I've been thinking about the concept of the fully transportable
Electronic Health Record, and there seem to be some problems.
I imagine a large number of the people who gave advice on this ( and
other interested parties..) are on GP-UK, so could I pick your brains,
and also ask who is planning to apply to be a Beacon Practice for the
development of the EHR?

I accept that the mention of new solutions and private financing of GP
computing implies a single, new system - and the death (or sublimation)
of *all* our present systems.. which again raises problems of current
investment and information held in legacy systems..

As I understand it, the EHR will contain a cradle to grave record of all
primary care encounters (i.e. general practice plus community care) and
summaries of other health related encounters (hospital and mental
health) with possibly some social services data.

This document will constitute the *only* medical record , as it will be
freely and electronically transferable when the patient moves to a new
practice.

There is mention of using the existing and new Internet Technology to do
this, and a doubtful claim that the NHSnet supports SMTP protocols...

Now for the questions.
1.Extraction and insertion of the EHR.
2. How can the EHR be legally authenticated?
3.Completeness of information
4. Legacy data.
5.Quality of data.

1.Extraction and insertion of the EHR.
I can see that it might be possible to extract a complete EHR into an
HTML format from almost any system - but is it possible to *insert* an
EHR into any existing or new but non-identical clinical system at the
new practice?

(I use EMIS - so my perspective is coloured by this)

If you can insert the EHR into a different, existing system , what
happens to your coded data?
(background - we had a conversion from Read 4 to Read 5 in 1994. I
analysed the conversion table, and the problem is generic - *what do you
do with coded data when the new coding set does not contain a Term which
is identical in meaning and position to the coded data in the old set*?
There is *No Way* a meaningful conversion can be guaranteed, even with
human intervention. 
Remember, this is a cradle to grave record .. so it's likely that the
patient will move a number of times.. and.. did you ever play Chinese
Whispers? ;->>)

I suppose the implication is that, by this time, all systems will be
using Read Code version 3 (assuming it passes the scrutiny.. which I
think it should) and the problems of implementation and use are not
insurmountable. 
If we're not all using the same set of codes for all purposes (including
the same drug dicionary..) , will transfer of an uncorrupted EHR be
possible?

2. How can the EHR be legally authenticated?
At the moment, my system maintains a record of which user entered which
bit of information, and the audit trail records any alterations.
*Is* the audit trail transferable, and if it is, how will it be possible
to authenticate the original entry, when the individual who made it is
not recorded in the computer security system?
Will the system in the future have to maintain records of *everyone* who
is entitled to enter (or view) data in the whole of the NHS extended
family? (as well, of course, as everyone who has retired or left..
presumably with some mechanism to remove lapsed rights.. but perhaps
thatt belongs to a separate thread on the EHR and Confidentiality?;->>)

3.Completeness of information
While I would agree that something over 90% of general practices are
computerised (in the sense that there is a PC somewhere in the
building), there seems to be a fair amount of evidence that a lot of GPs
(*even, according to a study reported in the Monitor, when the GPs say
they use the computer in consultation*) don't actually use it in
consultation.

*Is the current EHR sufficiently complete to be used as a basis for a
total record*?

4. Legacy data.
I am using this for all past data which has not yet been entered.
We'd like to go paperless - but if there is a large MRE , the task of
entering possibly significant data is daunting.
For practical purposes, another year or so of scanning all incoming
letters and and continuing with doing all consultaions on computer will
allow us to manage most problems without reference to the MRE - but I
can't see that we have much hope of entering the entire past record -
and having it legally acceptable - or even safe!

5.Quality of data.

I think what the CHDGP is showing is that the quality and/or consistancy
of data held in computers is very variable - and I'd suggest that the
use of tools such as MIQUEST to produce pooled data to assess Health
Care Needs is therefore, at present, limited - or even dangerous.

If a tool such as MIQUEST (which searches on specified codes) is to be
useful, there has to be a knowledge of *what* codes have been used to
monitor a condition, even if you can be sure that the condition is
monitored *using the computer* in the first place!

In addition, there may be a problem as to the data items checked - for
instance, in diabetes mellitus, which codes do *you* use for retinal
checks? why these codes? and how do you record absence of diabetic
retinopathy? (I haven't looked it up for the 4byte set..;-<<)
If our performance is to be judged (and enforced) by computer audit,
will uniformity of entry be a necessity?
How is it to be "encouraged" by "clinical governance" - and what will
happen when a  EHR of unknown provenance is inserted into *your*
database?

Diabetes is bad enough - but just think of asthma! ;->>
(best definition of asthma I heard was "a patient receiving regular
prophylaxsis for asthma" - this was a definition put forward for chronic
disease management .. we'd failed to reach agreement with the HA on who
was your family and what was premature for IHD! It beats the "documented
10% reversibility" one, which prevents most children under 6 or so from
having a diagnosis of asthma in the first place...;-<<)


I'm just trying to get a discussion going, so I'll stop at that.. for
the time being.

Obviously, we would all like to have a complete EPR which could be
transferable.. but how do the people who got this incorporated into the
Strategy see it happening?

Mary
PS I feel like the person who, when asked directions by a traveller,
said "If that's where you want to go, sir, I wouldn't start from here if
I was you!"

Mary Hawking Kingsbury Court Surgery Church Street Dunstable LU5 4RS
tel:01582 663218 (surgery)fax:01582 476488 (surgery)
Member of British Healthcare Internet Association
Dunstable and Houghton Regis Locality Commisssioning Pilot


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