The problem
There has been a steady rise in general practice consultation rates, which research indicates soared from 3.9 to 5.5 consultations per patient per year between 1995 and 20091 – a trend that shows no sign of abating.1 Maintaining control of consultation rates within primary care is therefore a real challenge. Our early findings and research elsewhere suggest that practice resources – particularly for routine follow-up appointments – can be most efficiently deployed in those patients we would describe as ‘online' and enabled.
We wanted to give patients greater ownership of their own health, and help them understand what was happening and why we were doing what we were doing.
The vast majority of our patients were – and still are – unaware that they have the right to access their medical records. They have not been aware of what the benefits might be should they access their records and some feared the notes would be difficult to understand even if they could access them.
But the feedback from our practice's patient participation group was that patients felt they should be encouraged to do more for themselves wherever possible through self-care. We wanted to respond to this by improving access to records.
There were concerns among practice staff about litigation, that patient access would add to workload – especially if patients did not understand information – or that there might be harmful data in the records that would upset patients. Some felt that it was not the role of our staff to promote access to records and that it was unfair for those patients who did not have access to the internet and who could be disadvantaged by this process.
How we did it
In 2000, we installed EMIS LV and since then we have gradually moved away from writing in Lloyd George paper notes to exclusively writing in an electronic health record that includes all consultations, blood test results and other investigations, and letters. All clinicians and non-clinicians have been encouraged to use electronic records.
Entries also contain salient points of the history, examination, possible diagnoses and a plan of action. We find this type of record useful for immediate problems such as chest infections, and for ongoing long-term conditions such as diabetes or depression or unexplained problems such as abdominal pain or sleep disorder.
Our practice started to offer a range of online facilities to patients, including providing access to health records in 2006, as reported in Pulse in 2009. After early success and involvement with our patient group, we embarked on a determined effort to actively engage with our patients online via a purpose-built patient website – htmc.co.uk.2 It was created in conjunction with experienced electronic publishing and patient e-health specialist Glen Griffiths, who implemented a content management system (CMS) that made it easy to create and update multimedia content.
We developed a three-stage process for patients to sign up for the service. First, patients collect their PIN from our receptionists, which activates their account and allows them to register online.
Second, we invite patients to fill in an online questionnaire that determines whether they have understood what records access means and how they can safely deal with some of the challenges – such as seeing abnormal test results. This is embedded on the practice website along with YouTube video tutorials, information developed by patients on the advantages and potential pitfalls, and the passwords for a test patient record so that patients can try the system out before committing themselves. This is all part of a self-contained explicit consent process that allows patients to learn online when it is convenient for them.
If there are no potential problems, the records are activated and an email is sent to the patient to confirm their request has been accepted and encourage them to look at the practice web portal for further information to help them understand their records. If there are any concerns around the record or because of answers in the online questionnaire, they are passed to the doctors for review. The staff deal with any queries patients may have, so the clinicians simply ask patients to sign up for the service.
Third, all practice staff and clinicians are given support material – including leaflets and consent forms – so that whenever patients contact the practice, they can be encouraged to sign up for access to their records.
The website also provides a section on ‘self-care for family and friends'. Being able to easily add content and pages without needing any special technical knowledge has meant free text can be embedded alongside photos and videos we have made or that have been supplied by patients.
This functionality to build our own content linked to national online resources makes it very powerful – we can respond to the practice's or patients' needs as soon as they arise without having to wait or being charged for the privilege. We can inform our patients about new developments or initiatives and help people to learn for themselves instead of relying on coming to see us at the practice.
We've created specific web pages for patients with diabetes, heart disease and asthma, for example, which helps them to understand how access to medical records could help them. Our site is a web portal with testimonials from patients, specific information encouraging personalised care and links to national resources. We also use the website to promote health events put on by our patient participation group, and host videos of these.
We have developed a robust process with responsibilities for different staff members to process requests for records access. This is mainly an administrative process, with our reception staff looking after a table in the waiting room area where there are posters, consent forms and leaflets. Our reception staff hand out PINs and reset passwords, certain back-office staff members download the online questionnaires and process the answers.
Staff check whether there might be any problems with the patient accessing information in their record that might be regarded as harmful – for instance, mental health or psychiatric notes that they might be unaware of – or third party information such as health concerns voiced by a spouse or carer. We follow the guidance laid out by the RCGP on these cases.3 We also try to pre-empt problems by raising the possibility of that the patient might see ‘unseen information', using the questionnaire stage of signing up to records access.
Results
We now have over 1,850 patients accessing their records. Some 16% of patients have currently signed up, with on average 10-30 patients signing up every week. Patients from the ages of zero to over 90 have joined the scheme, with the largest group being women between the ages of 20 and 65. Nearly 30% of our patients with type 1 diabetes, 34% of our obese patients, 46% of patients on methotrexate and 9% of our Bengali patients now have access to their records.
Overall 16% of our practice's patients have signed up. Over the last three months there were over 40,000 page views on our website, averaging over 13,000 page views per month, and over 3,400 recorded logins for a range of online services and access to electronic records.
There were an average of five online visits per patient – well over 650 individual patients out of the total of 1,850 patients registered went online over this time. An average of 50 appointments and 20 appointment cancellations were made online each month, helping improve access and reduce DNA rates.
We have recently completed a joint study with Manor House surgery in Glossop to show that, as a result of providing patients access to their records, we could make savings of almost £20 per patient per year in saved appointments.
Our study showed that on average, we have saved more than one appointment per patient per year and that we saved more than three telephone consultations per patient. The full results of this study will be published soon.
The future
We are now developing a programme with the local strategic health authority to support CCGs that may wish to encourage local GP practices to follow in our steps – our evidence indicates that basing rollout on a comprehensive practice website is required to achieve scale. Other vendors, including TPP, are beginning trials to enable their patients to access records too. We would be keen to reach out to other practices that are offering access to records, or would like to do so, to learn and share experiences.
Dr Amir Hannan is a GP in Hyde, Greater Manchester, and primary care IT lead at NHS North West. He can be contacted at amir.hannan@nhs.net
References
1 NHS Information Centre. Trends in consultation rates in general practice – 1995-2009. 2009. tinyurl.com/msnuxw
2 Haughton Thornley Medical Practice. Access data. 2012. tinyurl.com/7renb99
3 RCGP. Enabling patients to access: electronic health records – guidance for health professionals. 2010. tinyurl.com/2u45ypg
