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.
I walked - nay slid, through the rain that had frozen to snow which in turn had warmed to slush as I turned the corner which would deliver me into the arms of the EPR.
As I took that corner, I could distinctly hear the seasonal tones of well played brass. A sound that tells me the shopping days to Xmas were reducing at a pace. I detected some wassailing1 too from the hospital choir. Once a year, all is forgotten with all tensions being put on hold. Whether a porter, cleaner, manager, nurse, doctor, OT, Physio, Radiology or Admin matters not a jot because they are all singing from the same carol sheet. Austerity paused. Brexit put on hold - for one night only!
1 The tradition of wassailing (alt sp wasselling) falls into two distinct categories: The house-visiting wassail and the orchard-visiting wassail. The house-visiting wassail is the practice of people going door-to-door, singing and offering a drink from the wassail bowl in exchange for gifts.
The Sally Army band always does this NHS gig and together with the hospital choir they start off in Outpatients foyer then meander along the corridors, pausing outside the wards, and finally playing and singing outside A&E before crossing the road to ‘do the street’.
Each and every pub and shop is targetted and in every pub, the well-oiled festive revellers dig deep. No doubt feeling that they are playing a part of a real live Christmas Carol. Imaging little Tiny Tim’s face when Scrooge appears with the goose held firmly in his ink-stained wrinkley hands - a goose bought with their donations. Life’s sadly not quite like that, but these charitable endeavors certainly bring smiles to everyone’s faces, as they remember there is always someone worse off than them.
I see the band and choir getting ready to cross the road, so I speed up just a bit to get in before they do. Bill is back behind the bar again after Trev, who had been acting as locum while he took his pre-Christmas hols.
‘Hows things Bill? Busy?’
‘Steady away Lad. Steady away’. (That’s Yorkshire for ‘yes it’s OK. Not too busy but people keep coming and going at regular intervals imbibing in my lovely alcoholic beverages. Thanks for asking.)
’So, have you had a good break?’
‘Yes just six weeks in the sun. And what a time to do it eh? Just as the weather goes all ‘Pete Tong’ over here!’
‘You can say that again. A pint of your best Badgers please before the Sally Army gets here’.
‘Oh yes – it’s that time again isn’t it. Do you know it doesn’t seem like a year since I was trying to get those pine needles out of the carpet! Plastic this year. Plastic I say!’
‘Good King Wenslas looked out on the feast of Stephen’ came floating through the cracks in the door a minute or two before the Sally Army and choir made their entrance.
‘Thanks Bill’ I said quickly taking my pint and looking around for a free chair. It was a busy night down at the EPR Arms. Folk staying behind after work for a quickie before venturing home. There was a group in the corner from across the road with a couple of spare chairs going begging. I remember them from another night in the bar - Medical Records I think, with a hint of coding.
‘Loz! I said 'How are you doing?’ I said pulling up the spare chair.
‘Fine. Fine. Even better now ‘cos I’ve done for Xmas. Two full weeks off. Wa-hey! Do you know the others? Michelle the coder with Jane and James. Same business-coding.’
‘Hi there. Merry Xmas! Busy time isn’t it with work and then all that shopping and kids getting excited and stuff’ I said to no-one in particular but Michelle grabbed it.
‘Actually I love this time of the year. It’s the only time I can get my kids to behave! ‘If you want something from Father Christmas then make your bed. Eat your tea. Sit quietly.’ The list goes on and on.’
‘Or threaten them with Santa’s Radar!’ added James.
‘What?’ we all asked.
‘My uncle tells his young children that the house alarms motion detectors in each room,you know, the thing that goes red if you walk passed it, well - he says that’s Santa’s radar and he is keeping an eye on all children to make sure they are behaving!’
‘That is SOOOO cruel’ was the collective response.
‘Come to think of it, he’s the same Uncle who tells his kids that Ice Cream vans only play that tinny music when they’ve run out of ice cream. Bit of a miser my Uncle’
‘And you remember Louisa from Records?’ continues Loz seamlessly.
‘Hi there Louisa. Isn’t this nice? All cozy and warm and seasonal. Roaring fire. Love it! Love it! And now the Sally Army and hospital choir to finish it off. What more could you hope for?’ I asked (I thought) rhetorically.
‘A job - that’s what!’ said Louisa.
‘But you’ve got a job haven’t you?’
‘Yes but my job is in medical records. You know? Where the PAPER records are. And guess what - they are getting rid of the paper record!’
‘Not till 2018’ said James.
‘2020 now’ added Jane.
‘I’d heard it was 2022’ contradicted Loz.
‘Actually 2023 is the latest’ I added my threepence worth.’ So things are not as immediate as you think Louisa’.
The First Noel, the angels did say, was to certain poor shepherds in fields where they lay’.
I need to nip this one in the bud or all the seasonal bonhomie will be out the door. ‘Well, for a start it will take a while yet. As you said yourself, it’s like chasing a rainbow: as soon as you get close to your crock of gold, it moves on. And so the date for going paperless is constantly shifting. And anyway, whatever happens, records still need to be managed. Getting rid of paper does not get rid of the need to manage the records. An electronic record is still a health record - just in a different format, so all the good practice still needs to apply. It won’t ‘just happen!’’
‘In what way?’ Louisa asks.
‘Right - Well. Access to the record. Who is going to manage that? Who knows (and understands) the rules about access to records? You do –that’s who. And who knows what bits you can show and which you can’t? And who has a legitimate right of access and who doesn’t? And what you actually are allowed to share? And how you record the complicated stuff like gender re-assignment and visitors to the NHS? And who knows how long to keep them?’
‘Keep them forever innit’ said the young Mark I hadn’t seen in the corner. One of the IM&T Department’s support team ’When Man first landed on the moon they had less computing power and storage memory than I had in my last but one mobile- iPhone 5. Storage isn’t an issue any more. We can store electronic records for ever. No more culling. No more destroying. End ov’
‘AH yes Mark but are you ALLOWED to keep them forever? Don’t you know about the Data Protection Act?’
‘Just because you can technically and physically store them forever doesn’t mean you should.’ continued Louisa.
‘But if you can, then why wouldn’t you?’ said Michelle Coder, joining in. ‘If we want to understand the complete patients holistic lifetime clinical journey, surely we should be able to access ALL their record from birth onwards’.
‘Yes but again, it all has to be done within the law. If it’s illegal to store everything forever then it’s illegal to store everything forever’.
‘In which case the law is wrong!’ added Mark.
No one actually argued with that.
You see, that little interraction demonstrated the ongoing need to have people that understand records and their management. And don’t get me going on the actual structure of these electronic records!
‘You should be in there in the middle of whatever is going to replace your paper Louisa. You should be providing that expertise. Don’t just leave it to the teckies. They’ll just scan everything into a single massive PDF file. Most of them don’t actually understand record management. You do!’ I aimed that at Louisa or anyone else who was listening.
‘OK OK a fair point. Perhaps the pictures not as bleak as I thought’said Louisa.
………‘Snow was falling snow on snow, snow on snow’……..
‘It will be if you let it be’ I added. ‘And you Coders,’ I said swivelling on my stool to James, Jane and Michelle, ‘what does the future hold for you? You’re not going to be doing clinical coding in ten years’ time are you? Where are you going?’
‘Coding Auditor I reckon.’ said James.
‘Coding teacher’ said Jane.
‘Actually I don’t know,’ said Michelle. ‘I might actually do something completely different. Something in this new world of electronic records. I might do one of them there Informatics exams. New career might be my way forward. I don’t want to wait till I’m pushed out.’
‘Good plan,’ I said, ‘Why not. Get on the front foot.’
As the band and choir crept out to the dying strains of ‘In the Bleak Mid-Winter,’ a tired and damp looking elderly chap with a ruddy face, bushy beard and a red coat with well-worn leather boots came over to bagsy the spare stool (or buffet as they call them in Yorkshire – which might be confusing when someone shouts ‘the buffet’s ready’).
‘It’s pronounced Buff-it NOT Buff-ay’ said a Yorkshire translator usefully.
‘Mind if I join you? I’ve just finished my shift’ said the man in red.
‘Be our guest’ said Loz, ‘Shift where? Making childrens toys in Lapland by any chance?’
‘Toys? Lapland? No – at t’post office. I work forT’ Royal Mail. A postie. Have done man and boy. Rain or shine. Forty years. As I wuz comin’ in I heard you talking about losing your job. You know, I’ve been terrified of losing mine ever since that T’interweb started up. I mean, who needs a foot-slogging Postie when you’ve got email and text and WhatsApp and Face-off and LinkedUp and Snapface and all them stuff? ’
‘Good point’ says Mark, ‘and almost right! So how come you’re so tired and still working?’
‘Cos actually because 16 billion letters still get posted every year. Granted it’s down from our peak of 20 billion in 2004, but now they’ve added parcels to us round. What I lost in letters I med up for with all those packages from Amazon and ‘Not on th’ igh Street and ….It’s all gone mad.’
Louisa started to reminisce about the old days: ‘I remember when I used to order things from the paper or magazine. Titbits or Womans Own or something like. There would be a £5.99 delivery charge for something that cost a tenner and it would take 28 days to get to you. 28 days I tell you!’
‘Like those two footed slippers?’ joined in Louisa smirking. ‘I was almost tempted to try those.’
‘No – I never actually bought one of those. But now you can even get stuff delivered same day – same day!’ said Jane. ‘I mean – where’s the fun in that? I used to enjoy waiting for the delivery but now, I see what I fancy and click, it’s ordered and ding-dong, it’s arrived. No time to change me mind or what!’
‘We still and always will need ‘stuff’’ joined in James.
‘So in these last 15 years my job’s changed.’ said Mr Postie.
Yes, I thought. All our jobs have changed. When I first started work in the laboratories in the NHS, we used to do pregnancy test by concentrating the patient’s urine and injecting it into mice for four consecutive days. Every NHS hospital had an animal house. Nowadays you just need to lean on the chemist window and they can tell you the time and place you actually conceived. OK maybe not the place! Laboratories are now a very very different place to what they were, but they still need staff, albeit for roles that no longer involve fluffy/furry creatures...
‘I think the management of records will continue to be critical in the future and the IM&T guys don’t ‘own’ this role. Records, be they electronic or on paper, must be actively managed. It will not just ‘happen’ and for this to be achieved, the NHS needs staff with those record management skills. So Loz, don’t worry. It will take years and years and there’s always a place for you in the same way there will always be a role for you Mr Postman’
‘Ay – ‘appen. But if not, I reckon I could always get a job as Santa meself eh?’
And with a Ho Ho Ho he shuffled towards the door swinging his now empty sack behind him ‘And a very Merry Christmas to you all!’
As one we raised our glasses and clinked where we could and echoed
‘Merry Christmas to you all.’
And as he opened the door to slide his way down the road, the disappearing brass and choir sounds of Christmas were drowned out as Noddy Holder took over on the JukeBox with a less subtle IT’S CHRISTMASSSSSSSSSSSSS !
And so to you, readers of this EPR Arms column/blog and members of IHRIM, you too have a very Merry Christmas and a prosperous New Year. And look to the future now – it’s only just begun
‘Ay Up lad!’ said Fred as he let me go first to open the door of the EPR Arms, ‘You’ll have tae gee yit a whallop! All tha’ sun then’t rain then’t sun. Swelled it annit!’.
You don’t need to go abroad to hear another language. I pushed the door and it didn’t budge.
‘A bigger whallop than that yer Jessie!’
I kicked the bottom of the door and simultanously pushed with my shoulder.
‘Tha’s better lad!’
And I was in.
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.
"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
'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 available here 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?
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.
‘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”
“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.”
“Yip. Clever innit? The ‘lectricity flow across the milk is affected by things like 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.’
‘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!’
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.
‘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’
‘‘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’
‘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.
2 Cleaned up a bit!
3 Cleaned up a bit more!
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