The electronic patient record (epr) in mental health

The Electronic Patient Record (EPR) in Mental Health

Speakers:

Dr Mike Robson

Lancashire Care NHS Foundation Trust

Laurie Beed

Dr Ashimesh Roychowdhury

St Andrew’s

Service user and carer perspectives – some reactions

How long will my electronic record be kept?

Will it be stored in more than one place, to make it secure against loss?

Why can’t apparently easy things be done, such as sending the diagnosis to my GP following a consultation?

How do I get access to my record? Will I see it in a patient-friendly format, without jargon?

Will people without computer access or skills be able to see their record?

Will my record be portable if I move?

Do other local services have access to my record? Do commercial organisations have access?

Will doctors be trained so that they are experts in using these record systems?

Is an electronic system being brought in as a money-saving exercise, or for the convenience of health staff, not as a quality improvement measure?

Laurie Beed, May 2013

Some patients will welcome online access to their records,

booking appointments and ordering prescriptions, because it will give them ready access to

their records, improve their understanding and help them to

manage their health better

Some patients will not use online access to their records because of cost, difficulty of

understanding the technology, an assumption that it’s always breaking down and in any case they just like to see the doctor

Some patients will welcome online access to their records,

booking appointments and ordering prescriptions, because it will give them ready access to

their records, improve their understanding and help them to

manage their health better

Some patients will not use online access to their records because of cost, difficulty of

understanding the technology, an assumption that it’s always breaking down and in any case they just like to see the doctor

Laurie Beed, May 2013

Service user and carer perspectives - opposing views

Service user and carer perspectives – possible responses

• If new systems work well, are easily accessible, and produce benefits in care, confidence about them should grow

• The Royal College of Psychiatrists might produce a leaflet about Electronic Patient Records, allaying some of the fears about EPRs

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘The Francis Report’, 2013) Recommendation number 244 Theme: Common information practices, shared data and electronic records

Service user and carer perspectives – remember it’s about safe care

There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems:



• Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible, the summary care record should be made accessible in this way

• Systems should be designed to include prompts and defaults where these will contribute to safe and effective care, and to accurate recording of information on first entry

• Systems should include a facility to alert supervisors where actions which might be expected have not occurred, or where likely inaccuracies have been entered

• Systems should, where practicable and proportionate, be capable of collecting performance management and audit information automatically, appropriately anonymised direct from entries, to avoid unnecessary duplication of input

• Systems must be designed by healthcare professionals in partnership with patient groups to secure maximum professional and patient engagement in ensuring accuracy, utility and relevance, both to the needs of the individual patients and collective professional, managerial and regulatory requirements



Systems must be capable of reflecting changing needs and local requirements over and above nationally required minimum standards

S W O T

A Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis of Electronic Patient Records

Helpful to achieving the objective(s)

Harmful to achieving the objective(s)

Attributes of the Project (internal factors)

Attributes of the Environment (external factors)

S W

O T

Strengths Weaknesses

Opportunities Threats

A method for making a structured analysis of a project, plan or development

S W

O T



(Internal factors)

Identifying the SWOTs of an Electronic Patient Record (EPR)

What are your thoughts?

Strengths of an Electronic Patient Record

• 24 hour a day access, improving out of hours continuity of care

• Availability of information means less asking of the same question over and over again

• Remote access to information facilitates sharing by users who are geographically separate

• The record is legible and can be standardised • Can include automatic processes, such as

calculating assessment scores • Records can populate dashboards, giving

clinicians feedback about the progress towards reaching standards or following care pathways and helping to focus clinical time where it is needed most

• Records can be searched, filtered, viewed in a variety of different ways

• Records can be made portable • Information is more securely held than on paper,

with backup copies being made automatically

Weaknesses of an Electronic Patient Record (1)

• Access to a computer and network are needed • Overall usability of systems is poor and

developments are slow to happen • Downtime may be needed for updates and

system may fail entirely • Systems may not be intuitive to use, so extensive

training for users will be required • It is time-consuming to enter the clinical

information, which is frequently duplicated, copied and pasted, and ‘dumbed down’ (loss of richness, tendency not to update, just to copy)

• Gaps in systems cannot easily be worked round, unlike on paper

• Too much inconsistent / over-inclusive data and not enough information?

• Highly structured records may mitigate against formulation and explanatory description

• Information, once entered, can sometimes be very difficult to find - potentially creating clinical risk. Legacy records will often be in a different system

• Information may be entered long after the clinical event

• They often don’t reflect (and therefore don’t support) clinical processes

• Opportunities for connectivity and information sharing are frequently not taken. Primary and secondary care systems don’t communicate, for example. Opportunities for mobile working are lost

• Systems in neighbouring areas may not be compatible – how can the record be shared if a patient moves?

Weaknesses of an Electronic Patient Record (2)

Opportunities created by an Electronic Patient Record

• Connecting up the records held by various organisations such as primary and secondary care

• Clinical records can be created collaboratively by professionals, patients and carers, with the record becoming richer as time goes by

• Structured information can be collated and harnessed for audit and research

• Standardisation facilitates information sharing • Information about local patterns of disorder can

be used to commission appropriate services • Automatic analysis and display of information can

help clinicians to comply with guidelines and assess the patient’s progress through pathways

• Patient safety can be improved through information sharing and the use of decision support – improved governance

• On-line services for patients, such as repeat prescription requests, booking of appointments

• Money-saving in the long term?

Threats related to an Electronic Patient Record (1)

• Task-shifting can occur – for example, a higher proportion of clinicians’ time is spent creating the record

• Users may create ‘workarounds’ for deficiencies in the record, meaning that information is entered in various ways, or the display of the information may be generally poor, potentially creating clinical risk when trying to find the information later

• The processes of commissioning, specifying and purchasing systems have long-term consequences. Contractual arrangements made are difficult to alter and once a system is being used it is difficult to contemplate moving to another system even if the replacement would be better

• Information may be held in ‘silos’ and not shared appropriately across organisations, creating risk

• If clinicians are not competent in using systems, patients may lose confidence in them

• Systems are ? used to monitor staff, rather than concentrate on patient care

• Sensitive information may be too easily available / exportable – or service users won’t trust it’s secure, not hacked and not shared – Care.data

• Clinicians may decide not to enter sensitive information, in case it’s too widely seen

• Patient narrative may be lost in ‘tick-box’ systems • Information may be assumed to be accurate or up

to date when it is not • Systems may become obsolete, paper never will • Patient access may create complaints • Perceived need to ‘fill the boxes’ and not assess

and treat the patient • Commercial interests may mean systems are

designed to create profit rather than fit a need

Threats related to an Electronic Patient Record (2)



• 24 hour a day access • fewer repeated questions • shared record • standardised • automatic processing of

information • clinical dashboards • searched easily • portable • secure

• connecting organisations • collaboratively create records

with patients and carers • enhanced audit and research • standardisation facilitates sharing • reactive local commissioning • compliance with guidelines and

clinical pathways • improved patient safety • on-line services for patients • money-saving

• equipment needed • usability is poor • downtime • training requirements • time-consuming to enter the clinical

information • gaps in systems • inconsistent / over-inclusive data • against formulation? • important information is difficult to retrieve • clinical processes not reflected • delays in making entries • separate systems don’t communicate • Information in one system cannot readily be

exported into another

• task-shifting • clinical risk created when information cannot be

found • choice of system can have long-term negative

consequences • information held in ‘silos’ • perceived lack of competence • staff feel monitored • handling of sensitive information • clinicians censor their entries • loss of narrative • spurious accuracy • obsolescence • generates complaints? • box-filling without thinking • commercial interests affect system development

Summary of the SWOTs



9

9

13

15

Summary of the SWOTs

Electronic Patient Records

A Patient Perspective

Laurie Beed

Questions and Concerns

Affordability

Reliability

Sustainability

Affordability

• Will equipment be affordable for those on low income, or even relatively higher income?

• First/Second/Third class or Economy/Premium/First class access options are not acceptable in healthcare. Full access or better quality and download speeds can be offered at higher charges. This can lead to disincentives for patients to use the electronic records

• Will access to records, initial outlay on equipment and system operating access, start cheap but, due to creeping cost inflation, gradually become unaffordable to too many?

Reliability

• Secure, accurate, understandable

available and user friendly?

• Changeable without notification. This can

lead to confusion or lack of confidence by

the general public

• Trustworthy? Can I trust the records

always to be there and available?

Sustainability

• Will the facility always be there? • In for the short or long term? Permanency is important

• Sustainability will be dependent on Affordability and

Reliability

• Impact on Telecare and Telehealth

• How much faith do we have in the system

• How easy will it be to maintain and deal with upgrades?

• What is the situation on standardisation. Agreed national

standards in Healthcare throughout the country will be a

positive contribution to quality and Sustainability

The Future/Predictions

• The hope/expectation is that it will work successfully, save money and improve quality. But will it?

• Implementation problems should be expected and must be resolved efficiently to maintain credibility. This is achievable

• Significant cost savings are less likely. Healthcare improvements are likely to be more achievable and this may not be readily identifiable on certain balance sheets

Extra points

• Are GPs up to this? What are their views and problems with electronic records?

• “I am more interested in my GP being able to access my records than I am accessing my records.

• I want a GP to access relevant data quickly not searching through a long list. Everything in date order has no important priority listing and is time

wasting searching.” My daughter 39, mother of 2 children

The record

• What is a patient record? We talk about a Patient Record as though we all know what the record is and we all have the same view. Do we?

• Thinking about how the Record will appear to the patient - will the Record be displayed in date or medical conditions order. Other subdivisions could be hospital, consultant or GP

• Will patients be able to submit comments or correct errors?

• Will allergies or other severe life threatening conditions be prioritised and highlighted?

• Relevant/important family histories – will or can this be available in the Record?

Communication hazards/problems

• Sensitive information and bad news – how will this be

handled?

• Examples: terminal conditions especially when

conveying that news to parents of a child

• Also disappointing and upsetting news e.g. a lady unable

to conceive (there are male parallels) and disability

conditions

• Possible stigma or embarrassing conditions. Husband

and wife, after numerous attempts, the wife found unable

to conceive so they legally arrange the services of a

surrogate mother. I know of a case where the child is

now four. Making this public at the wrong time could be

difficult

Final comments

• Mistake/error can be more likely to get through and be believed in electronic recording causing more problems

• Paper records containing errors and mistakes can often be noticed and more easily corrected

• Direct debits and online banking I suggest are less likely to be checked by customers than when we received paper accounts from banks

• Implementation and applications must be considered and patient access to their records must be an available facility not a requirement

The objectives of the project to create and deploy an Electronic Patient Record

Having considered the Strengths, Weaknesses,

Opportunities and Threats, objectives for the project can

be determined

The objectives should have

reference to the SWOTs in order

that they are realistic

Achieving the objectives

Whether the objectives have been clearly defined

Whether the objectives are achievable

Whether everyone agrees about the objectives

If some groups have justifiably different objectives, whether the project can accommodate their objectives too

Whether the objectives have face validity or are supported by evidence or experience

Whether the benefits of achieving the objectives are clear

Whether the objectives have been communicated effectively at the start of the project

Attributes affecting the satisfactory achievement of the objectives could include:


Whether the objectives have been clearly defined

Whether the objectives are achievable

Whether everyone agrees about the objectives

If some groups have justifiably different objectives, whether the project can accommodate their objectives too

Whether the objectives have face validity or are supported by evidence or experience

Whether the benefits of achieving the objectives are clear

Whether the objectives have been communicated effectively at the start of the project

Clearly defined

Achievable

Everyone agrees

Accommodating / flexible

Valid or evidence-based

Clear benefits

Effective communication

Some related questions could include:

Have we clearly defined the objectives of the project to create and use an Electronic Patient Record (EPR)? Can we assume that improving patient care and safety is the main priority and it should be achieved if clinical records can be created efficiently and made available so that they facilitate communication and information sharing and provide a basis for evidence-based practice, audit and research? Does everyone involved have the same shared objectives, or do we at least understand the overlaps and gaps? Is there flexibility - can the objectives be changed in order to allow the EPR to develop in response to clinical need and national and local policies? Can the most up to date technologies be harnessed via agile developments to create a modern EPR, compatible with other systems? Are local and national contracts negotiated effectively?

Attributes


Professionally agreed record standards

‘Anywhere’ access through mobile working initiatives – bring / choose your own device – but ensure their security

Intuitive interfaces appropriate to the device being used, eg touchscreens

Offline working

Data warehouse solutions allowing information from different sources to be collated

Electronic prescribing systems

Fast log on solutions – fingerprint recognition / swipe cards / proximity devices and smooth roaming

Integrating clinical process redesign and system design

Near to care inputting with rugged tablets, etc

Task-based apps – no need to open a whole record to enter specific information

Forced fields / error trapping and conditional logic to improve data quality

Key enablers and ways to minimise problems could include:


Describing some of the key enablers:

Implementation of standards for referral, admission and discharge documents, approved by the PRSB and developed by the AOMRC. This drives integration beyond just seeing other record systems from your system Anywhere access and near to care inputting: e.g. roll out of ruggedised tablet devices to wards, mobile devices to community staff and using software to enable staff to input information into applications, at the point of care, that then send securely to the healthcare record via wifi or mobile networks Offline working solutions allow clinical data entry with sending once a wifi or other network is next available. The data can be encrypted and secure whilst on the device Use of data warehouses: extracted and cleansed data from the clinical system can be used to populate dashboards, improving clinical care and guiding the use of resources to where they are needed Intuitive interfaces : older systems developing mobile UI e-prescribing: to deliver improved safety and cost savings (especially from formulary costs), which would then encourage the digitization of the rest of the record and drive primary and secondary care integration Fast log on- e.g. use of biometric readers on keyboards in secure areas where swipe cards cannot be taken Task based applications: developing interfaces for tasks e.g. outcoming of therapeutic activity, recording of physical health signs on a ‘round’ without the need to log in and out of each individuals record and then find the correct form to input into, saving significant time

Attributes of the project and the environment

The project to create and use an EPR will take place in a context

Internal factors

Project objectives

External factors

Attributes of the project and the environment (internal and external factors)

These factors could include:

The resources made available for the project

How widely there has been consultation about the project

The political will to carry the project through

Whether the funding of the project is guaranteed

The commercial drivers which pertain to the project

Whether appropriate expertise is being used to achieve the objectives

Whether an appropriate, up to date, technological framework is being used

Whether contractual arrangements support the project appropriately

Some related questions could include: Factors

Attributes of the project and the environment (internal and external factors)

The resources made available for the project

How widely there has been consultation about the project

The political will to carry the project through

Whether the funding of the project is guaranteed

The commercial drivers which pertain to the project

Whether appropriate expertise is being used to achieve the objectives

Whether an appropriate, up to date, technological framework is being used

Whether contractual arrangements support the project appropriately

Resource allocation

Wide consultation

Political will

Guaranteed funding

Commercial drivers

Expertise

Technology

Contracts

Have we considered how best to make use of local and national expertise, as well as learning from past experiences – both successes and failures? Have the needs and view of patients, carers, clinicians, providers and commissioners all been taken into account – has the thinking about the project been broad? Have we considered how general economic conditions may affect the project? How do the contracts and relationships with system suppliers affect the project?



• 24 hour a day access • fewer repeated questions • shared record • standardised • automatic processing of

information • clinical dashboards • searched easily • portable • secure

• connecting organisations • collaboratively create records

with patients and carers • enhanced audit and research • standardisation facilitates sharing • reactive local commissioning • compliance with guidelines and

clinical pathways • improved patient safety • on-line services for patients • money-saving

• equipment needed • usability is poor • downtime • training requirements • time-consuming to enter the clinical

information • gaps in systems • inconsistent / over-inclusive data • against formulation? • important information is difficult to retrieve • clinical processes not reflected • delays in making entries • separate systems don’t communicate • Information in one system cannot readily be

exported into another

• task-shifting • clinical risk created when information cannot be

found • choice of system can have long-term negative

consequences • information held in ‘silos’ • perceived lack of competence • staff feel monitored • handling of sensitive information • clinicians censor their entries • loss of narrative • spurious accuracy • obsolescence • generates complaints? • box-filling without thinking • commercial interests affect system development

Putting it all

together

Clearly defined, achievable, widely agreed, clear, flexible, valid objectives . Key enablers in place

Resource allocation Wide consultation Political will Guaranteed funding Commercial drivers Expertise Technology Contracts

Questions, answers and

discussion

The electronic patient record (epr) in mental health

Healthcare

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