping run across all the cases I see’ Health Ombudsman • British J of Healthcare Computing & Info Man. 2004;21 (2):10

  28. 3-. No improvement in Communication He noted that if more care was taken with ‘communication, record keeping and complaint handling at the local level’ then there would be less work for his office. ‘The Annual Report, and the Fourth Report of the Health Services Commissioner for England, Scotland and Wales. HC811 and HC812’

  29. 3-. No Improvement in Communication • ‘Patients records are not just for individual doctors, but are a way of communication with other doctors and healthcare professionals. If they can’t be read then the doctors are failing in their duty to communicate effectively’ • Matthew Robson Clinical Risk Manager MDU • Clare Hughes BMJ Careers 30.08.03 s67-68

  30. 4-. The Human Factors • There are three definitions of MI in use in England, which is the approved professional one? • ‘The wide variety of definitions used will result in patients being given different diagnoses, with implications beyond their immediate management’ • British Journal of Cardiology 2004: 11: 34-8

  31. 4-. Human Factors • What is a diagnosis? • Diagnosis for international comparisons of morbidity = ICD 10 [population level] • Diagnosis for the care of individuals = in peoples’ heads [individual level] • A label for communication consisting of all diseases, disorders, syndromes and specific physiological states e.g. pregnancy • Falls example

  32. 4-. Human Factors • Cancer of the Colon; Can you ever be cured? • GMS contract: severe and enduring mental illness; what is the incidence and prevalence? • GMS contract: CT scan and stroke; why isn’t this a primary AND secondary care communication standard?

  33. 5-. Failure to link to education [educational quality standards]

  34. Does Shows how Knows how Knows Miller’s pyramid for assessing clinical competence

  35. 6-. Finance driven standards before Professional standards? • We ‘are just realising how much extra care we are having to take to record what matters. Actually patients are getting more systematic health care which is what the new contract was about any way’ • Dr Laurence Buckman. BMA News June 12th2004. p3 • Shouldn’t the driver for record keeping be the effective care of individuals rather than remuneration?

  36. 6-. Finance driven standards before Professional standards? • ‘The increasing commercialisation of medical care has created conflicts of interest for the many practicing physicians who have financial stakes in the health care facilities to which they refer their patients’ • Relman A NEJM 1989;320(14):933-934 • They could also gain by not referring their patients

  37. 6-. Finance driven standards before Professional standards? • Retrospective medical record study of 5 tertiary, teaching and non-teaching hospital in Boston USA • 1003 records reviewed for accuracy of ‘myocardial infarction’ diagnosis • Tertiary hospitals 41.7% were not supported • Non-teaching hospitals; 9.1% were not supported • 66 Teaching hospital patients were not supported having been admitted 5-8 weeks after the diagnosis for angiography! • Important implications for funding and income • Iezzoni LI et al NEJM 1988;109:745-751

  38. 6-. Finance driven standards before Professional standards? • Financial Risk and Hospital Cost in medical Non-Complicating Conditions Analysis of 12340 medical patients • The more NCC’s per DRG the: • Higher the total hospital cost • Longer the length of stay • Greater the number of procedures/patient • Greater the financial risk to the hospital • Higher the patient mortality • Munoz E et al Arch. Int Med 1989;149:417-420

  39. 7-. Capacity not converted to leadership • Not enough primary care information experts in professional leadership roles • Not enough primary care information experts in policy leadership roles • Needed to convert innovations into mainstream thinking, planning and dissemination

  40. CONCLUSIONS • GP’s have led and continue to lead all clinical professions in the use of IT for patient care. • Other professions should learn from the GP experience • Most of the sins of GP’s with regard to IT are shared by all clinical groups and are not unique to General Practice • There is evidence that the next step involves a shared agenda with other professions; GP’s need to be at the heart and part of that effort

  41. Parting Thoughts • ‘Management [the control of an organisation] is impossible without data’ • Professor Alan Maynard HSJ 10th June 2004 p20 • Accurate data is dependent on common record and communication practice standards • Goldfield et al BMJ 2003;326:744-7