New clinical lead expresses support for SCR
17 Mar 2008
Personal experience convinced a new national clinical lead (NCL) for Connecting for Health that electronic records were an important future development.
Dr Joe McDonald, 46, a consultant at South of Tyne and Wearside, who will be the new NCL for mental health, explained: “Two weeks before our wedding, I got a telephone call from an accident and emergency department to say my wife [to-be] Fiona had crashed her car into a lorry and was in a coma.
“I jumped in my car and drove the 20 miles to the hospital in record time. I arrived to find my wife awaiting neurosurgery. The staff were unaware that Fiona was an insulin dependent diabetic and was merely suffering from hypoglycaemia and a bump on the head. After the administration of glucose she was perfectly well in 15 minutes.”
He says that if staff had been able to access his wife’s records, they would have been aware that she was a diabetic, and could have administered glucose immediately.
“Electronic records strike me as a good idea. I am looking forward to the challenge of developing electronic care records in mental health, where every recent report into psychiatric disaster has pointed the finger at ‘failure to communicate’.”
Dr McDonald is one of eight newly appointed CfH NCLs, who CfH say will build on the current work being done to involve their colleagues in the National Programme for IT (NPfIT).
The new NCLs practice across a variety of medical fields including ophthalmology, pathology, diabetes, mental health, public health and medication management and represent their own professional groups.
Their role is to involve colleagues directly in developing the benefits the National Programme offers to clinical practice. They take up their appointments between now and April.
Dr Nigel Beasley, 43, a consultant Ear, Nose and Throat (ENT) surgeon and deputy medical director at Queens' Medical Centre Nottingham and Dr Robert Pitcher, 54, medical director trained at Treliske Hospital in Cornwall, will both be NCLs for hospital doctors.
Dr Adrian Scott is becoming a NCL for diabetes. He is consultant physician in diabetes and general medicine at the Diabetes Centre, Northern General Hospital, Sheffield.
Dr Gifford Batstone, 64, will be NCL for pathology. He works at Brighton and Sussex University Hospitals where he is also involved in teaching medical students.
Sharon Hart, 44, a freelance healthcare management consultant, will become NCL for medication management.
Mr John Sparrow, 53, will become NCL for ophthalmology. He has been a consultant ophthalmologist at the Bristol Eye Hospital since
Mr Sparrow has worked on and had published a range of national benchmarking and audit projects covering most of the common ophthalmological conditions, the most recent having been an analysis of Electronic Patient Record (EPR) cataract care data from 55,567 operations.
Finally, Miss Parul Desai will become NCL for public health. She is presently consultant in ophthalmology and public health at Moorfields Eye Hospital NHS Foundation Trust, and was clinical lead on the CfH ‘Do Once and Share’ Glaucoma programme between 2006 to 2007 and is the Clinical Lead on the ‘Eyes & Vision Specialist Library’ programme for the National Library for Health.
Miss Desai said: “As a consultant in public health in an acute provider trust, my epidemiological interests lie at the interface between community and hospital-based health services, principally in the areas of needs assessment, outcomes assessment, measurement and standardisation of clinical criteria, and clinical audit.”
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1 Anecdote falls at first hurdle17 Mar 08 14:01 >>The staff were unaware that Fiona was an insulin dependent diabetic and was merely suffering from hypoglycaemia and a bump on the head.<< Like many 'if only we had the SCR' anecdotes this falls twice at the first hurdle 1. It is negligent not to check the blood glucose on any unconscious patient in an emergency situation. This would have identified the immediate problem and enabled remedial action without recourse to any record. 2. Can the identity of an unconscious patient in an emergency be adequately confirmed to ensure that a search on a database of 60 million people has returned the correct record? 2 anecdote fails?joe.mcdonald@nhs.net 18 Mar 08 09:27 1) It is negligent not to check blood sugar in an unconscious patient, but it happened. I was there. 2) Fiona had enough ID on her for the A&E to contact me by phone. 3) If your wife is admitted to hospital unconscious (God forbid) how much information would you want the doctor to have?
3 i.d.18 Mar 08 12:27 Quite a few patients wear id bracelets/necklaces - perhaps this would become commonplace if people knew that it would provide access to their records in an emergency.
4 I love anecdotes19 Mar 08 22:27 Look at the one about the Therac-25, the infamous "they forgot to set phasers to stun" accident: Link
5 A poor example which undermines the NCRSgji@nhs.net 19 Mar 08 23:02 However, this misses the main point, that often the first diagnosis of any disease is when admitted to hospital in an acute crisis. This episode rather highlights a problem with the work-up rather than the lack of access to prior information. It is a common observation of experienced clinicians to find that in-experienced clinicians have relied on previous histroy to make a diagnosis, rather than consider a new diagnosis, or even challenge previous diagnoses. This type of story undermines rather than aids the support of the NCRS, which is a pity, as it will prove useful if implemented properly. 6 It's just an anecdotejoe.mcdonald@nhs.net 20 Mar 08 10:26 Fiona's story was just the reason I became interested in Connecting for Health. It's not the raison d'etre of NPfIT. I was until I recalled the incident, a fairly fierce critic of the program. Subsequently having become interested in it and done some reseach into it, I now believe electronic records can deliver a great deal to my patients. It still boils down to the question "if your wife/child/husband is ill , how much information do you want the doctor to have?". If you can honestly answer "none" then I guess you are against the Care Record Service and we will just have to agree to differ. 7 Good question - wrong conclusion!21 Mar 08 17:14 "am I more likely to be saved by central data when the clinicians treating me are incapable of doing the most basic test, or am I more likely to have my private life laid bare by one of the million or so who will have access so the record?" Who says the clinicians were incapable of carrying out the basic test? Results are subject to interpretation, if the patient is unconscious the clinician won't know whether they're looking at fasting levels or those of someone who recently ate a couple of Mars Bars washed down with coke. The WHO describes anything below 140 as normal - other sources state 99 as the maximum. With a shared record, clinicians would know the medical context before interpreting the results - or would order the test immediately instead of wasting valuable minutes eliminating other possible problems. How the heck would a million people have access to your shared record? Potentially they might have but would they have the motive or opportunity. Potentially 60 million people already have access to your GP record if they have a crowbar and a car, but similarly lack motive and opportunity. Please don't bleat on about MI5 or the police - if they want access to your records strongly enough believe me they will get it whatever system is in place. Even with the current immature NPfIT systems there are safeguards such as audit trails of user access details in place which would mean that anyone doing so is likely to get caught. As systems evolve, security will be tightened and the likelihood will reduce. Surely the balance of risk will reduce as we move away from the current plethora of unencrypted systems open to burglary and theft from cars. How many millions of GP records were sent through the post last year to GP system suppliers, loaded onto unencrypted CDs and backup tapes? How many GP systems still have "password" was the admin password? How many hospitals still tolerate the use of generic logons because they can't face the task of putting in place robust starting and leaving processes? eg username nurse1, password nurse1 - SHO1/SHO1 - bank1/bank1? 90% of the population rarely move far from their GP and local hospital but as one of the remaining 10% and as a patient with a couple of serious longterm conditions I would value anything that reduced the risk of me being killed by well-meaning clinicians working on the law of averages in a busy ED with a hypo full of meds which would be beneficial for 98% of people but deadly to me. I just hope Joe McDonald had his wife's express and informed consent to share the details of that particularly harrowing episode of care! 8 A final year student should know to check a glucose in an unconscious person22 Mar 08 14:35 It is absolutely standard practice to measure blood glucose with a near patient device in an unconscious patient. We do not need a CRS to teach good practice! It would have been FAR quicker fo check a blood glucose than logon to the national spine! Also I bet when they opened the lady's purse to identify her, there would have been an "I am in insulin dependent diabetic" card in it. There are many powerful arguments for a CRS, but lets use good arguments not bad ones! 9 its just an anecdotejoe.mcdonald@nhs.net 23 Mar 08 23:24 I see that people are against the idea of electronic records and hate the true story of how I got interested in the idea. Nonetheless, if your loved one is admitted to hospital in an emergency, how much information do you want the Doctor to have? None? Or slightly more than none? 10 Flawed assumptionscolin@clinformation.com 25 Mar 08 08:53 I'm personally quite keen on the idea of electronic records - held where most healthcare is actually delivered i.e. locally. However, I'd suggest that Joe Mcdonald's arguments for a wider SCR are based on several assumptions that are flawed, of which two examples are: 1. That attempting to provide NHS-wide access to individual clinical records is a better use of increasingly scarce funds that, say, tackling hospital-acquired infections or providing state-of-the-art cancer treatments. My impression is that my nearest-and-dearest are more likely to succumb to either (or both) of these than than from CFH's ongoing failure to deliver a national SCR. 2. That the clinical content of a national SCR will be useful and useable. Credible solutions to the issues of expressivity, representation, ambiguity, currency, definitions and shared meanings across professions have still to be provided. (And that's assuming that there are no technical problems associated with its sheer scale). Henry Ford said "Exercise is bunk. If you're healthy, you don't need it; if you're sick you shouldn't take it." I wonder if - for the SCR - "if it's not an emergency, you don't need it; if it is an emergency, you shouldn't trust it" might turn out to be the case? 11 NPfIT is not EPR25 Mar 08 11:22 "I see that people are against the idea of electronic records and hate the true story..." Unfortunately Joe suffers the same delusions we often experience with those involved with the National Programme. Their argument basically goes like this. Without the National Programme there will be no electronic records and the national programme is the only way of getting electronic records to work. Therefore anyone arguing against the National Programme is arguing against electronic health records. Of course once exposed this can be seen for the nonsense it is. Electronic records are already widely used across the NHS and are available mainly where they are needed, that is where the care occurs most often. Connnecting for Health introduced a new 'centralist' model which ignored the learning of over 20 years and assumed that one or two large suppliers were the panacea for poor communications. Many people who have been in IT for a large number of years, in my case over 20, are of the sincere opinion that the National Programme is simply unworkable. The model and strategy is wrong. It is actually a monstrous waste of money. There is another way of doing the same thing. Meta data stores using internet technologies could allow search faciltiteas against local standard data for example. This could easily look up and transfer data on the odd occasion when it is needed, rather than build one giant database. The standards approach has never been properly looked into because NPfIT simply won't countenance any alternative. It is my personal belief that, despite what anyone does or says, or how much money is pumped in, the centralised Care Records Service will never work in the format being proposed by NPfIT. Now I might well be wrong, but I certainly do believe electronic health records should be shared and I do care about your story, Joe. 12 re NPfIT is not EPR25 Mar 08 14:09 Here in Yorkshire and the Humber we have SystmOne as part of the strategic solution. This will provide a single system delivering all Community Nursing, Health Visiting, Specialist Community Nursing, Child Health, Therapies and , so far, 30% of GPs. We are now looking at how we use that resource to support diabetes care accross Primary and Secondary care and how we can use A+E access to the system to improve emergency care. Both of these examples go to the core of the discussion. Access to the record by A+E would have immediatly flagged up the patients diabetes staus. What is more a discussion with a local A+E consultant was about how, with access to community nursing systems, he could avoid admitting elderly patients and reduce the risk of them getting hospital aquired infections. Is this NPfIT? Is it EPR? Who cares! It is about using the tools at our disposal to generate improved services to patients. It almost twenty years since I came across an attempt to generate standards for exchange of patient information. We have spent too long trying to find clever ways to bolt together heterogeneous systems in order to pander to the "not chosen here" view of the world. We need to select a small number of appropriate systems and start applying them to the job in hand. 13 Re: Good question - wrong conclusion!27 Mar 08 21:16 That's the problem with anecdotes like this - without the associated medical knowledge non-clinical readers of the anecdote assume that the SCR information was useful. The blood sugar of someone in a hypoglycaemic coma is not high, it is low, and it is not on any threshold of normality. Furthermore, even having found sufficient ID to look up the SCR you would still have to check the blood sugar - so checking the SCR would just slow down the treatment. As for "who would bother to check your record", just look to the passport agency in the US and presidential candidates, celebrities in hospital having their records checked, the apparent ease with which people can access the PNC and DVLA databases, the "special arrangements" for tax returns of politicians and the famous. So long as you can be sure you will never become famous - or notorious - or annoy anyone in the health service - then don't worry. 14 SCR et al28 Mar 08 14:33 I have to say reading the comments directed at Joe here I am staggered by the almost vitriolic condemnation of what essentially is an idea designed to aid all our loved ones and ourselves at the time we need it most ... when we are ill or in need of emergency care. If more of you actually put your energies into putting forward constructive answers and less time undermining proposed solutions or ways ahead on this we'd reach our goals a great deal faster! 15 Risks outweigh benefits: Confirmed.drpaulthornton@nhs.net 28 Mar 08 14:34 Contributor No 4 to this thread, “I love anecdotes”, asks the most pertinent question. “I wonder if anyone has assessed the risk of people avoiding health services because of the fear of loss of privacy?” He will be pleased to learn that such a study has indeed been done. He will be reassured that he is in contact with reality because it supported his “guess” that “more lives will be lost because of this than saved in extraordinary circumstances”. Indeed the risk-benefit analysis was commissioned by Connecting for Health and involved some of their leading protagonists. The results should have precipitated a redesign of the project. Predictably, it seems to have been ignored by the project leaders at the time. It is not too late. The analysis is at http://tinyurl.com/y8yh54 And was initially reported here at http://tinyurl.com/2tj5fp Though belated, I welcome the clinical engagement that should follow from the recruitment of more clinicians from across all the specialties into the higher echelons of CfH. The concept of a single detailed care record for each patient across all specialties , all departments and even all institutions in a “locality” is fundamentally flawed. There is still time for the CfH infrastructure to be redirected to the provision of discreet and discrete databases that provide the particular facilities required by each department, including the ability to push focused, targeted information that is, in DPA terms, “relevant, necessary and not excessive”. 16 Is this true?GooderhamEP@Cardiff.ac.uk 28 Mar 08 16:59 Blood glucose measurement stat is part of managing the unconscious patient in A&E. If true, this anecdote demonstrates poor management and is not valid support for the SCR, and its associated cost and confidentiality issues. 17 Odd anecdote28 Mar 08 18:06 The anecdote is rather odd and certainly not supportive of a centrallised record for the variety of reasons so eloquently described above. I think the clinical leads will need to establish some integrity by listening to the concerns of the various clinicians that are expressing them and showing that they are relaying up to their superiors. In this case it was a mistake to demonstrate the issue in this anecdotal way, as any criticism made is taken personally and I am sure that is not intended by anyone. 18 Is it true? Is it odd?joe.mcdonald@nhs.net 31 Mar 08 13:48 Yes its true. Yes its odd. But it happened. I was there. I dont mind people having a pop at NpFIT but I do get a teeny bit peeved when people imply that I'm a liar. The Instituteof Health Improvement in the States estimate that there are 100,000 deaths a year caused by avoidable medical mishaps. I believe electronic records will make a contribution to lowering that number. For those people who have a condition which is likely to render them speechless (like my wife) the SCR is jolly good thing. I also think that Connecting for Health have moved smartly in the right direction by bringing in more clinicians to help steer the project and involve frontline clinical staff. Cheers. Joe national clinical lead for IT (mental health) 19 Risks outweigh benefits: <
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