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Information technology in the new NHS: Standing Medical Advisory Committee advice (2/2002)

  • Document type:
    Publication
  • Author:
    Standing Medical Advisory Committee
  • Published date:
    1 January 2002
  • Primary audience:
    Professionals
  • Publication format:
    Electronic only
  • Gateway reference:
    Not required
  • Copyright holder:
    Crown copyright

The priorities and speed of introduction of Information Technology (I.T.) and doctors' perspectives and involvement.

IMPORTANCE:
 All modernisation and development of the NHS depends on good information. Better access for patients needs better and faster information flow. The NHS is a very large organisation and the I.T. falls far short of that of equivalent sized international companies. Whereas 98% of general practitioners have computers in their practice the use in secondary care is far lower but monitoring, audit and planning activity depends on accurate and quick analysis of sound data. Timing is urgent.

BACKGROUND:
 This initiative is against the background of an acute shortage of doctors and nurses and the need to ensure that professional time is used as efficiently as possible. The other important factor is that doctors are increasingly working in health teams with other professionals and working across organisational boundaries (see SMAC paper 1996 "In the Patient's Interest. Multi-Professional Working Across Organisational Boundaries.").

PRESENTATIONS:
 Presentations were given by Sir John Pattison on plans and principles and Dr Benbow and Dr Mark Johnson on personal experience with an electronic personal record system in psychiatry.

Advice

GENERAL ADVICE:
 There is great enthusiasm for I.T. in the medical profession despite some doctors' unfortunate experiences with unsatisfactory systems in the past. However, it must be (1) user friendly, (2) seen to answer needs of the clinician, and (3) a national network so that information can be passed from hospital to hospital. It should be nation-wide, simple, useful and reliable. SMAC emphasises the aim of I.T. is to enhance not replace the doctor/patient interaction. Clinicians should be involved at all levels of IT system management.

SMAC agreed that the three important priorities were (1) electronic lifelong patient records, (2) electronic prescribing, and (3) on-line booking systems for appointments. With adequate funding and organisation it should be possible to set these up within the next three years.

Electronic Patient Records
The aim is a lifelong comprehensive patient record accessible to doctors in primary and secondary care and other appropriate members of the care team, not least the patient.

  • ISSUE: How can the present system of paper notes be enhanced by a new electronic system?
    ADVICE:
    1. SMAC appreciates that for many years there will have to be electronic records alongside paper records but there is no reason why electronic records should not start very soon by including demographic data and past history, recent discharge summaries and patients' drugs. This will give the essential details of the patients' present management.
    2. Once established the records can be downloaded onto laptops or hand held computers, which is very convenient for domiciliary visits or visiting patients in other hospitals. Clinicians must be responsible for the security of portable items.
    3. It is essential that perpetuated records have an ability to be both corrected and updated easily when necessary.
  • ISSUE: What happens when things break down?
    ADVICE:
    4. The system will need 24-hour technical backup because it is vital that doctors do not lose faith in the system early on because of unreliability. In addition, at the very outset plans should be made for the maintenance and upgrading of the system in the future. One lump sum of money alone to set the system up will not be adequate.
  • ISSUE: Will the system be used mainly to obtain activity and financial data?
    ADVICE:
    5. SMAC strongly advises that in order to persuade clinicians to play a major part, benefits, such as quality and safety to the patient and rapid access to investigations, should be stressed rather than the financial aspects.
  • ISSUE: What about confidentiality? There are a number of sections in secondary care such as GU Medicine and Psychiatry that even now keep records separate from the main system. In addition, in many hospitals medical notes, nursing notes and notes of other professionals are separate.
    ADVICE:
    6. Whilst SMAC would strongly urge a single patient record with all professional input, authentication of those allowed to access such information remains a big issue. Confidential information must be safeguarded through coding and passwords and, although patients are responsive to exchange of information, the system must be sensitive to the patients' concerns.

Electronic prescribing
SMAC is very enthusiastic about this use of I.T. because, when correctly used, it can be safer and take account of drug interactions automatically and general practitioners have been using this system for a number of years.

  • ISSUE: What about electronic signatures?
    ADVICE:
    7. There is some natural anxiety about not using the standard signature on prescriptions especially with controlled drugs. PIN codes are used and may be easier to read than traditional doctors' handwriting! For controlled drugs two PIN numbers from different clinicians can give the extra security required. Other countries have shown that this can be effective.
  • ISSUE: How will information be transferred between primary and secondary care?
    ADVICE:
    8. This system is ideal for this important information because either group can obtain the prescribing of the other directly from the record.

Electronic Booking System
This must be seen against the background of huge excessive demand over supply and the need to prioritise by relative urgency and to achieve the DOH guidelines e.g. cancer initiative.

  • ISSUE: How can such a system guarantee an equivalent wait for equivalent urgency from different general practitioners, and that one enthusiastic general practitioner does not take all the urgent out-patient slots!
    ADVICE:
    9. The DOH is committed to equity of access and the elimination of 'post code' prescribing. Consultants in secondary care spend much time classifying referral letters into urgent, soon and routine and deciding which of their team should see which patient. Sometimes a clinician will decide to arrange an investigation before seeing the patient to save time. Sometimes an appointment can be avoided altogether and advice given in reply. There are pilot studies in progress and lessons need to be learnt from these. Care will have to be taken that ease of booking does not lead to even more overloading of the facilities. In many areas such as requests for endoscopy and MRI scanning patients wait many months or even years unless the request is marked urgent or soon. This can easily lead to abuse of the system. Booking guidelines would have to be laid down and the process carefully monitored.

Speed of introduction and maintenance
The introduction of these systems could be quite quick provided there was agreement about a national system because most doctors are computer literate and now is the time to capitalise on both the enthusiasm of professionals as well as the obvious need for such systems.

  • ISSUE: How can doctors be persuaded to take part?
    ADVICE:
    10. As soon as doctors see that a good I.T. system has the advantages of (1) improved access to up to date information for all, (2) it replaces case files and multiple records, (3) it helps clinical management and care co-ordination, (4) it is easier for secretarial and administrative functions e.g. discharge letters and (5) a tool for research teaching and audit, then it will be readily accepted. However, doctors must be given time to work with a new system and to be properly trained otherwise it could rapidly lead to disillusionment. Time is the scarcest commodity in the present health service.

CONCLUSION

Co-ordination, collaboration, communication and commitment to long term financing are the keys to the success of a nation-wide I.T. system. SMAC is very happy to be consulted at short notice on any specific issue or to recommend doctors to be involved at different levels and stages.

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