The demands on GPs today ratchet up. There’s the huge workload treating patients in the context of austerity and budget constraints. Then our role in the NHS is expanding as we take on more counselling services, GP registrar training, and other clinical care shifts from secondary to primary care.
Add to the mix, the ambitious challenge from the Health Secretary, Jeremy Hunt, for the NHS to go paperless by 2018. The job is getting busier and harder and there’s a massive space impact coming GPs way. Simply put, we need more room for clinical care.
We’ve taken the pioneering step to computerise our complete Lloyd George patient records library using a new online managed service from St Helens & Knowsley Health Informatics Service (StHK HIS) called the electronic Lloyd George Records Service (e-LGS ). We’re the first GP surgery in the country to use it.
e-LGS is a fully managed service to collect, prepare, digitise, archive and host Lloyd George patient records with Internet access them provided back to them. It costs us 60p per patient record per year to use it.
The problem
Most practices are reasonably comfortable using IT, with solutions like EMIS, Synergy and INPS as GPs’ primary clinical systems to record patient consultations, treatment given and store other electronic documents.
However, one area still completely paper-based are the Lloyd George envelopes which contain patient notes written prior to computerisation. They’re a huge burden on the efficiency of almost all UK GP practices. In our practice, we have 13,000 of them.
In our practice we store them in huge racks in our reception area and a storage room. They have to be kept as they follow patients around the NHS when they change practices providing continuity of patient care and treatment.
As you know, most medical information in Lloyd George envelopes isn’t used in day-to-day consultations. Its reference material required when GPs write letters to solicitors, employers and insurance companies or provide a historical view on a patient to colleagues.
Irrespective of the time it takes to access this information, it’s a huge workload to manage the library and a drain on practice efficiency.
Getting started
Our IT is provided by StHK HIS and when we saw what they had achieved digitising records at St Helens and Whiston Hospitals, we felt a modified system would be ideal for Lloyd George records management in primary care, especially as the paper is deteriorating and we need a system to save it.
At our practice, these records are the only area not computerised and the missing link for staff to access all records electronically from their desktops.
The aim of the project was to remove this paper overhead, improve practice efficiency and increase space available for clinical care.
In close collaboration with StHK HIS and a software supplier, CCube Solutions, we were developed software functionality and piloted the hosted service based on our input.
For example, we helped design the digital version of the record so that e-LGS replicates the paper notes. This resulted in the online system being split into four main chapters: letters, continuation sheets, results and summary reports.
We also ensured that there was a facility to print off or save the whole digital record to encrypted CD-ROM when patients leave the surgery.
What we did
First, StHK HIS collected the paper records. We worked closely with their team to ensure that this was done in a controlled manner during quiet surgery times and at weekends. Much thought was given to the boxing of files which was done alphabetically split by patient sex and ordered so that a particular patient file could be found immediately from the 13,000 envelopes if required.
The records were then cross-referenced by StHK HIS against our master patient database to check all records were correct and present. This auditing was important as it was the first time a third party had done Lloyd George records collection and scanning on such a large scale. The auditing showed which records were missing or those we still had for patients who had left the practice.
We spent time working with our PCT and Strategic Health Authority, reviewing guidance from the RCGP and NHS information governance documentation to confirm we were allowed to destroy the contents of our Lloyd George envelopes once scanned. StHK HIS also sought approval from the Trust’s solicitors who reviewed guidance and legislation.
It was agreed that we are the data controllers, and therefore have the right to manage Lloyd George records irrespective of the medium (paper or digital) as long as we meet governance rules.
We now access e-LGS using a standard Internet browser on our PCs or laptops. Full training was carried out for staff although the system is so intuitive that this took just ten minutes per person.
New patients coming into a practice have their paper records scanned and added to the system at agreed regular intervals. This is included as part of our contract so no additional costs are incurred.
Challenges
E-LGS has been a significant organisational change project and we went out on a limb to do it. Given such a system has never been used in a GP surgery, we spent time working with staff to achieve consensus and agreement to adopt the system. At first, our PCT was resistant as well. On more than one occasion, people said, ‘you can’t destroy the record’. But that’s exactly what we’re not doing. We’re scanning and preserving it. However it took some time for everyone to come round to this idea.
Some GPs reading this case study might consider scanning their Lloyd George records themselves. Our view is, DIY is not an option. It’s just too expensive and impractical, given the volume of records to process. You’d spend far more money on staff and equipment irrespective of the disruption to your surgery. Indeed, it would be scary to do the cost calculation of how long it would take to scan just 1,000 records ourselves, let alone the whole 13,000 library.
In contrast, StHK HIS has invested in Kodak production scanners (which handle thousands of pages per minute), the EDMS and portal software from CCube Solutions, and its team are experts at preparing medical paperwork for digitisation.
Other commercial companies have offered services where they take away records, store them off site and then you request notes back when you need them.
But this is an imperfect, half-way-house solution. It’s like having an outsourced photocopying service. It doesn’t solve the problem of managing records long term given paper degrades, and then there is the inevitable time lag getting information back or a premium to pay if you want something immediately. Furthermore, what do you then do with the record once received, even if it’s a PDF? You’ve got to store it somewhere and have a process which governs this.
Results
In our view, e-LGS solves all of these issues and has delivered a variety of improvements in terms of patient care and practice efficiency.
We’ve become more efficient overall, with administrative time spent on Lloyd George records filing now used for patient centric activities. e-LGS is saving us a full day of administrative staff time per week not filing and retrieving paper records.
We’ve freed up premium surgery space and now got back a clinical room which was being used for storage. As a result, we will take on a GP registrar in the autumn. Put another way, e-LGS is saving us around £30,000 on not building additional storage space to cope with the Lloyd George records filing.
We now have fast access to Lloyd George notes, which now takes a minute – not two or three hours as before. If required, information can also be shown to patients with the contents of the paper record now preserved.
We’re now well positioned to take on additional work from our CCG in the future given all patient medical records are available electronically at a touch of a button.
E-LGS also allows easier sharing of patient information within the NHS should individuals leave a practice – records can be burnt to encrypted disc and money not wasted on photocopying.
The future
Based on the success of our pilot project, StHK HIS has now introduced e-LGS to GPs nationally. It’s a cost effective and easy to deploy service to remove the Lloyd George notes headache everyone universally faces given the valuable surgery space they take up, the time required to access information and the clerical overhead needed to look after libraries. e-LGS is a simple and safe solution and sold on a fixed cost contract basis so budgeting is easy.
Frankly, Lloyd George documentation must be removed. There are numerous NHS agencies around the country handling the flow of this paperwork when patients move practice. It’s a massive overhead for the NHS and millions of pounds could be better used to enhance patient care.
Dr David Wilson is a GP in Runcorn, Cheshire
