On Saturday, August 08, 1998 4:18 AM, Huw Thomas 
[SMTP:[log in to unmask]] wrote:
> More morbid thoughts!
>
> I am still trying to "get my head round" the main reasons for
> computerised disciplined morbidity recording, and have been a little
> disappointed at the responses (although fully understanding the reasons
> behind them :^):
>
> >So apart from "urging",  what renumeration and incentives do you offer 
for
> >this laborious data collection exercise, as I have not seen the 
requirement
> >to do it within the TOS? yet? :-(

I heard some ideas this week about carrots and sticks to encourage the 
recording of good data. One suggestion was that perhaps it could be 
connected with the reaccreditation process that is being assembled at 
present. It would be one of the markers of a good practice. At present 
registrars training should bring them up to the level of the other members 
of the practice - I know the reverse is often nearer the truth and the 
practice is brought up to the level of the registrar!

A further thought I had was that it could be included with the "Health 
Promotion" data something along the lines of 40pence a Read Code. I have 
now doubt it would be taken out of net intended renumeration. Quality of 
recording is much harder to assess here than quantity.

>
> More thoughts:
>
> Why computerised records?
> 1. Easily accessible structured records
> 2. Rapid searching for common features
> 3. Warnings/alerts to decrease likelihood of prescribing errors (eg drug
> sensitivities and interactions).
> 4. Audit, both outcomes and the delivery of care (we recently took part
> in a county audit on secondary prevention of IHD/risk factor recording
> and we are definitely nowhere near as good as we think we are!!)
>
5. Easy printing of medical reports  PMAs etc
6. Easy returns of Health Promotion or other data required for HAs etc
7. Potential to sell data to drug companies etc
8. No lost/missing notes in typing, doctor's cars, road side gutters etc
9. Ability to make reasoned claims for extra patient funding based on local 
morbibity.
10. Electronic linkage to lastest EBM, guidelines, specialists, Self help 
groups

> Taking point #4, my partners continue to argue that the figures are
> wrong.  They argue that the number of patients on aspirin excludes a
> large number taking it OTC, inspite of a code in the IHd template
> reminding us to ask. Similar arguements on BP recording, and we only got
> 45% of the most recent recording <160/95  "I don't put all the
> recordings on the computer"........or put it on as free text....."BUt we
> are now "paperless" in the consulting room at least.. to avoid
> duplication.
>
> When does the use of computerised templates/protocols become good
> practice.... and the random haphazard risk screening unacceptable? I am
> certainly not arguing for the imposition of dictates from anyone outside
> the practice, but surely we must record screening and morbidity
> information in a standardised way so we can audit ourselves. Seeing a
> patient with an ongoing complaint and either choosing three different
> codes, or saying three different episodes occured (getting the episode
> typing wrong) completely wrecks the audit. You (or your nurses) either
> spend hours going into each consultation record and trawling the data
> manually (free text searches are only a very poor partial answer) or
> your audits have such large confidence intervals that they loose most of
> their potential to initiate change.
>
> At the very least we ought to be TEACHING and disseminating good
> practice - as the more computer literate of our collegues.

There is a great need here I agree. It also needs to be properly financed. 
If there is a real spin off for better health planning and delivery of care 
in the future as a result of data capture, which I believe there is, then 
investment by Government, Health Authority and PCGs needs to be made to 
enable those entering the data to be given the tools and training to 
accomplish this. If a major company feels a cultural shift is needed in the 
short term to ensure long term survival then without question the 
investment is made.

> Either don't
> use codes (cholelithiasis etc) until we are certain (RUQ pain will do
> here) or ensure we go back and alter it afterwards. (i know read 3 has
> afix for this but we need to get recording better NOW).

I don't know if all  systems can automatically change previous diagnoses 
but I can with EMIS. Just enter the new Read code for the "Problem" and say 
this is a changed title and I am prompted for which previous "Problem" I am 
changing and the previous entries are updated to the new Read Code.

> We should be thinking quality of care, what are the important things I
> need to record for patient X with condition Y..... if we remember to ask
> we should record it (and templates etc are the quickest way to do
> this).... we have had asthma self management plans since 1989, but only
> when i put "asthma management plan?" in the template did I remember to
> photocopy some more and issue them (I must have been 6 months without!!)
>
I agree It is impossible and unneccessary to record everything. We need to 
agree at Practice PCG or National level what is really required.

> we need to continually help our collegues/registrars to come to grips
> with the principles of good records.....any ideas how?
>
Now that's a challenge.
1 Seeing potential benfits either in terms of patient care in the 
consultation
2 Seeing benefits of patient care by planning, extra funding for secondary 
or new resources for primary care
3 Financial benefits
4 Personal satisfaction knowing not only that the doctor is doing a good 
job but can demonstrate it to others
5 TOS - maybe in the future

Stuart

Stuart Skeates
GP and Course Organiser
Romsey, Hants






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