Back @ The EPR Arms: “Don’t let the perfect be the enemy of the good”.

(Please note the  views expressed in this EPR Arms blog do not necessarily represent the views of IHRIM)

I’d been doing this pilgrimage to the EPR Arms for decades now and you could almost measure how many pints of badgers I’d sunk by measuring the stretch marks on my six pack. (Party seven if truth were known!)

I was thinking about an earlier life I’d had – as an Information Manager in the hospital across the road. We thought we would have an electronic patient record by now, thirty years on and, apart from my aching back and knees, relatively little has changed. But now things are moving at a pace.

Back @ the EPR Arms: December 2017 A Christmas Record

A Christmas Record

Approaching the EPR Arms on a starry, starry (twinkly, frosty) night.

’ ……and a partridge in a pear…’

The door opened and shut again.  I walked closer.

‘……...five gold rings, Four calling….’

Shut again. Lots of comings and goings tonight. Open………

and a partridge in a pear tree’.

I held the door opened and this time heard all the remaining days of the twelve days of Christmas.


Back at the EPR Arms: Quality is key

Back at the EPR Arms: Quality is key.
‘By ‘eck its warm Sal!  I’m glad I ditched the heels for flats I tell you. In fact, I was tempted to put me flip-flops on tuneet.’
‘Whoa Whoa. It’s not that hot tha’ knows’.

Back @ the EPR Arms: September 2017 Finding stuff and understanding it once you have

Another night in the EPR Arms. The sky achieving a darker, dusky hue when another Hugh walked in through the main door.

‘Hugh. Pint?’

‘Yes please. Usual’.

‘We’re sat over there near the window (I gesticulated with my empty glass) – grab a chair I’ll just get these.’

Hugh joined Keith Lamont - the hospital’s Medical Director.

‘Hi Keith. Busy day?’

‘The usual. A bit of stress in the morning followed by a stressful afternoon and early evening. You?’

‘Busy kiddie clinic then ward round. Really struggling with where to find our clinical letters at the moment. We’re moving onto this American EPR system – which will be great once it’s all in there. But at the moment it’s a mess. Finding where my letters are in the scanned record is just a nightmare.’’

‘I once knew a doctor who had a Montblanc fountain pen which he always used for writing in the casenotes.’ said I, depositing three pints of badgers on the table carefully.

‘Montblanc – that’s well posh and expensive isnt it?’ said Keith

‘His was at the cheaper end – only £450 smackerrooners’ I replied.

‘Another world. It’s just another world isn’t it? ’ said the Paediatrician with the Noddy & Big Ears tie still loosly wrapped round his neck.

‘And he used a turquise QUINK ink’

‘Why so?’

‘So, when flicking through the patients casenotes, he’d know which letters were worth reading - i.e. His own!

‘And he used to write in code for him and his mates’ said Keith. ‘But then again, didn’t we all!’

‘NFH!’  exclaimed Hugh.

‘NFH?’I queried.

‘Normal For Huddersfield!’ He explained.

‘TEETH’ said Keith.

‘TEETH?’ I asked.

‘Tried Everything Even Tried Homeopathy’. explained Keith.

Hugh added ‘And in some sad cases AGMI – Aint Gonna Make It! ‘

‘You see, what is recorded in casenotes has to make sense to whoever reads them and they need to know where to find it. And nowadays, that also means the patient, so you have to be very very careful what you write in there.’ Keith summarised.

‘But if you don’t know what the abbreviation means, you don’t know what the abbreviation means!’ said Hugh.

 ‘For example?’ I asked.

‘Well -  WNL – is used for recording vital signs. It can mean “Within Normal Limits” or “We Never Looked! or NAD: No Abnormality Detected OR Not Actually Done. A minefield.

‘And so the colour of the writing helped him navigate through the hundreds of pages of documents to find the note he had written earlier in the episode?’ said Hugh.

‘Exactly’ I replied.

‘But no use to anyone else?’ Keith this time.

‘Exactly so. So, the question is, how will all this pan out when it’s all digital?’ I asked cautiously.

‘That’s a very good point. Unless there is some agreed structure to these digital records, then it will be a real challenge finding the clinical information you need.’ Keiths turn.

‘But in the Trust across the road there, they’ve just implemented a big American EPR system. That will have a structured record won’t it?’ I asked, remembering the news item in the local daily paper.

‘Yes from when it goes LIVE. And that other Trust, 20 miles away will have a completely different EPR with a completely different record structure to it from when IT went live and Junior Doctors will be oscillating twixt the two! And don’t get me started on the scanning debacle’ said Hugh.

‘Go on – tell me about the scanning debacle.’ I pleaded.

‘Just as soon as we’ve got fresh drinks-this may take a while.’ said Keith.

I handed over my empty glass to Keith who obviously was in need of some refreshment to blunt the tired but sharp edges to his day. ‘Badgers. Pint please and some crunchy pig.’ I said.

‘Badgers and some scratchings. Wilko. And you Hugh?’

‘Same for me Keith. Ta.’

Keith was squeezing between the tables and chairs and ‘buffets’ (stools to you and me but not in Yorkshire pubs!) and shouting his order as he approached, ‘Three large badgers and three bags pork bits please.’

‘I am surprised at you Mr MD getting some Scratchings. Shouldn’t you know better?’ I attacked him as he was depositing the drinks and bags of grub randomly onto the table.

‘Actually, hard to believe but this bag of bits is better for me than a bag of crisps. No carbs. Some good fat (and granted some bad fat) but sooooo delicious with a pint. All in moderation of course!’

I couldn’t argue with him over that one, taking my pint and having a quick slurp whilst trying to manfully pull apart the cellophane bag of pork bits. ‘So, Hugh, what’s this scanning debacle then?’

‘Well. There are some Trusts who think that going paperless simply means scanning in the paper record and so have embarked on a very expensive and complicated paper record scanning process’.

‘Well whats wrong with that?’

‘Going paperless should NOT be the objective. Getting rid of the paper will be a natural consequence of using clever clinical IT to do prescribing or ordering labwork, recording clinical histories or even completing profiles or pathways of care.’


‘And the outcome will be less paper. But that is NOT the objective, but the outcome.’

‘So how’s this scanning all going wrong then?’

‘Because there is no national standard or guideline for scanning in paper case notes. Every Trust can invent its own list of document names.’

Keith joined in.  ’And it’s actually worse than that. Some Trusts are simply scanning the contents of these huge paper casenotes into a single PDF file. ‘


‘And because they haven’t got an all-singing all-dancing Amercian EPR system, most of the clinical information is sadly still held on that paper.’


‘And if I want to know about my patient, I need to read the relevant paperwork.’


‘And my six letters of consequence are buried in and amongst a thousand other scanned pages with no record structure. As a busy clinician I haven’t time to wade through page after page of a massive PDF file. I didn’t write the notes in Turquoise ink. They were typed and I want to know where to look for a discharge letter or an A&E discharge note. Ideally I want any scanned piece of paper to have what they call ‘metadata’ attached to it that tells me what kind of document it  is, who wrote it, what specialty that person worked in and when it was created and then when it was scanned and by whom. And I expect this metadata to be the same in ALL the NHS.

‘And isn’t that what they are doing with the scanning?’ I asked. Seems a bit obvious that you need to know what documents you have so you can file them in a sensible structured record.

‘Sadly not. You see, if you are given a five hundred page, over-stuffed casenote to scan, it has first to be broken down into all the separate documents. They won’t all be filed in the right place. They won’t all be on A4 paper. Some may be lab reports which have to be cut off the backing sheets. Some will be ECG tracings on ticker tape. Then these have to be indexed i.e. a code added saying what kind of document they are. Then put in date order. Then scanned. It would cost the earth to do that level of detailed Indexing, so most Trusts simply scan the paper casenote in the existing casenote sections. At best all correspondence will be ‘tagged’ as correspondence. All nursing notes will be ‘nursing notes’ etc., etc.

I drained my pint quickly and got up to leave. ’To be honest guys, I think this conversation is a four or five pinter so I’m gonna have to go now but why don’t we meet up again in a month and I will get you an update on where we are nationally with this scanning issue?’

‘Good plan. I’ve got to dash anyway’ said Hugh draining the last of his craft beer.

‘Me too. Heavy meetings tomorrow’, added Keith.’See you in a month!’

As we all made our way out, I looked back into the bustling EPR Arms and was reminded of one more casenote abbreviation that was more appropriate in this non-clinical setting; LGFD. Looks Good From the Door.

Back @ the EPR Arms: February 2018 An Anniversary or two

‘Pint of your best mild please kind landlord. It’s been a busy day.’

‘Certainly Dr Woodcock. Busy then? That will be one and three please[i].

 ‘I’ll be glad when the whole world settles down a bit. It’s a time of great change Mr Landlord, great change. Have you seen Mr Barmforth recently?’             

‘The records man from the hospital across the road? No not seen him or Alf Gubbins for ages’ 

 ‘No Alf passed on. He never really got over his injures did he – poor fellar. No - I was goin’ to ask Mr Barmforth about how he is coping with all these recent changes in his hospital. Has it settled down now four years on?’

‘To be honest Doc, it still looks the same to me. Not changed much since it were a workhouse. Just painted up a bit.’

‘Oh I see him now crossing the road. ‘Watch your fine hat doesn’t get blown off Barmey’ as the door opens, allowing some fresh air to flutter through the gloom.

‘Oh hello there Dr Woodcock. And quite balmy it is too. What on earth brings you down my neck of the woods? I would have thought you would be in your practice this time of day.’

‘Well, I just needed a pint to be honest -whet my whistle after work. But I also wanted to talk to somebody about something more than just bad backs and runny noses.’

‘Funny you should mention backs ….’

‘Enough! I tell you I am sick of them. We’re a few years in now with this NHS but I reckon there are still more trials and tribulations to come?’

‘Yes, perhaps youre right - but isn’t it a good thing? It seems to be settling down a bit now – although I must admit, expectations are that we will cure everything at a stroke. Do you remember what was it like on your first NHS day in 1948? ‘Cos I do.’

‘Yes, I remember it well. As a GP, we were previously paid for each visitation but this new fangled NHS caused quite a stir amongst my ‘flock’ I tell you. When I arrived at my surgery on day one, I was greeted by a queue half way down Westbourne Street. I remember it well. It was the day DFS didn’t have a sale on so it was a quite memorable day!


‘Sorry – never mind. To be honest I think they only came to see how they could get their medicine for free! Especially the woman and children who hadn’t been covered previously by any work insurance schemes.’

Mr Balmforth added ‘Yes I remember. They often subscribed to dubious and often downright dangerous old wives cures. I remember one particularly dodgy ‘cure’ of putting butter on a burn!’

‘As much use as an ashtray on a motorbike I’d say’ said Dr Woodcock in an unusual display of comedy. ‘Right – yes – so that was me, but how did your hospitals work before 1948 then?’

‘Well, they too charged up front for their services, which could then be claimed back by the poorer people. But they often didn’t have enough money to pay up front. It was a mess. And to be honest, hospitals really only were involved wirth ‘serious’ conditions and you’d be in hospital for weeks and weeks! Oh and local authoriteis looked after elderly care and mentally ill patients.’

‘Well I guess change was long overdue, that’s for sure’ said Dr Woodcock. ‘Do you remember the torturous process it went through – a difficult and protracted birth what?’

‘Yes after thirty years of Reports and White Papers and consultations eventually the Cabinet endorsed the White Paper which was published in 1944.[[ii] This White Paper includes the founding principles of the NHS: it was to be funded out of general taxation and not through national insurance, and services would be provided by the same doctors and the same hospitals.’

Dr Woodcock picked up the baton of history: ‘Yes the other principles being:

  • Services were provided free at the point of use;
  • Services were financed from central taxation;
  • Everyone was eligible for care (even people temporarily resident or visiting the country).’

‘Not an easy birth either by all accounts, with your lot almost putting a block on it all together!’

‘Yes, Bevan encountered considerable debate and resistance from my very own BMA I seem to remember, who voted in May 1948 not to join the new service,[13] but Bevan brought them on board by the time the new arrangements launched on 5 July 1948.

‘I suppose though we are looking at a reducing need aren’t we Dr Woodcock?’

‘In what way Mr Barmforth?’

‘Well – if we get rid of the sickness first then concentrate on preventing sickness, surely we won’t need to be spending a lot on the NHS in the future. It stands to reason.’

At that moment, through the grey blue throat tickling fog of the pub, came a shimmering bright light. Bright. Brief. Then it returned to being dark and gloomy again.Two giggling young people walked in - the young girl in a very flowery gay coloured dress, brushing off what looked like brightly coloured little paper pieces. They fluttered to the sawdusted boards. Him in some sort of camouflage trousers with tan jumper with a hood. Very strange apparel for an Army personage.

‘No not in here George. I just can’t breath. It’s so foggy. I thought they’d banned smoking in pubs!’

‘You’re right. This just won’t do Katie,’ replied George. ‘Shame, it looked so quaint from the outside. Let’s just find another one down the road’.

As he turned to leave, a rolled up newspaper fell from his back pocket onto the floor as the shaft of light from the opening door showed up the swirly smokey grey and black atmosphere that was the Volunteer Arms[iii]. The door shut.

Standing up, Dr Woodcock quickly picked up the paper and smoothed down the front page. ‘What a strange publication this is – and all in colour too.’

‘I dont believe it. I just don’t believe it! Our very own PM at the time of the founding of the NHS - Clement Atlees’ great granddaughter has just married the grandson of the first ever NHS patient at Trafford General[iv]. Now if that’s not completing the circle of life I don’t know what is!’

‘I don’t believe it either!’ this time Mr Barmforth.


‘The year is 2018 and they still using paper!’ 

The landlord pushes between them and points to an advert on the bottom of the page with his mucky looking glass drying cloth.

‘And whats this then? A pint of beer is £3.45p and it’s made from a badgers crushed paw. Wow – what DOES the future have in store for us eh?’

Indeed dear reader, (whoever and wherever you are), what does the future have in store for us?

2018 is 70 years since the NHS was created and no coincidence; it is 70 years since IHRIM (formerly AMRO) was founded. Since the very dawn of the NHS, good record keeping and its safe management was seen as a fundamental requirement to deliver an efficient and effective health service. In 2018 we are looking at reducing reliance on paper but simply shoving a computer in the loop does not deliver good records. These records will still have to be managed effectively, have good sensible structure and created with agreed national standards. YOU will continue to be a part of that process. Be ready.

[i] 1952 Pint of beer 1/3 (old pence) = 6p new money.


[iii] Re-named EPR Arms in the year 2000











Back @ the EPR Arms: June 2017 Cyber Cyber Cyber

Soggy spring is transitioning into soggy June via soggy May.

May called an election. Shocked us all. We all shocked (collectively) her.

Drama and sadness: London then Manchester and London again.

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