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Analysis: GPs at sharp end of online access drive

Online access is all the rage at the Department of Health at the moment. Health secretary Jeremy Hunt has pledged he will deliver a ‘paperless NHS’ by 2018, with civil servants claiming this will save the health service millions.

GPs are critical to the success of Mr Hunt’s plans, and practices have been working since last April to give patients access to online appointments and repeat prescriptions as part of this year’s online access DES.

But the big change comes next month, with the 2014 GP contract in England stipulating that practices must provide patients with online access to their records.

The DH claims the move will free up appointments and improve care, but others disagree.

The GPC cited evidence last year that found significant increases in ‘encounters with patients’ as a result of online records access, while some 33% of patients surveyed in a separate study of access to medical records reported difficulty in understanding them.

Negotiations ongoing

As Pulse went to press negotiations were ongoing with GP systems providers to ensure practices are technologically prepared to fulfil the demands of the new contract from April through GP Systems of Choice.

Dr Robert Morley, the GPC’s contract and regulations lead and secretary of Birmingham LMC, says: ‘The wording of the regulations is being discussed at the moment and it needs to be fit for purpose to reflect the deal, but also to reflect what practices have on the ground at the minute.

‘Most practices are moving to the stage of online repeat prescription requests and towards appointment booking as well.

‘Patient access to records online is still a more contentious area; there are still concerns that we probably need to resolve.’

The plans for online records access have been significantly watered down since they were first proposed in 2011 as part of the Government’s so-called ‘Information Revolution’. The minimum requirement now is that practices will be expected to provide patients with access only to the limited information that appears in Summary Care Records – medications and allergies – instead of the full record as originally planned.

Ministers have also taken notice of a report they commissioned from the RCGP, published last year, which recommended practices should not be forced to give patients access to retrospective information in their record – to ease workload and protect the doctor-patient relationship.

They are also considering an automatic delay before test results are added to online patient records, so that practices have time to discuss them with patients, although it is not yet clear whether this will be included in the specifications for GP systems providers.

What will GPs have to do from April?

• Promote and offer online appointments and repeat prescriptions.

• Give patients access to their Summary Care Record (SCR) ‘as a minimum’ before April 2015.

• Upload SCRs at least daily, or have a published plan to do so by the end of 2014/15.

• Use the GP2GP facility to transfer patient records between practices, or have a published plan to do so by the end of 2014/15.

• Include patients’ NHS number as the primary identifier in all clinical correspondence, in particular referrals, whether via Choose and Book or on paper.

• The requirement for practices to offer ‘secure electronic communication’ with patients has been dropped, pending discussions with the GPC.

Concerns persist

But not all GP concerns have been addressed. Dr Andrew Mimnagh, a GP in Sefton, Merseyside, told Pulse that although he is not against the idea of offering online access for patients, GPs’ rising workload is an issue.

He says: ‘If someone could show me where the time is saved, or what I can stop doing to get time to do something else, I’d be happy to work smarter. But everything that’s being thrown in seems to be on the presumption that I’ll work harder and I haven’t got the time to work harder. I think everyone’s in the same position.’

Dr Mimnagh warns that addressing the practicalities of a ‘paperless NHS’ will be essential if it is to succeed where similar initiatives have failed.

‘As a concept, brilliant. But where have I heard these ideas before? What is the track record of state-delivered large IT infrastructure? Abysmal.’

Dr Dermot Ryan, a GP and clinical researcher in Loughborough, thinks online access could increase patients’ anxiety. He says: ‘I personally do not think patient record access is either necessary or desirable.

‘Patients will not – cannot – understand the nuances of clinical reasoning and may become much more anxious than is necessary and end up presenting themselves in A&E looking for a second opinion, for example.’

Trialling online prescriptions and online booking

We’ve offered online prescriptions for about three years and online appointments for about two.

Prescriptions have gone very well, because we’ve got lots of people who are online all the time so they like that. They’re only repeat prescriptions and they’re all screened; there is a free text place where they can write: ‘The cream you gave me last year was really helpful, I’ve got the same eczema, can I have some?’ It’s a limited number of words so they can’t write an essay.

We have been fine-tuning online booking as there is no screening or filtering. You can’t say, actually that’s inappropriate.

In theory it reduces telephone work, but the more appointments you put online, the more are booked, because it’s easy. But we don’t open them all, we have some blocked for particular times. Probably about one in 10 would be ‘inappropriate’ bookings, so it’s not too bad.

We don’t want to go fully online. Some people don’t have access, and we also want to screen some of them.

Dr Fiona Cornish is a GP in Cambridge

Workload fears

Pulse has learned that even GP systems providers harbour some concerns about the workload implications for practices.

Dr Mike Robinson, medical director of INPS, which operates the Vision system, says: ‘It’s saying you have to work out, for each individual patient, exactly what you’re going to expose. And the minimum must be that you can only show prospective stuff.

‘But if you want to show historic stuff you have to actually flag the records individually – I mean the individual items within a patient record – to say whether they can be exposed to the patient.

‘This seems a bit like a huge burdensome overhead for general practice.’

The GP system providers EMIS, SystmOne and INPS have told Pulse they are confident they will be able to provide online access to records by the April 2015 deadline, and they are working with the Health and Social Care Information Centre to provide the capability to restrict parts of the record where necessary.

A spokesperson for EMIS says: ‘The next version of our medical record viewer software will give GPs more control, allowing them to configure the elements they want patients to see. 

‘For example, they may wish to restrict access to key information such as allergies and medications, or to only show free text information from when the online record is switched on.

‘This new software is currently in development and we hope it will be available to users of our flagship EMIS Web system by this summer.’

Early adopters

And then, of course, some GPs are enthusiastic about the move to online access. Dr Brian Fisher, a GP in Lewisham, south London, has already developed a system to give patients access to records and recently published a paper reporting that doing so had led to a reduction in attendances.

Dr Fisher says: ‘There were substantial workload benefits. The simplest way to explain it is if 30% of a practice’s patients were to access their record about twice a year, the practice would save about 10% of its appointments – which is quite substantial.’