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  • Back @ the EPR Arms: February 2017 Daisy's Record

    When do I stop saying ‘Happy New Year’ I asked Frank in the pub the other night.

    ‘Well, to be fair I think you’re milking it a bit now were in February’ he said with his usual frankness. Well it would be wouldn’t it?

    ‘Speaking of milking it, how’s your cows getting on?’ he asked.

    ‘Two pints of Badgers Crushed Paw bitter please landlord,’ I shouted in the direction of Bill the ever-busy barman/landlord/chef.

    ‘Daisy’

    ‘Daisy?’

    ‘Yes. Daisy the cow and Jasper the dog’.

    ‘Is this the start of one of your jokes? A cow and a dog walked into a bar’

    ‘By ‘eck you’ve lost it big time. Cheers’ he said taking one of the pints from me and heading to a table in the corner. Bustling busy Thursday. Nearly weekend. Nearly. ‘ I saw you do a presentation once about Daisy the cow and Jasper the dog’.

    ‘OK and now I’m back in the room’ I said, now confident that I hadn’t slipped into a paralell universe’.

    ‘ A presentation. That was years and years ago.’ I continued pulling the buffet towards me. (Buffet is a Yorkshire stool and is NOT food related.)

    ‘I know, but it left an impression. Not sure if that was a good or bad one but remind me and I will tell you’.

    ‘Well ,’ I said licking the froth from the side of the glass. Not a good habit but waste not want not (as they say in Yorkshire.) Frank adds ‘many a mickle meks a muckle’ as the say in either Scotland or Jamaica (depends on where you search on Google for proverb meanings! )

    ‘Well – it was based on a conversation I had with a farmer - in here actually Frank. And he was called Frank, Frank. Coincidence or what. Back in 2005. Wow! Eleven years ago. Gosh! Anyway, he told me his tale. This tale to be frank:

    “In the old days, I used to get up at 4.30am and bring all the cows in from the fields and milk them at 5.30am and then again at tea time.”

    “I bet that was hard chasing them all.”

    “Well no actually. They want to be milked, ‘cos they get full and uncomfortable don’t they? Their udders is busting and swollen. So now’s I’ve got this fancy milking parlour, they come and get milked whenever they want. 24/7”

    “How?”

    “Well, I’ve chipped them all: a little tag on their ear. They know that when they enter the parlour they’ll be fed, so they approach the unit and the unit knows who it is by their chip. It releases the right amount of feed and checks if they’ve already been milked. They know the teat configuration and size (‘cos all cows udders are different), and the teats config has been measured by laser and stored in the unit. It then sterilises the teats. Attaches the milking cup thingy-bobs and milks each teat one by one.”

    “One by one?” I asked.

    “Yip. Instead of sticking a four teat vacuum thingy-bob on and sucking till all milk has come out, it measures milk flow and conductivity for each individual teat, and stops when the flow stops.”

    “Conductivity?”

    “Yip. Clever innit? The ‘lectricity flow across the milk is affected by things like infection.”

    “Infection?”

    “Yip. It plots graphs of the milk flow and conductivity of each teat. You can see which teat is infected and it sends me a text message on my mobile. And I’m still in bed!’

    ‘No way!’ I said.

    ‘Way!’ he replied.

    “And wait for it, and this is the best bit, I end up with an electronic record of Daisys health and stuff.’

    ‘Health and stuff?’ I asked incredulously.

    ‘Yip. I have a record of Daisy’s milk yield, weight, food eaten, so I can work out if there’s a problem. I’ve even got her wearing a pedometer so I know how far she’s walked.”

    “So why is this the best bit?” I asked.

    “Because you’ve been going on for years about your electronic health record, your EPR and how that record should be a by-product and not simply the objective.”

    I was impressed he’d latched onto my mantra – oft repeated, mostly by me! “Yes. Support clinicians in what they do and what they’ve done is automatically captured” I repeated mainly for Frank’s benefit.

    “It’s the same with Daisy. My aim wasn’t to produce a record of Daisy’s health or milking history. I just wanted to get her milked efficiently. The computer is supporting the milking process and offering decision support and guidance: not too much food today. One of the teats is poorly etc. But you end up with all of it recorded electronically.”

    ‘Wow!’ So you’ve got an EPR equivalent?

    ‘Yes sir. Instead of having lab test requesting or your electronic prescribing, I’ve got milking. My milking is supported with technology. The computer directs me to capture the correct information that I need, it offers me guidance and support and it gives me, in return two things.’

    ‘TWO things?’

    ‘Yip. An electronic record AND a lie-in!’

    Back to today:

    ‘You see Frank, some folk in our NHS lose track of what EPR is all about. Some think going paperless is the objective but it’s not. Supporting our busy doctors and nurses with computers simply improves their effectiveness and ensures all the right clinical data is captured by them during that episode and makes that available to others to impove their interractions with the patient. The fact that we need less paper is simply a by-product of using these epr type systems to support them in what they do.

    ‘So those Trusts that are responding to Jeremy Hunt’s vision by scanning their paper casenotes are barking up the wrong tree?’

    ‘Not necessarily, scanning the old legacy paper has a place in this emerging electronic record. But simply ‘going paperless’ by scanning does not give you the real clinical benefits of a proper epr system.’ I detected that I was losing Frank - he was eyeing up the Guest cask ale hand-pulled pumps and twitching nervously.

    ‘Frank! Frank. Let me explain: We could take the paper drug charts from the ward and either get someone to scan them every night or type in the drugs/dose etc for each patient on that patient’s EPR. That would give us an electronic record of what drugs had been prescribed and which were administered and by whom and when’.

    ‘Isn’t that what you want?’ asked Frank frankly losing interest by the minute.

    In part yes, but we actually want these clever EPR systems to influence what drugs are being prescribed. We want decision support at the point of care. It’s all very well knowing later that what killed the patients was a dose six times higher than normal. We want to know that while the drug is being prescribed and certainly before it is being given.

    ‘And you end up with an electronic record of what was prescribed and administered?’

    ‘Yes- we end up with Daisy’s record!’

    So that was where you got your presentation from? And what about Jaspers record?’ asked Frank being Frank again.

    ‘Jasper is another story for another night. Same again? Your shout!’

  • Back @ the EPR Arms: October 2016 Wachter

    Digitising the NHS.

    Another busy night in the EPR Arms. Not quite autumnal but going that way. Nights getting shorter but  leaves refusing to leave their tree. TV Sofa ads promising delivery before Xmas. You get the drift - but not for a few months yet - not cold enough.

    James Beattie, is the new Information Manager across the road at the local Trust and he’s just popped in after work for a 'snifter' before going home to his hot-pot and red cabbage. He had found Rupert, Surgical Directorate Manager, just getting them in for me and him, so he cleverly slipped into his slip-stream and sneaked a pint of Badgers off him.

    "Ay Up! James,’ I said acknowledging the recent addition to the round, then back to Rupert,  ‘I am not saying it’s better Per Se Rupert,' I continued, taking my pint of Badgers from his outstretched hand, 'I am just saying that is the way of the world. You just can't stop modernisation just as you can't stop globalisation and mobilisation and any other 'ation' you care to mention. Digitisation is happening whether you like it or not'

    'John Lennon!' said Tim - the hospital electrician sitting on a bar stool who had swivelled round to join in. 

    'Eh?'

    "I've had enough of reading things by neurotic, psychotic, pig-headed politicians' said Tim by way of explanation.

    'It's nothing like!' said Rupert and I in unison.

    ‘Wrong song! ' Apologised Tim, 'everybody’s talking about revolution, evolution, flagellation, regulation, integration, meditation, United Nations.'

    'That's better and thanks for your input Sparky. Haven’t you a fuse to go to?’

    Rupert now directed his comments to James while his eye searched for somewhere to sit, ‘I was just saying James, this rush to digitise the clinical record is causing real issues with my docs and nurses. I mean real issues.’

    ‘In what way Rupert?’ asked James. 

    ‘Well for a start the number of separate clinical systems and their passwords. Nightmare. And there’s still lots of sharing passwords - on wards and in clinics. I see it every day in my Directorate'

    'Is that still happening Rupert?’ I asked, assuming this had all been put to bed years ago. ’Doesn't everyone know passwords are to be kept private?'

    'Yes perhaps they do, but the clinical systems that these busy doctors and nurses are using are the problem.' James replied

    'How?'

    'I'll tell you how!' said a very grumpy and tired looking Junior Doctor – bursting through the door and wiping the rain from her wax Barbour jacket. Just off-duty from A&E, it was Dawn by name and grumpy by nature. 'I'll tell you what! ‘Gin & Tonic Simon' she bellows across to one of her 'Caz' mates who’d just arrived at the bar. 'Simon, this guy wants to know what I think about 'computers'.' She spat out the word with enough venom to make all of us take three steps backwards. 'I'll tell you what. The Trust has made moves towards some almost integrated electronic patient record systems or EPR as they call them. That sounds like I am logging on to one system doesn’t it. One EPR. Wrong. Wrong. Oh how so flippin’ wrong. It actually means us busy clinicians accessing three or four different systems. Don't you think we've got enough to do without having to mess about with computers? Don't you?'

    'I've watched Casualty on the telly on a Saturday night and Charlie is never busy. He just spends his time checking the ceiling tiles are still in place’ I said sidling over to a free table to bagsy and at a safe distance from Dawn.

    'Don't believe all you see on telly Sweet Cheeks' replied Dawn. 'Not all systems are linked - most of them we have to log in separately: That means remembering - Log in Names. Passwords. Four different log-in names and four different passwords for the four different systems. I can't remember them all so I just write them down on a post-it note on the monitor'

    Rupert looked at James across the table.

    Dawn continues, 'so imagine you are on a busy ward or in a busy clinic or in A&E and you've logged in to your 'EPR' and you get called away to look at another patient in another cubicle. Someone takes your place at the PC and needs to urgently order some tests or prescribe a drug. It is very, very tempting for them to just carry on with the EPR logged in to YOUR log-in details. Saves time.

    James jumped in at this point. 'OK Dawn – we appreciate that. But don’t you realise that’ll mean that anything done on that machine will be done against YOUR name?’

    ‘Exactly! If I don’t log out, because I’ve got called away urgently, then anyone can do whatever they want in MY NAME’

    James continues, ‘But in court you will have no defence. If someone 'takes over' your PC and then prescribes a drug incorrectly - then what defence do you have? The overdose was prescribed by you as far as the court is concerned.'

    "OK. OK said Rupert, ‘the basic issue here is why do folk not log out?' he directed the question at Dawn who by now had finished her first G&T and was waggling her glass at the bar for a refill. ’Simon! Another!’  Wow she MUST have had a bad day!

    'I'll tell you what: Time. It takes SOOO long for a PC/workstation to fire up and allows a new user to log in with their own details.'

    'But that is changing isn't it?'

    ‘Yes but will it change in my lifetime? They have been promising an all singing all dancing EPR for decades. Decades.’

    Rupert begins to waken up to the theme. ‘You know, I'm beginning to think this electronic record just isn’t worth it. Just keep paper. It works fine.’

    'What you guys talking about?' said Simon another of the JD’s from Cas, struggling with two beers (for him) and a large G&T (for Dawn) and a bag of scratchings clamped in the corner of his mouth (hopefully for us all.).

    "Rupert was just saying that all this palaver with electronic records, he wants to go back to the tried and trusted paper casenote.

    'Can't do - no turning back the clock' said Simon tearing open his scratchings and offering them to all on the table.

    'But there was nowt wrong with how it was. I think we should go back' said Rupert.

    'And I want to be twelve stone with brown hair' I said. 'It ain't gonna happen'.

    Simon continues, 'And anyway, the NHS has changed. Moved on. It's no longer the place where you can have a leisurely tonsillectomy with a ten day length of stay. It's all different. All changed. More care in the Community. Changed. For all we hate these flipping computers, we need them. But we need them to be right.'

    'And how do we do that?’ asked James.

    ‘Wachter’ said Simon.

    ‘Bless you!’ I replied.

    ‘No – Professor Wachter. He has written a brilliant pragmatic guide to IT in the NHS which came out last month (and a summary is availablehere on the NHS Digital website with an even more concise summary here on the IHRIM website).

    He continues, ‘Professor Wachter reckons, and I quote ’The goal is not digitisation for digitisation sake, but rather to improve the way care is delivered in the NHS, in part by using digital tools.’

     

    ‘And that is exactly what the NHS EPR Programme concluded in 1998’ I added. ‘We seem to have lost our corporate memory.’

    ‘In what way?’ asked Simon.

    ‘Have a look at the final reports from the EPR Programme. It concluded that it wasn’t about creating an electronic record in hospitals Per Se,it was about supporting the clinical care processes with technology and the record will be a natural by-product. Use decision support tools where appropriate with the aim of improving clinical care. It seems that the NHS is on the road to getting rid of paper, but this is the end product not the goal in itself.’

    ‘Yes’ added Simon, ‘a senseless drive to scan paper without putting it in the right context for the clinicians is asking for trouble. Simply scanning paper into a single PDF file is asking for trouble. Expecting busy doctors to have to log on to four or more different systems is plainly asking for trouble. And if we aren’t ready for it then putting in a half-baked solution is just…..’

    ‘Asking for trouble?’ finished Rupert.

    ‘Exactly’ we all said almost together.

    ’And the time to do it is when all the appropriate infrastructure is in place, and we have all this logging-in nonsense resolved and enough hardware to stop us queuing for a free PC’ added Simon.

    ‘Yes actually that is a very fair point Simon’ I said, ‘I was in Malaga airport last month. Worked brilliantly – on-line booking; turned up at the airport and plane left on time, suitcases delivered to the right country BUT the queue at Passport Control was a nightmare’.

    ‘In what way?’ asked Rupert.

    I continued, ‘They are going over to this digital/retinal scan/finger-printy model. Brilliant concept. But there is not the infrastructure yet for it to work. They only had two digital/retinal scan/finger-printy workstations!  TWO and a man in a box for Luddites who preferred the old way. The queues were almost back to the plane. In the end, the man in the box just waved everybody past him grumpily. They are not ready yet. You only get one chance – make sure the timing is right. Make sure you have the right technology in place, otherwise there will be trouble.’ I finished with a flourish.

    Speaking of trouble, Dawn was well through her second G&T and detected a summing up of the discussion so she stopped drinking to add her twopence worth. ‘The techies have got to really understand how we clinicians work. We can’t have separate systems with separate passwords. That is crazy. We’ve got to have a quicker way of logging in and out. A Proximity card tap. I’m in. Tap I’m out. Simples.’

    ‘Is that all?’ asked Rupert.

    ‘No – it has GOT to be fast and well designed. I just haven’t got time to look for ‘stuff’ in three hundred scanned pages of rubbish. I need to see it in a well-designed place. Zap Zap Zap and Zing. Got it. If I can’t find it I’ll miss it. That could be dangerous. With the paper record, at least there was an understanding that not everything was necessarily there but you could easily flick through and find enough to crack on. But with these computers, we ASSUME everything is there. It may well be, but unless we can get into it quickly and find it, we’re up a creek without a paddle.’

    ‘Anything else?’ enquired Rupert, ‘Before we go?’

    ‘Yes – computers can be brilliant. They can help guide busy clinicians through decision support. Just because someone has said we have to be paperless in 2018 – no! -  2020 - no!  2023, doesn’t just mean simply scanning the paper casenotes. Oh no! We have to use technology to get all the above clinical benefits. To change the way that we deliver clinical care. Make it easier and also safer.

    At that point everyone decided to move out into the wind and rain without a paddle or umbrella, at the end of another hard day at work and harder evening in the EPR Arms.

    How is your Trust designing your electronic records?

    Are they involving the doctors and nurses?

    Are they involving you, in Medical Records?

    How are they scanning the paper record? Is it being structured in an easy to access way or is it simply a single big fat file?

    And why does Charlie Fairhurst keep looking at the ceiling?

  • Paper heavy

    nhs20englandIt’s eighteen months since health secretary Jeremy Hunt said he wanted a ‘paperless’ NHS within five years.

  • Scanning the future

    How much paper is it worth scanning as part of an electronic document management project? It's a fraught question, but the answer seems to be 'less than you might think' with legacy records and 'only what you can plan for' with new ones.

  • What is EPR Arms?

    The EPR Arms is an imaginary pub in Yorkshire opposite a busy General Hospital. It first opened in 2002 but closed down after a couple of years. It has now re-opened and is a meeting place for hospital and other NHS staff together with the public where regulars (and others) meet and, over a pint or cup of coffee, chat about everyday NHS issues that affect you and me.

    Some call it 'Quirky' but why not have a read and find your own word to describe it!

    To view all issues please hover over the EPR Arms tab on the navigation bar at the top of this page and click Archive.

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