Does Lorenzo mean the end of GP electronic patient records?

Tags: CSC diabetes Lorenzo Quality SystmOne TPP

15 Apr 2008

GP computing has been one of the great success stories in patient care and the use of IT in the NHS.

Since its earnest start in the early 1980s, GP records have gone from paper based narratives held in A5 Lloyd George envelopes to fully interactive records, capable of handling the complexities of modern patient care, including the Quality and Outcome Framework (QoF) used for performance related pay and its central reporting mechanism, Quality Management and Analysis System (QMAS).

Without the universal use of electronic GP records throughout the UK, neither the targets introduced in 1990, nor the 2003 new General Medical Services contract, would have been achievable.

In the North, Midlands and East (NME), the area where Computer Sciences Corporation (CSC) is the Local Service Provider (LSP) under the National Program for IT (NPfIT), CSC is planning to introduce Lorenzo, which is understood to incorporate GP records, by 2010.

At present, CSC are supporting TPP SystmOne as their official alternative GP solution, with a view to incorporating it fully into Lorenzo by 2010.

Managing shared records

A great deal has been written about access to medical records held centrally, including the Summary Care Record (SCR) and the risks of unauthorised access. However, as far as I am aware, little or no attention has been paid to the management of the record itself. Has full consideration been given to the management of how such shared records should be arranged?

Lorenzo is planned as an early manifestation of the SSEPR (Single Shared Electronic Patient Record), defined as “a single electronic patient record for each individual patient used by, and contributed to by, all the organisations caring for that patient”, and scheduled to be introduced within two years.

Regardless of the access controls (and who controls access permissions), there are problems in managing a SSEPR which should concern everyone – and for which at present, I believe, no-one is claiming responsibility.

According to board minutes, Yorkshire and the Humber SHA is currently introducing a new shared record system to local NHS organisations, using a GP system with an integrated community module. The approach used within the TPP SystmOne SSEPR is understood to only let records be amended by whoever made the original entry.

The rationale for this is that the record also belongs to the organisations outside the general practice and only the organisation making the entry can change it: GPs can alter GP entries, community can change community entries and so on.

But using shared records that can only be amended by the service that made the original entry may present some worrying hazards.

Take the example of the patient who is sent to chiropody and returns with a diagnosis of diabetes mellitus, which the GP knows to be wrong; the entry on the records can then only be amended by the service that made the wrong diagnosis originally.

Currently Diabetes Mellitus gets picked up quickly thanks to the searches developed for QOF, and it is expected that patients with the diagnosis have the disease and should be managed appropriately.

Managing future veracity disputes

How in a future of SSEPR will disputes about the veracity of entries be resolved? How can we ensure safe patient care while such matters are being discussed? How much time should we allow to resolve queries about other practitioners' opinions and diagnoses?

Have such data conflict and veracity problems already occurred? If they have, what is the strategy that has been developed for managing them, and does it work? What are the information governance and audit policies? Finally, who has final say when such problems occur?

I am not sure whether any community can, in a second episode of care, change the information entered in a previous episode, quite possibly in a different community trust.

If the data includes prescribing it would seem that there is a considerable risk of inaccurate information being preserved – rather than being corrected when spotted - with potential risks created to medical care, life insurance and job prospects!

Medical records need to be changeable

In a medical record, it is important that diagnoses are accurate if the record is to be used in the management of the patient, and changeable if the condition is disproved or evolves into something different over time. Most GP systems can deal with this by keeping the diagnosis originally entered in text and showing the coded diagnosis which replaces it, thus removing the mistaken diagnosis from problem lists, searches and decision support.

Has this problem been considered in the development of Lorenzo and other SSEPR systems? If so, where can the solution be found, and accessed and who is charged with dealing with the queries of future prospective users?

Lorenzo, as I understand it, is intended to provide a further development in the integration of medical records across different NHS organisations, and include hospital as well as GP and community records.

I’m a GP and my practice has been paperless since 1997: believe me, records do not take care of themselves – and Read Code is not easy to use at the best of times. I have a great deal of sympathy for those outside general practice who have different requirements for record keeping – both hospital and community deal with narrative records of episodes of care, or repeated, care for single conditions rather than the cradle-to-grave GP record – and have had no previous training in the concept of the EPR or Coding, whether Read Code or its planned replacement, SNOMED-CT.

Unanswered questions

With this being the case I find it surprising that what seem to me to be key questions surrounding the management of the record remain unanswered. Who, in this SSEPR, for instance, is the Data Controller and Caldicott Guardian?

Who is responsible for maintenance of data quality - including correction of errors and how prescribing is to be managed? Not a trivial point as the person who signs the prescription is legally liable.

Further questions include: how will data that requires action – such as abnormal blood results – be handled? Similarly, the question of what the effects will be on existing mission critical interactive GP records, does not appear not to have been considered.

If they have been considered and policies set, the agreed solutions are not readily available and have not been clearly communicated or published. Or, if they have, I’ve not been able to find them, and I’ve spent time searching for them.

In the worst case scenario, if GPs are persuaded to migrate to an LSP solution and their records are degraded, what might be the consequences? One scenario could be that GPs in NME will have their accreditation to hold electronic records withdrawn and be forced, in the interests of patient safety, to revert to the Lloyd George envelope!

Mary Hawking

Reader's Comments

Headline

gerard@careprovider.com

15 Apr 08 21:04

The headline does not quite tally with Mary Hawkin's views on the shared record as expressed in her article. She articulates what most GPs feel.

I do not see the need to share anything other than a summary which can be uploaded to the spine by GPSOC systems.

There are risks of a shared record. One is that doctors in casualty will rely on what was written before, and fail to start again, take a history and examine patients. I would ban casualty from seeing the shared record, and only allow consultants to see it the next day! Patients change and we must not be prejudiced by what was stated in the record.....but that is the assumed benefit of a shared record, that we are prejudiced by it, saving work and time. Like everything in medicine there are risks and well as some benefits of the shared record. The risk are never mentioned, except by the likes of Mary Hawkin.

Time to move on?

ben.toth@gmail.com

16 Apr 08 08:04

While the record of primary care computing is one of success it is surely time to move on from both the Lloyd George envelope and the isolated primary care electronic record. It is right to move forward with great circumspection, but it is time to move on nonetheless.

Patient Safety concerns

mikh@micklefield.demon.co.uk

16 Apr 08 14:04

Mary Hawking has hit the nail firmly on the head by asking some vital questions relating to control, management and quality issues surrounding the development of wider electronic patient records and the obvious potential patient safety risks that exist. These are areas that must be clarified before too much development and piloting occurs. GP practice have long led the field in EPR development in the UK and the Health Informatics community must address these concerns relating to Patient Safety as soon as possible. There are opportunities at next week's Healthcare Computing conference to debate some of these and other safety related issues and it is a topic that UKCHIP would wish to see registered HI professionals contributing to. UKCHIP's future development agenda intends Patient Safety and Professionalism to be a key part of its London based workshop in early June and would welcome additional views. (sent to Press Officer - see www.ukchip.org )

Secondary Care Casenote Folder

17 Apr 08 11:04

In secondary care many different "clinicians" contribute and sign entries in a patient's casenote folder. Medications are changed, results ordered and acted upon, various treatments administered from simple aromatherapy to highly complex chemotherapy. Most of these important secondary/tertiary "interventions" are not recorded in the GP record which is in effect incomplete. The idea beind Lorenzo is that all (fully registered) healthcare "clinicians" can contribute to a patients electronic health record whether in primary, secondary or tertiary care. I agree that the recommendations and decisions must be owned by their authors and that the GP must have "overall" control of the record but I feel a complete pan-sector electronic health record is safer and more auditable.

the patient's perspective

john.aird@uhl-tr.nhs.uk

22 Apr 08 16:04

Looked at from the patient’s perspective; don’t patients (us, our families) deserve an NHS that functions as a smooth, efficient, “joined-up” service, with the patient being served and supported by all aspects of the NHS, regardless of which branch or funding stream contributes to the health care.

That being so, shouldn’t we expect all associate clinicians and supporting functions to see all appropriate medical and administrative information. Else it would be like an Airline processing passengers and luggage separately, with neither group knowing fully where the other is or what is happening.

So why do we still have this debate and divide between primary and secondary care, aren’t we all serving the same patients. The original NPfIT vision proposed an overarching patient view, to benefit patient care, is that now wrong? There are many technical ways to achieve a collective view, but we continuously seem to get stuck in the proprietary ownership debate.

Throwing IT at a problem was never a good solution on its own. The IT needs to support organisational and business function development. Maybe we are laying too much emphasis on late NPfIT systems for not driving through a shared Primary/Secondary record, when more fundamental business relationship and transformation issues might be equally to blame

Joint Record Causes Numerous Problems

gji@nhs.net

22 Apr 08 22:04

There are numerous problems caused by a single shared record, some of which are picked out by Mary Hawkin.

There is a problem that with a joint record across organisational boundaries the concept of a single guardian to ensure accuracy and confidentiality cannot be assured.

There issues regarding editing rights - what happens if there is a disagreement between two clinicians - do the records constantly see-saw between diagnoses?? This is not uncommon, and GPs are adept at ensuring all information is included, but in a balanced fashion.

A more simple example of editing is if a SHO in O&T erroneously diagnoses diabetes - whose role is it to correct this information, and who can overwrite whose information??

Then we have the problem with the 'wood from the trees'. A single complex episode of secondary care (e.g. which involves a two week stint on ITU) will produce a deluge of information which may then result in an unuseable record (particularly if there is not a single record guarding who can downgrade/prioritise/hide/delete parts).

The next issue is confidentiality - although as someone else has pointed out, many different hospital specialities share records, there are some, for confidentiality reasons, are never shared - specifically GUM and Psychiatry. The same issues and problems are commonly raised in general practice, and should be given the same respect.

I am aware of cases where patients have allowed access to other professionals, outside of their general practice, without realising that this meant the whole record, including embarrasing or personal information from years before. One case which resulted in a complaint upheld against the practice at all levels was where a physiotherapist access a patient's records, and then mentioned to the patient regarding her recent bereavement. From a dispassionate point of view, the bereavement may have exacerbated her condition, but the patient was devastated about the therapist knowing the information.

The Shared Care Record will rely on the concept of sealed envelopes - do we really want to have to introduce these for the Local Detailed Care Record?

The next point is that the general practitioner acts as a generalist providing long term care, whereas the vast majority of episodes in all other services are short term or discrete. This has a huge impact on how a clinician approaches, and developes a record.

I have yet to see an episode of 'Casualty' or 'ER' where the receiving physician shouts 'bring me the unified record' when an acutely ill patient enters casualty. I was taught not to look at a patient's previous records when they present either with an acute illness, or indeed with a long term non-diagnosed illness. I frequently hear the mantra 'patients should only tell their story once'. This is the most dangerous statement with severe clinical governance connotations that I have ever heard! Reliance on a previous record leads to misdiagnosis and bending the reported history to known problems, rather than recognising that patients frequently develop new problems, and have not infrequently been previously mis-diagnosed!!

The final point is that the GP acts as the 'ringmaster' receiving all information from the myriad of different strands of care that a patient receives over their lifetime, sifting this information, and incorporating it into a competent record.

In summary, a shared record across organisational boundaries, and across longitudinal and episodic care is more likely to decrease quality of care, will complicate the work of the clinician, will increase risk of breach of confidence and erroneous records, and could result in patients being less candid with their clinician, or refusing for certain facts to be recorded.

Dr Grant Ingrams Secretary, General Practitioners Committee West Midlands Deputy Joint-Chair JGPITC Clinical Governance Lead Coventry tPCT GPC GP, Coventry

Records GPs and accuracy

daryl.mullen@nhs.net

23 Apr 08 09:04

The unspoken fear of most GPs is that we don't want other clinicians mucking up the acuracy of the patient's record. As Mary says records need ongoing work to check the veracity of the information in them. We don't want just anyone inputting data that then stays forever in the record. For example one Dr may code someone as having depression, another may code it as dysthymia and a third as major depression, each will result in a new episode being coded and trigger all sorts of QOF issues for the practice and potential insurance issue for the patient. Similarly in ischaemic heart disease one SHO will code acute coronary syndrome then a second will code the same disease as angina. Again new episodes are created in the record. Currently such issues are dealt with at the practice where data coding is carried out and duplicate entries such as the above are dealt with.

As to the analogy to airlines. Airlines don't know what colour your underwear is :-)

Change the way you think

23 Apr 08 20:04

Dr Hawking is quite right to raise these issues, but I feel she is asking the wrong question - or at least with the wrong emphasis.

The shared record will impact on current clinical practice - this is definitely true, but perhaps about time.

That an A&E clinician should apply their own wits and observations is good clinical practice which should continue, but enlightened by what has gone before, but with wise caution as to what the record says - the fact that it is now easily legible, does not make it any more accurate.

It is about time that clinicians started thinking about and planning for what joined-up care would really look like, which requires working as a team across institutions - and that doesn't include playing ping-pong with the diagnosis. That example implies just too much arrogance - we should all know that we are not infallible (nor Read Codes that reliable).

I doubt that this has been well thought through in the applications either, but the professions must take a lead on this, not merely snipe from the sides.

To paraphrase Kennedy, it is not what CfH can do for you, it is what you can do for CfH (well, the NHS as a whole and the patients in particular, then).

Dr Hawking is quite right to issue a clarion call for action, but let us at least gather around the right banner!

Are we losing sight of the vision?

01 May 08 14:05

As neither a GP nor a Acute Clinician I have to sit back and read all of the comments on the article, and the article itself, with a distanced and impartial mind.

The one thing that has always concerned me is the mental fences put up by various elements of the health service. I can understand the desire to retain control and ownership of data and patient records by certain sectors however this is, to my mind, an isolationist point of view. We all need to break down these fences, treat each other as competent profesionals and adults. We should also remember that at some point each and every one of us will also be a patient and as such we are all trying to get things done properly, accurately and with patient confidnetially and clinical competance at the forefront of our policies and practice.

As such isn't it time we reminded ourselves of the vision of a joined up service giving the patient a smooth and speedy service with choice. The only way to achieve this is to work together to create a joined up series of procedures / systems and to release our grip of our own data and trust in the professionalism of our fellow clinicians to use that data in a clinically safe manner to the benefit of the patient.

Connecting for Health responds

07 May 08 11:05

NHS Connecting for Health sent the following answers to questions raised by Dr Hawking

Has the issue of changing / mistaken diagnoses been considered in the development of Lorenzo and other SSEPR systems? If so, where can the solution be found, and accessed and who is charged with dealing with the queries of future prospective users?

A. This has been considered at length. There is the ability to strike through incorrect information but not to delete it altogether - the exact procedure around this is included in one of the Functional Design documents. Following the NHS Local Ownership Programme, SHAs will deal with future prospective user queries in the first instance.

Who, in this SSEPR, for instance, is the Data Controller and Caldicott Guardian?

A. Each individual (and their organisation) using the system will be responsible for the quality of the information they enter.

Who is responsible for maintenance of data quality - including correction of errors and how prescribing is to be managed?

A. As in the previous question, the individual (and their organisation) will be responsible for the quality of the information they enter. The local administrator will support correction of errors along with the individual who made or discovered the error.

How will data that requires action - such as abnormal blood results - be handled?

A. An action message will be sent to the "in-tray" of the requesting clinician or to the team that the clinician works with (depending on local arrangement). There is an escalation mechanism if the message is not acknowledged as 'actioned' within a specified period.

What will be the effects on existing mission critical interactive GP records?

A. Current data flows to and from GP Systems e.g. discharge summaries, will be maintained and improved over time through implementation of the new solutions.

Connecting for Health responds

maryhawking@tigers.demon.co.uk

10 May 08 14:05

Many thanks to Connecting for Health for responding - but I'm afraid the response doesn't do much to allay my fears. It is good to know that the problem of correcting data has been considered and is in "one of the Functional Design documents". This document - and it's origin and requirements - appear to be unknown to the other people with whom I am communicating, and I have not been able to locate it online. Could we have a URL?

"Each individual (and their organisation) using the system will be responsible for the quality of the information they enter." This doesn't answer the question: individuals are responsible for the quality of the information they enter - but data will be entered by individuals who lack the training or authority to enter that information, and diagnoses which were considered accurate at the time of entry will evolve and require changing. Good quality data entry is no replacement for good clinical governance of the record. The very serious problem of how prescribing - an area which accounts for a lot of the risk to patients - should be managed is ignored. Prescribing, by it's very nature, is going to need review every time a new medication is introduced, and the introduction of a new medication may well mean that an existing medication should be canceled. Surely there are some rules in the Functional Design document on who can do this - and surely these rules have been discussed with the relevant professional and legal bodies? I think we - and everyone working with these records - should be told? Finally problems have been reported when entries made by organisations outside general practice were erroneous - and could not be corrected. This damages the quality of the medical record - and if the damage is bad enough, quite apart from the safety of potentially inaccurate records, accreditation to hold the GP record electronically might theoretically be withdrawn: where would QOF and government statistics be then? The GP record is highly structured: hospital and community are not - and it is quite possible that a SSEPR would be un useable in any situation.

so again, CfH - thanks for replying - and could you reply again?

Bad Example.

drmurdoch@cogeco.ca

12 May 08 04:05

Your theoretical concerns are interesting but your example is quite poor. Your example of a chiropodist diagnosing diabetes and it "causing problems" is more fiction than fact. #1) why exactly would chiropodists do that ? #2) with the patient's lab results easily available ... who would believe the chiropodists diagnosis when the glucose readings and A1c scores are normal ? #3) it would be easy to prevent certain diagnoses to be made by certain professions (within their scope of practice). As well, I don't think practitioners would leave their name beside incorrect diagnoses too long. I think their reputation would be at stake and they'd ensure they'd followed the guidelines. A more likely concern is the shying away of making diagnoses based on uncertainty. Let's say rheumatoid ... better not call it rheumatoid .... as the diagnosis isn't " certain". I think the mental health diagnoses might be quite a bit more problematic ! GP disagrees with the Generalized Anxiety diagnosis .... Psychiatrist disagrees with the Primary Care diagnosis of Borderline ... :)

Bad example?

ian.pace@nhs.net

14 May 08 18:05

I have certainly seen diagnoses "made" by attached community staff - diabetes being one code entered erroneously by a district nurse, resulting in the treating of a patient (nurse led clinics) with, unsurprisingly excellent control on diet alone, until it was picked up months later by the GP who asked the patient who had made the diagnosis. The attached staff had had no reason to see the patient after the code was entered and therefore had no reason to check or correct the code. Dr Hawking is quite correct in her statement that it may well be others in the healthcare field who question and pick up a miscode. In addition once the code is there in the record is holds as much value whether it was entered by the janitor as by a qualified clinician. We are not always in a position to go back and check the veracity of every code entered - that is a like reading the Lloyd George from cover to cover on every occasion and devalues the care record. If hundreds of healthcare workers across all fields can access and modify the record how can we be sure that they all achieve the standards that are required for an accurate record. I am certain that there may be disagreements in coding of some diagnoses, particularly psychiatry and perhaps neurology - but that rather reflects the inadequacies of the coding structure.

A Real-Life Example

15 May 08 11:05

"Your theoretical concerns are interesting but your example is quite poor. Your example of a chiropodist diagnosing diabetes and it "causing problems" is more fiction than fact."

I work on a linked system which connects 3 practices with community services and we have encountered precisely this problem. A podiatrist made a diagnosis of 'diabetes' apparently based on the appearances of the patient's feet. All the other evidence is against this diagnosis. The podiatrist has declined to change her mind, arguing that this is her professional perogative. And, despite this being our practice's registered patient, there is nothing we can do about this, except record in the notes our disagreement. For QuOF purposes, the patient remains 'diabetic' and we are therefore required to maintain full diabetic management (without of course any prescribing).

In response to your specific questions: #1) why exactly would chiropodists do that? - because they, like other human beings, from time to time choose to think they are right.

#2) with the patient's lab results easily available ... who would believe the chiropodists diagnosis when the glucose readings and A1c scores are normal ? - QMAS, SCR and any other non-human 'reader' of the notes.

#3) it would be easy to prevent certain diagnoses to be made by certain professions (within their scope of practice). - It has not been possible to prevent this one and there is (we are told by the suppliers) no way of modifying our system in this way.

As you may imagine, this is one of the reasons why we intend to withdraw from this linked system as soon as practically possible.

Engage don't Disengage

21 May 08 09:05

I worked with a SystmOne Podiatry service in setting up templates. I refused to allow them to record anything other than "History of" codes for any part of the body other than the foot. trying to get any GPs to comment was impossible. (We ended up working with the Primmis team for Governance) If the local GPs had been prpared to talk with us we could have done a better job in laying the foundations for a cleaner single Patient Record in the future.

Good points but ...

14 Jun 08 21:06

... surely Lorenzo for GPs was blown out of the water when GPSOC came along? This is a pointless argument as it seems highly unlikely that any GP worth her salt would consider moving onto Lorenzo.

What is needed is a decent interface between GP systems and Lorenzo which allows essential information to be transferred between different parts of the patient's pathway - subject of course to their informed consent and compliance with the data protection act.