Introduction
Until the recent Health and Social Care Bill, I was a member of the professional executive committee of my local PCT, with responsibility for IT and urgent care. A recurring issue for A&E and out-of-hours doctors at our regular meetings was the inability to quickly access patient information from the GP record when needed.
A number of doctors spoke of the frustration of having to ring the patient's practice, convince the receptionist of the legitimacy of the request, then wait for a record summary to be securely faxed over. The whole process could easily take 15 minutes per patient – if indeed the GP practice was open in the first place.
Urgent care clinicians do not always need to check the GP record, but when they are faced with a seriously ill or unconscious patient, real-time information about current medication or pre-existing conditions can be invaluable. For example, a patient with a heart condition may be on 10 or more medications. Their current drug regime could be contributing to the emergency they present with, or could potentially interact with a drug prescribed by the A&E or out-of-hours GP.
It seemed clear to us that 24-hour electronic access to the GP record could help improve urgent care and make it more efficient.
What we did
An important decision was how to enable the sharing of information between clinicians. The solution was obvious, given the widespread use of EMIS systems in our region. All of the 29 GP practices in Central and Eastern Cheshire PCT that refer into Leighton Hospital use EMIS systems (LV and PCS), and all are ‘streaming' live patient data into the next generation EMIS Web system, which we plan to adopt as our new GP system.
EMIS Web was developed as a cross-healthcare information system, and it can enable secure data-sharing between different clinicians, not just GPs. I was already using it to import and match SUS data into my own system, so I knew how it worked.
Our plan to introduce urgent care record-sharing coincided with a separate project initiated by a consultant in diabetes and endocrinology at Leighton Hospital. He was already using EMIS Web to share patient information – in this case, enabling hospital consultants to access diabetic patients'GP records.
My colleague had prepared most of the groundwork by getting practices to think about data sharing and, on the technical side, working with the hospital to enable clinicians to access one another's systems via its firewalls. This made it a lot quicker for us to get our project moving.
How we did it
Rather than try a ‘drip-feed' approach, we wanted to get as many practices as possible on board with the project. This would ensure that A&E staff quickly saw the benefits, rather than being frustrated by coming across patients whose practices were not on the system.
The challenge of getting practices signed up to the data-sharing agreement was a big task, we knew that many would have questions and concerns and that some would not be immediately willing to give others access to their records.
The task of working with the practices was shared by a project team of Cheshire ICT, the hospital, EMIS and several clinicians including myself. We made as much time available as we could to meet with practices face-to-face – at GP and practice manager meetings – to explain the benefits of the project and security aspects such as the detailed audit trail that would show how and when patients'records were accessed. Meetings were supplemented with a lot of emails and phone calls.
In all, 27 out of the 29 practices have signed the data-sharing agreements to date – including one practice that was initially vehemently opposed to the project.
Who can access information?
The EMIS Web client was installed on a number of key terminals in A&E, the urgent care centre and at the triage desk. Staff could then log on to EMIS Web and view the summary screen of the patient's GP record at any time, day or night. The screen provides a brief summary of the patient's medical record with headline entries for active and significant past problems, acute and repeat medication, medical and non-drug allergies, recent alerts, recent activity and the latest health status values. All access is recorded in the audit trails of both the viewing and sharing organisations. The system prompts for and records the point of contact consent from the patient, before allowing any shared data to be viewed.
For maximum data security, we restricted GP records access in A&E to the consultants and staff grades on a permanent contract. For added security, we restricted access to three terminals in the department. As well as needing smart cards to work, the terminals were configured to close down after five minutes to minimise the potential for unauthorised viewings.
Regular medical staff that provide out-of-hours care – all GPs – can also access the system. These teams are located in the urgent care centre next door to A&E, but here access is available to GPs from their own computers.
In A&E, conscious patients are asked for permission to view their record before the doctor logs into the system; the senior doctor can give consent on behalf of unconscious patients. EMIS Web provides a full audit trail of all records accessed – including noting when permission was given for an unconscious patient. The audit trail is accessible to appropriate users within the A&E department and the GP practice sharing the data.
Thanks to the previous work with diabetic patients, EMIS Web was already installed in other locations in the hospital, thus firewalls were already configured. All that had to be done was to install the EMIS Web client on to the required PCs, give users individual logon details and hold some quick ‘getting started'training sessions.
The benefits
Just three months into the project, A&E consultants are already seeing the benefits of record sharing. One said: "I have found it very successful. It's not something I would use every day, but it is of particular use with patients who are critically ill, providing vital information that we wouldn't have had during the initial resuscitation period."
Another colleague said: "It has been very successful for me, once with a critically ill elderly lady, and once when we needed to confirm some medication. It is especially useful outside normal working hours when you can't contact the GP practice. I think we will see more benefits as time goes on."
While urgent care clinicians and of course, patients have been the main beneficiaries of the project, it has been good for GP practices too. There are far fewer phone calls and requests from the hospital for faxed records. And this project has also sowed the seeds for future record-sharing initiatives.
The future
The EMIS Web shared care record system has the potential to improve urgent care for 220,000patients across Central and Eastern Cheshire. We are currently auditing the system to establish whose notes are being accessed and why, so that we can provide documentary evidence of the benefits of the project for clinicians and patients.
We would like to extend access to the care record summary screen to other teams –for example, intermediate care and district nurses –and to other sites, such as the minor injuries unit. Once all of the GPs go ‘live'with EMIS Web as their new GP system, we hope the information will become a two-way flow, improving clinician to clinician communication particularly with these extended teams.
Eventually, we will use record sharing in other areas such as planned care and mental health, and will extend it to neighbouring PCTs –subject to similar strict data sharing agreements. The potential for ‘joined up' care across multiple clinical pathways is enormous.
Dr Neil Paul is a full time partner at Sandbach GPs, a large (21,000 patient) practice in semi-rural Cheshire. He is on the board of his local GP consortium www.SouthCheshireHealth.org.uk and is in the process of setting up a provider federation. In his spare time he writes apps for the iPhone.
