Back @ the EPR Arms: August 2016 Coding

Isndie the EPR Arms this week I was rding an intrsing atrilce in a sicintiifc juronal: Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.

‘Mmmm I thought. I need aonethr pnit’.

‘Whats that you’re reading?’ asked a young woman who had just bought herself a drink and sat down next to me.

‘An interesting piece of work done yonks ago by GE Rawlinson (1) about how we only read the words as a whole and not each individual letter and yet the reader can make sense of it by skimming it. Like a 6th sense. A feel. Don’t I know you – from across the road. Medical records or something?’

A loud groan came from across the room.’Gerrim Off. Useless person (2)’ shouted the crowd gathered around the massive TV screen on the wall. England were playing football in some competition or other in which they will not progress much beyond the initial stages. ‘England are rubbish!’ shouts one very aggressive grumpy person. Oh – it was me! I really must control myself.

‘Yes - My name is Jane and I am a clinical coder’ she said.
‘A what-er’?’
‘I summarise a patient’s hospital episode by selecting codes from my ‘Bible’ of clinical codes.’
‘Why? What for?’
‘Well, think about it. Where do you look to find out any information about any patient who has been treated in hospital?’

‘I can read their notes or letter to the GP from the hospital.’

‘Yes that is correct, but what if you want to know how many fractured necks of femur you’ve had this year compared to last. What if you want to ensure the Trust gets sufficient funding to cover the costs of these fractured necks of femur. What if you want to look at your clinical outcomes for patients with a particular operation for a particular condition?’
‘I would look it up on computer’.
‘Correct’ said Jane.

‘You couldn’t hit a barn door with a beach ball you useless Wombat (3)’ came the shout from the TV area of the pub.
‘As much use as a chocolate fireguard you are’ added another as the final whistle went. England were on their way out of the Euros 2016. Beaten by Iceland.

‘And how do you think that the computer knows who had what diagnosis and procedure done to them?’ she asked.
‘Someone inputs the information’
‘Yes! - with clinical codes: a clinical coder. That’s me. – Are you really listening?’
She noticed my eyes had wandered back to the screen like a magnet.

‘OK sorry’ I said making an effort to turn my back on the interview with heros from yesteryear - I remember him when he had hair. ‘So what do you record then and how?’
‘We are really at the mercy of what is recorded in the notes or in the discharge letter by the doctor’ she said.

‘Well that should be simple enough then?’ I optimistically suggested, hoping I could finish this conversation off quickly and treat myself to another pint.
‘Listen, why don’t I get us both a refresh and we can sit down over there and go through it’
‘OK – Vodka Tonic Ice and slice for me please’ she said shattering my hope that she was a half of lager girl but hey-ho.

I shouted the order to Trev who said he’d bring them over. I cleared someone else’s empty crisp packet from the table and using a beer mat, smoothed away some drips on the table as we sat down. They didn’t seem to mind and went to sit elsewhere!
‘So – I get it. You have to summarise a patient’s episode by selecting some codes from a book of wisdom. Pips!’
‘Well – not ‘Pips’ at all actually. It’s a real pain sometimes.’
‘In what way? Thanks Trev’ as the drinks arrived.
‘OK here we go. Firstly I can’t always find the casenotes. And we don’t have an electronic patient record yet. So nothing clinical is recorded on our computer. Problem Number 1- Not enough information to go on.’

‘Check!’ I said ticking an imaginery box as I licked the froth off my glass. ’Lets assume you always always get the casenotes on time. Then what?’

‘Lack of actual detail. For instance, almost every set of notes coming through the office on the General Medical side at the moment is for influenza, pneumonia & exacerbations of COPD... BUT.... is it due to infectious organism? If so is it influenza A with pneumonia (J10.0); is there consolidation present (J18.1); is it exacerbation COPD (J44.1); is it infective exacerbation of COPD (J44.0); is it emphysema (J43.9); is it chest infection (J22.x); is it a LRTI (J22.x).
‘What all that stuff in brackets?’ I said rather bizarely – as if I was reading her words!
‘Those are the ICD codes. J44.0. J43.9. J22’
‘Sorry – please continue’

At that point, a new group of customers came in and ambled straight over to where we were sat, obviously knowing Jane.

‘Hello you lot’ said Jane.
‘Are these your mates?’ I asked Jane. She nodded. ‘Fellow Coders’.
‘Hi – my name is James and I am a Clinical Coder’ offering me his hand.
‘My name is Laura and I am a Clinical Coder’ another handshake.
‘Barbara and I’ve been a Clinical Coder since Adam was a lad’ a grumpy nod - no hand.
‘I’m Adam and I am no longer a lad but I am now a qualified Clinical Coder’.

Well this is going to all get a bit intense I thought. It was like a weekly meeting of the Huddersfield Branch of ‘Coders Anonymous’.
‘So what do we call a group of Clinical Coders then? A gaggle?’ I asked.
‘How about a flock?’ suggests Adam.
‘A clutch?’ said Jane.
‘A conspiracy?’ added James.
‘An Enigma !’ offered Trev who had been hovvering by the table ready to pick up any empties. An Enigma of Coders was the winning entry with a hint of Bletchey Park.

‘So Jane, how are you today? I heard you were feeling a bit rough yesterday?’ asked James.
‘Not great, Woke up with a bit of a J02.9 so I worried it might be the start of J10.1’
‘Worried it might develop into G03.9 or G03.1?’ asked James.
‘I think it’s probably just a J02.8 + B97.8 but can’t rule out a J02.8 + B95.8 can I?’
‘No not at this stage’ replied Laura, ‘and you need to know if antibiotics will do you any good won’t you?’
It felt like I’d walked into a Star Wars convention and R2D2 or C3P0 would walk in any minute.
‘Wish I was retiring tomorrow!’ said Barbara which brought me back to earth.

‘Jane was just explaining to me what you lot do. I never realised so much depended on good timely accurate coding’.
‘Too right!’ said Laura ‘without clinical coding the Trust wouldn’t get its money and clinicians couldn’t do any research or clinical audit.
‘The Trust couldn’t do any planning’ said Adam.
‘….and I was hearing you have a few issues’ I suggested.

‘Issues! Issues! I’ll give you issues’ said Barbara, who seemed to be carrying all the problems of the coding world on her shoulders and not dealing with them with great humour.
‘Like?’ I prodded gently.

‘Well, the latest – I tell you – only just recently – today actually, this morning it were a consultant at our trust said "All pneumonia is bronchopneumonia" .... Well, we coders laughed. Hysterically some of us. If only it was that clear cut…. We can't just code all pneumonia as bronchopneumonia unless that is what's documented in the patient’scasenotes. A bit like the Eskimos have over 50 words for snow (4), we have hundreds of different codes for different types of pneumonia (blocks J09-J18 to be precise). If you just search for ‘Pneumonia’ that takes us to a J18.9 (pneumonia, unspecified) which isnt detailed enough for clinical and analytical purposes.’

‘So - You are like detectives (5). Searching through the notes to identify the primary reason for that episode.’
‘Yes and our job is made no easier by weasel words.’ Said Laura.
‘In what way?’

‘Well’ she continued, ‘we get stuff from consultants which we just can't code – ‘likely’, ‘suggestive’, ‘impression of’, likely to be’, ‘could be’, ‘may be’. ‘has a hint of’. More like they are describing a nice crisp chilled Chardonnay ‘with a hint of Apricots’ rather than a clinical episode.
James joined in ’actually most of the diagnoses we get are preceeded by one of these little buggers!! And when they are, we can't code them -they’re practically useless to us. ‘
‘OK’ I say, ‘Check! Problem number 3. Vagueness. Next?’

‘OK well. Issue number 4 is the recording of co-morbidities’
‘Co what?’
‘Underlying conditions.
‘Like Diabetes?’

‘‘Yes exactly that. According to our rule book, a co-morbidity is, and I quote, 'any condition which they have along with another disease that is currently being treated at the time the patient is in hospital or develops whilst they are an inpatient and affects the management of the patient's current admission.’ I was impressed that they had memorised the rule book!
‘OK I get that. So why don't you just record their chronic long term conditions then. Pips No. 2’ ‘No – we can’t.’
‘Course you can – go on’ I suggested with a hint of frustration.
‘No we are not allowed to!’ said Laura. ‘But you’ve got the notes. You can see they’ve got other issues. Just bung it in.’ I said ‘Simples’

Apparently not that simple, as James pointed out. ‘We are not supposed to code anything that hasn’t been recorded in the current episode. It is up to the doctors to record any significant clinical information. If they consider this current episode is likely to have been affected by an on-going condition, then they have to record it so. We are not supposed to. It’s in the rules. (See guidelines for coding and reporting here). It’s really frustrating. You can see the patient came in last week and you can see a list as long as your arm of co-morbidities on that episode which they have (diabetes, congestive heart failure, epilepsy, history of CVA....) and yet these underlying conditions have not been recorded as part of the current episode.’

‘And that can affect the Trust’s income’ added Jane. ‘It takes longer to treat a patient with underlying conditions than it does a fit rugby playing he-man adonis-like greek-god like creature with bronzed muscles on muscles…’

‘OK OK’ we get the picture Jane’ said Adam to Jane who had gone off into a strange place!

‘Oh I see.’ I said ‘But surely – the future’s bright with the electronic patient record we’ve been promised. Paperless by 2018 at the last count.’
‘Oh that! We’ve been promised that since – well, since Adam really was a lad!’ said Barbara. ‘What year were you born Adam?’
‘1993 actually! 23 next week’.
‘But surely with the electronic patient record, your job will be a lot easier’. I optimistically suggest (as I have been doing since Adam was starting Primary School in 1998!’)

‘Only if that EPR has some sensible structure and everything is brought together in one easy-to-navigate place’
‘I thought that was the plan?’ I added.
‘May well be the plan but the reality is not quite so slick. I’ve tried coding from an EPR up the road at the Uni hospital. They’ve scanned in their casenotes, so now instead of flicking through the paper, you have to scroll through 50 odd pages of scanned documents on an Electronic Document Management System (EDMS) and half of them are blank and all just to code an episode of just 2 days.’

Laura joined in. ’And it’s not all in one place. You have to log onto three or four different systems: The PAS, the scanned documents and the lab results. I ended up juggling all these different systems on two screens.... Tabbing between the Lab results system, then electronic patient discharge letters, then scanned letters from the GP and then opening up our coding system to add the codes to the patient’s current episode. I also have Google for researching the conditions I am coding. I need 5 screens and four pairs of hands. It actually took longer on the EPR because it is not structured.’
‘And then there’s SNOMED CT’ added James, as if we didn’t have enough to worry about.
‘SNOMED CT?’ I asked. (6)

‘Yes, we currently use the International Classification of Disease Version 10 and the intention, as I understand it,’ continued James, ‘is that clinical terms will be added to the emerging electronic record by the clinicians using the Snomed CT terminology. These will then be linked/mapped across to the ICD codes (currently version 10 moving to version 11 no doubt in a couple of years), these codes are for analytical use, financial and epidemiological uses and the coders’ role will change. Snomed CT is a very different structure with attributes and concepts and values of attributes and and ……..
‘….and I’m glad I’m retiring soon I tell you,’ said Barbara. ‘I’ve done my time. I’m not changing now for anyone! ’
‘Well for us it IS happening,’ Jane joined in. ‘EPR’s have to be in place by 2018 ready for SNOMED CT in 2020.
‘’………and I guess when I go, they won’t replace me. We’re all doomed’ added Barbara. This month’s two page column was rapidly becoming four and more like a Dads Army script!
‘Doomed I say! Drinks everbody?’ she ended with a flourish turning to the bar.

Jane took me to one side. ‘Most coders are scared they will lose their job when this long-awaited electronic patient record and the new terminology comes. Some of us think it will just change the role to more of a review/audit type of role rather than actually making them redundant.’
‘Yes - that was my understanding of this EPR,’ I added, ‘that the clincians would capture clinical words/terms electronically as part of the delivery of clinical care using live clinical systems in real-time using Snomed CT. But then my understanding is that someone (a qualified coder) still then has to go through this (now) electronic record and either assign codes using the rules of clinical coding or validate those codes that ‘the system’ has automatically applied’. ‘That may well be right but it doesn’t stop them from being worried’.said Jane.

‘So you Enigma lot, what’s the answer?’ I asked, turning round to them at the bar, and trying to bring the conversation to an end before the football programme did’.

Laura: ‘At present, we can only assign codes using the clinical data we have in front of us. If it is incomplete or incomprehensible, we can’t code accurately. If there are too many ‘ifs’ and ‘maybes’, we can’t code accurately. We aren’t allowed to go back and delve deeply into the records. If the clinician does not think an underlying clinical condition is relevant to this current episode or simply forgets to document it, then we are not ‘allowed’ to code it.’

One of them added ‘To be honest, I’m not convinced that all clinicians appreciate these implications. Clinical coding is not ‘just something for the managers’, it is essential to the efficient running of any Trust. It is essential for the funding of work done. But more importantly it is critical to get it right for the delivery of clinical care once the clinical terminology Snomed is introduced. In short, it is key.’

James:’ The new electronic patient record isn’t just a pulling together of lots of different computer systems into one view. It will contain coded information, free text; letters created on the PAS and other computer systems and not forgetting scanned documents. This 'record' has to have a structure that enables the users, be they clinicians or other secondary users, to find their way around it easily.’

'Otherwise it will take a lot longer doing any coding' added Barbara who looked like she'd just sucked a lemon!

Jane:’ Snomed is long-awaited but its introduction along with the new OPCS for coding operative procedures and then, in a couple of years, ICD-11 will have huge implications. I mean we’ve actually only just implemented ICD-10 ! These changes should not be underestimated – they have the potential to be a major upheavel for everyone’

Adam: ‘I wish I were a lad again!’

Barbara: ‘Glad I’m leaving soon!’’

The television inevitably drew my attention back like a moth to a light. Gary Linekar was interviewing Bobby Charlton. ‘How do you think your England team of 66 would have coped against Iceland’?
‘Oh wed’ve won 1-0’
‘Only one nil? Surely you would have scored more than that?’
‘Well, we are all over seventy now’ he said.

Vrey fnnuy

References

1 http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.470057
2 Cleaned up a bit! 
3 Cleaned up a bit more! 
4 https://www.washingtonpost.com/national/health-science/there-really-are-50-eskimo-words-for-snow/2013/01/14/e0e3f4e0-59a0-11e2-beee-6e38f5215402_story.html
5 https://www.theguardian.com/healthcare-network/2015/jul/17/clinical-coder-like-being-detective-nhs
6 http://systems.hscic.gov.uk/data/uktc/snomed

ICD 10 Coding used:

Sore throat (unspecified) - J02.9
Influenza A – B J10.1
Meningitis - G03.9
Viral throat infection - J02.8 + B97.8
Staphyloccocal throat infection - J02.8 + B95.8
Pain in the neck - M54.2

Back @ the EPR Arms: March 2016 Paperless by 2018?

‘She’s been at it for thirty years has our Thelma. Thirty years I said. Thirty years!’

‘At it? At it? At what?’ asked Louise?

‘You know. Medical records. Pulling notes. Filing notes. Lifting notes….’

‘Finding notes’ said a grumpy voice from across the table. ’Under consultants’ desks, in secretaries’ ‘secret’ hiding places. Stacked up behind cupboards. In coders’ cupboards absolutely anywhere. Flipping anywhere!’

‘Pushing notes in a trolley from the dusty basement to the records prep room to the clinics. Thirty years I say thirty years.’ continued Lorraine picking up her glass of chilled chardonnay.

‘Ay – haven’t we all’ said Louise slurping her vodka tonic and swirling the ice cubes round and around.

‘Well – no’ corrected Lorraine, ‘I’ve only been at it twenty years. I’m a relative newbie!’

They all giggled at that. The medical records staff were sat round a big table in the pub after work on a Thursday. It was Thelma’s last day. This after-work gathering was a rare occurrence.

‘Grab us a sausage roll wilt Suze’ shouts Lorraine to the queue at the buffet in a grating Yorkshire accent.

‘She started when she was 16 – straight from school. Had a 10 year brek for babbies but all in all 30 years she’s done. And now she’s free. Free I say! Free!’ Lorraine sounded like she’d just watched her best mate tunnell out of either Tom Dick or Harry in the Great Escape. ‘And what’s she got to show for it eh? A mouldy buffet with curling sandwiches and flakey sausage rolls. Oh and a clock. A clock! I ask you who wants to watch the time when you retire.’

‘It’s been a long thirty years’ says Thelma joining the group and pulling up a chair with one hand while balancing a plate of sandwiches with her other. ‘I remember when we were told we were going paperless.’

‘Oh by Jeremy Hunt? Paperless by 2018 he said’ reported Louise.

‘No not the Hunt – way before that. In the 80’s then the 90’s. Another hint in the noughties and again in the whatever we call ‘now’’ ‘The teenies!’ shouted someone coming over with a big bendy sausage roll in her hands.

‘Thanks Suse. Teenies? Is that where we are now? I like it. We are the oval teenies’ giggled Lorraine.’That teks me back’

‘Who are you calling Oval!’ said a large woman joining them with four pork pies.

‘……and you weren’t even in the war!’ corrected Louise.

‘Feels like I have been. Anyway, where was I? Oh yes. They’ve been threatening us with going paperless for yonks. Ever since Adam were a lad’ said Thelma

‘Our Adam? He still IS a lad !’

‘No – I mean Adam and Eve’s Adam. I mean, like, yonks ago! But still we’re pulling notes’

‘And filing them’ joined in Suzie

‘if you can find them’ repeated the same grumpy voice from across the table.

‘And prepping them’ said Adam. The token male of the group.

‘….and wheeling them’ mumbled Lorraine through a sandwich.

‘…and filing them again.’

‘I need a drink!’ said Suzie. ‘Want one Thelma? Another special ‘last-day’ glass of wine?’

‘What another one? I’ve still got two waiting for me. But go on then. Why not. It IS my last day isn’t it. But I’m gonna miss you all’ said Thelma with a hint of dampness at the corner of her left eye. She was either sad or had the beginnings of conjunctivitis. ‘I hated the job but I will miss you lot. I’ve seen more of you than I’ve seen of my Jack over these last 30 years.’

May not be conjunctivitis, (conjunctivitis (unspecified) H10.9). It could be Meibomian gland dysfunction (MGD) (Not sure of that code. Not used it for a while) thought a psychic clinical coder who had just joined the group with her glass of claret and a carrot.

‘Oh hello Michelle. How’s coding? Cracked it yet?’

Michelle was expecting another Bletchley Park jibe but didn’t get one. She quietly nibbled her carrot stick instead.

‘Good buffet Thelma ! You’ve been here a long time haven’t you?’ said Michelle as she raised her claret.

‘Aye lass she has and I bet she’s got lots of stories to tell,’ said Lorraine ‘….but she wont be here to tell ‘em no more. You’ll be sun-bathing in Spain or Italy or Cornwall won’t you Thelma?’

‘Huddersfield more like! And there’s no sun there !’ said Thelma. ‘I’m going nowhere. I will miss you – my mates. I really will’ ‘Well – listen, here’s an idea. Why don’t we all meet here once a month – on a Thursday - straight after work, and put the world to rights?’ Do you mean like a Thelma’s Thirsty Thursday night. Wouldn’t that be good?

‘And what will we talk about?’

‘We’ll think of something. You lot are always going about something or other.’ said Thelma, warming to the idea. ‘We won’t have any problem finding topics to discuss. In fact, why don’t we ask the readers of the blog to suggest topics?

That’s it, dear reader. Email your suggestions for the Thelma’s Thirsty Thursday to This email address is being protected from spambots. You need JavaScript enabled to view it. and every month we will join them all at the EPR Arms. Good idea?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Back @ the EPR Arms: July 2016 Medical Images

'Jimmy come over here and join my selfie'.

A crowd from the hospital gathered around another smiling leaver - Jimmy Rainsford. They were dropping like flies these days. All ‘Boomers’ ready to start their new life of bliss and pensions. Lucky blighters.

'Here Mate,' he said to me, 'can you take us a selfie'
'Hardly a selfie then eh?'
'Arms ain't long enough Bud'
'OK. Right. Now then. Say ‘Cheese!'’ I frame them all in the viewfinder.

Norm, the uni lecturer who knows everything there is to know about anything, sauntered over to me.

'Do you know, saying ‘cheese’ makes your mouth smile for the camera, but in Spain they say Patatas (Potato), in Argentina it is the English word - whisky and Bulgaria its Zele (Cabbage). (For more of these see https://en.m.wikipedia.org/wiki/Say_cheese )

'Ta Bud!’ said Jimmy. ‘I'll Fb you the photo unless you wanna Bluetoof now'

Fb? Bluetoof? Another language. Another lifetime. Another beer.

'Another beer Norm?' I asked tilting my near empty glass his way.

'I'll just 'ave half thanks.' he said following me to the bar pointing at the middle tap. 'That one. Leafy Dock. New. Sounds good. Nettle after taste. 5.5% will do for me'

'It's another world Norm: Selfies. Instantly up there on Facebook or Instagram or Twitter. Another world. And it’s caused a real ‘stooshi across the road’

'At the hospital?’ he asked, ‘in what way?’ licking the nettley froth from where Bill the barman had been sloppy. 'With patients or staff?'

'Staff - of patients. It's a bit easy isn't it?’ I continued, ‘See a rash or a bed sore. Click. Done. Don't bother the Medical Illustration Department – even if you had one. No need to wait. Click. E-mailed to yourself. Sorted.’

‘And the problem is……………?’

'There isn’t A problem Norm. There’s loads of problems’ said a voice which belonged to a pretty woman entering our drinking space.

‘Lucy!’ said Norm.
‘Lucy?’ I queried
‘She’s the Medical Photographer over at my Uni hospital up in the City.’ continued Norm.

‘Yes there’s confidentiality issues- how do you control who is looking at the photo. There’s consent issues: is the patient happy to have their photo taken and how can it be used. Then there’s quality issues. I mean, you can’t just take a photo – SNAP! - and that’s it can you? Are you getting the drinks in Norm? Lime and Soda for me – I’m driving. And don’t get me started on videos.’
‘Videos ?’ I asked, thinking Blockbuster had made a comeback.

Stooshie – A Scottish word for row or commotion or fracas.

‘Surgeons videoing operations. A&E videoing Trauma events. Physios videoing before and after hip ops. The list goes on.’

‘Wow, I’d not really thought about all of this. I just assumed it would all be locked down and managed.’ I said.

Lucy continued ‘You see, many Trusts have got rid of their Medical Illustration Department and that seems to have left a real issue - a vacuum, which it appears is being filled by staff using their own cameras and phones. No-one is responsible for the management of these images and to be honest, most of them are of rubbish quality. Remember, these may have to be used as evidence in court. Out of focus is no good. And then there’s confidentiality’.

‘But hasn’t that already been sorted with your X-Rays? Can’t you simply adopt the same rules?’ I asked as Norm returned with a Lime & Soda

‘Not the same. You can’t identify someone from an X-Ray. Well not easily. There are photos in hospitals floating around the ‘ether’ or on personal cameras or worse still by mobile phones, which are not being managed. Photographs are taken in Dermatology, by staff, of patients. Taking them on the member of staff’s personal camera and saved onto their desk-top. Dental/Orthodontists take photographs of patients’ jaws/head. Podiatrists and Diabetologists take photographs of feet. Community nurses have been given smart phones to take photographs of patients in their own homes with bed sores. The list is endless. No control. No management.’

‘OK. So I see there is an issue. What would a good hospital actually do if they had a Medical Illustration Department? I mean, what does ‘good practice’ look like Lucy?

‘Well,, there is no official guidance from the NHS but there is guidance from the Institute of Medical Illustrators‘

‘The Institute of what?’
‘It’s our professional body.’

‘Go on then – run it by me’ asked Norm taking another sip of his beer.

‘Well, it is recommended that medical photography/illustration departments have a policy/protocol covering the handling of confidential material. It also goes on to say that clinical photographers should only obtain those illustrations that have been requested by the clinician and which the patient has consented to, and no others.

‘That’s seems sensible,’ as Norm drained the last of his nettles.

‘There’s more’ continued Lucy, ‘All digital images must be correctly identified and stored in an image database protected by passwords in accordance with local policy. Data should be regularly backed up to maintain its integrity and should be clearly marked with the level of consent given by the patient.’

‘Different levels of consent?’ I asked. ‘What do you mean?’

‘Well, you may be happy to share your photo for diagnostic purposes but not for teaching. Or for publication. Or anonymised for publication but not as part of your record.These images have many uses and not simply there as part of the diagnostic record. It’s complicated.’

I continued ‘,,,,,but looking at it from the other side Lucy, I can see why a doctor who is seeing a patient thinks he may as well take a photo rather than get the patient to come again to see you or your colleague with all those parking problems and getting time off work and all’.

‘Yes but even if the photo is a good, well taken one, there MUST be rules about gaining consent and they MUST be stored correctly and the quality MUST be appropriate and admissable in court. I can sew but it doesn’t make me a good surgeon does it?’

‘And those rules can be found at?’

‘The Institute of Medical Illustrators here

‘I need another drink. A full pint’ said Norm. ‘And less nettles this time. I think I’ll give the Deadly Nightshade a go. A dark mild if I’m not mistaken - four point eighter’.

‘Cheese!’ came the cry from the group at the bar as another memory was taken to be lost for all time – or worse still, not.

How does YOUR organisation look after clinical images in YOUR place of work? Isn’t this something we should be getting alarmed about? Isn’t this something which needs some top-down rules and guidance? Or do you think it is not an issue. Please email your thoughts to This email address is being protected from spambots. You need JavaScript enabled to view it.

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.

Back @ the EPR Arms: April 2016 To share or not to share: That is the question

‘He went to Wales I think. Angelsey. Somewhere foreign that’s for sure’.

‘Not sure Wales is classed as foreign Bill’ I said to the landlord.

‘Well – it’s a long way away and they speak funny!’ he replied while he emptied the pot washer. Steam gushed out like a rising cumulus cloud, momentarily fogging his glasses.

‘So when did you take over as landlord Bill?’ I asked while he cleaned his glasses with his pot towel which was still securely wrapped around his waist.

‘Oh about six years ago. You know the old EPR Arms shut in, what was it, 2004 I think. Just like that. No rhyme or reason.’

‘Didn’t it open again as a fancy wine bar or something?’ I asked vaguely remembering a period when it was all shiny noisy laminate floors and high tables and even higher stools. Not for me.

‘I ripped all that up and put it back to what it was. Even got the same real ales back. Badgers Crushed Paw Bitter to name just one’.

‘Tapas!’ snapped a regular sat on a stool at the bar. ‘Tapas in Huddersfield. I mean – how was that ever going to work. Only bottled beer. Only tiny portions. Little Plates. Big Prices. Died a death. I say died a death. Know your market.’ He looked (and sounded) a bit like Fred the Butcher from Corrie and coincidentally shared his name. ‘That’s it. Know your market. We want us beer. Good beer none of that fancy bottled fizzy muck wi’ a lime shoved darn its s’neck.’

He was warming to his theme of the old days. Any minute now, Fred would say it was different in his day.

‘T’were different in my day’ said Fred, not letting me down. ‘I worked darn’t’pit and on us way back home, I’d have us pint to wash’t muck awa. It were part of us routine. ’

‘See you later Fred’ I said picking up my pint of Badgers Crushed Paw Bitter and having a quick slurp to get me across the room safely. I spotted a rowdy lot coming across the road from the hospital, so I wanted to grab a seat before they arrived.

Fred stayed where he was – on his stool at his bar drinking from his tankard. Not many folk do that anymore do they? Old Albert (God bless him) sat in that place. The only thing different between Fred and Albert was that Fred didn’t have a ferret. Or a flat cap. The world’s moved on. Old Albert used to cause quite a storm in the old days but now ferrets, along with ciggy smoking, have been banned. I must admit I don’t miss either smell.

The gaggle crashed through the door and they were all talking at once. ‘Did you hear what she said – her from Manchester way? They’ve done some brilliant work sharing records across their social care and GPs and hospitals. Why can’t we do that eh?’

‘Because our IG lead won’t let us’ said one lad pointing to Robert who had been pushed to the front to get the drinks in.

‘Why not?’

‘Consent.’

‘What scent?’

‘Consent. To share a patient’s or client’s information they have got to say they are happy to share their information. We have to tell them who we are sharing it with.’ said Robert attracting Bill’s attention with a curious wave of his wallet.

I listened to this from afar.

I noticed one of the gaggle was someone from medical records. I’d seen her last month at Thelma’s leaving do.

‘Ay up Loz’ I said. Lorraine was happy for me to save my breath on her name.

‘N’athen. Hows you doin’?’ she asked – like Geoffrey Boycott in a frock.

‘Whats this lot then Loz? What’s occurrin’ I asked.

‘Just had a DFC sesh over road’ she said..

‘Fried Chicken?’

‘No – Dame Fiona Caldicott. DFC. All about sharing records or not.’ She grabbed her (large) Chardonnay and popped across the room to join me. ‘Thanks Robert’ she shouted at the poor harassed (and now considerably poorer) man who had got the round in. ‘Have you heard of the Caldicott Review? The Caldicott Guardians? The Caldicott committees?’

I admitted I had. Actually a pet subject of mine.

‘Well you will know that (Dame) Fiona Caldicott was initially asked by the NHS Chief Medical Officer (CMO) to come up with some rules about sharing patients’ information,’ said Lorraine, ‘Mmm a hint of apricots’.

‘That was yonks ago though wasn’t it?’ I said, thinking about getting my second pint.

’Yes, you could say that. The original report was written in 1997. It was a different world then though – you could say far more ‘paternalistic’ and much less patient centred. It was officially known as guidance on "the protection and use of patient information" and identified the issues and complexities……’

‘And tensions!’ I interjected.

……………’ of sharing patients’ information. Tension? What tension?’ she retorted.

‘Well, we have on the one hand the need to protect and maintain patient confidentiality, and at the same time we need to share information about our patients. A tension.’

‘Yes you are quite right. There were some staff who adopted the ‘Computer says no’ attitude and used the Caldicott principles to smother any good meaning intentions to share data – speaking of which …….’

At that point, the bespectacled and harassed man who had just been relieved of twenty two pounds thirty pence by Bill at the bar decided he needed to sit down.

‘£22.30 that’s just cost me! Anyway, I can’t share an individual’s data unless they tell me EXPLICITLY that I can do so on their behalf.’

He sounded just like a jobsworth nasally stamp collecting trainspotter.

‘But how do you know WHO will need to see that patient’s data?’ I asked, wishing I had replenished my pint earlier as this could be a long long session.

‘Consent! Plain and simple. I need to know they are happy for me to share with anyone we intend to share it with.’ I could feel my BP rising and I don’t mean the cost of diesel across the road.

‘I think you will find that DFC’s Review of 2014 actually clarified that Robert!’ I said rather more forcibly than I had originally intended. ’She actually actually said ‘over recent years, there has been a growing perception that information governance was being cited as an impediment to sharing information, even when sharing would have been in the patient’s best interests’. And not just with named individuals but anyone with a legitimate relationship and delivering Direct Care. Anyone.’

‘If they don’t want to share their data then they are quite at liberty not to do so’ he continued in a nasally voice that instantly got up mine the minute it had left his.

‘Loz added gently ‘She also said that services cannot work effectively without trust and trust depends on confidentiality. However, people also expect professionals to share information with other members of the care team, who need to co-operate to provide a seamless, integrated service. So good sharing of information, when sharing is appropriate, is as important as maintaining confidentiality.

‘But if they don’t want their data to be shared with a member of any clinical team then I cannot allow any of that patient’s data to leave my organisation.’ A forceful end to an increasingly forceful conversation.

‘Whoa Whoa Whoa’ said Lorraine.’ I think we all agree that we must take care of all data we hold. And when we share it, I think we all agree that patients must be happy for that data to be shared. DFC said that her overarching aim has been to ensure that there is an appropriate balance between the protection of the patient or user’s information, and the use and sharing of such information to improve care. The issue is, we do not know who will need that data, so we can’t ‘up front’ ask for that specific permission for any specific individual. We must simply ask the patient to trust that we will manage their clinical information safely and securely and only people who need to see their information actually do do’

‘Doo –doo?’ I asked. ‘Doo Doo?’

And that seems a good place to pop to the bar to get my refill.

What is your experience of these tensions dear reader? How have you managed it? How do you ask and record consent? What do YOU do if a patient refuses to share their data? I would be really really interested and I can bring it up in the next episode of Back @ the EPR Arms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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