Informing Healthcare – a public health and clinical perspective

Ronan LyonsProfessor of Public Health Medicine UWCM/UWS

Honorary Consultant Swansea NHS Trust

The problems with poor information and communication

• Time wasting and frustration: – Booking appointments– Obtaining results, discharge summaries– Writing unnecessary letters– Duplication of existing information

• Danger to individual patient care– Illegible writing, wrong doses– Missing information on diagnosis/treatment

• Danger to population health– Inadequate response to individual/public concerns– Poor planning to meet health needs

What information does a clinician need about a patient?

As much as possible about his or her:– problems– story– concerns– preferences– past history– social background– medication– progress, including treatment by other

practitioners…….

……all in an 8 to 20 minute consultation, during which the clinician also needs to examine the patient, explain the diagnosis, formulate and discuss a management plan and arrange the next steps

…..The clinician also needs to know about his/her services

• What are my waiting times?• What are my outcomes?• How well are my patients doing from my perspective?• How well are my patients doing from their perspective?• What is the overall performance of my service?• What cases are my trainees seeing, and with what result?• What changes do I need to make in the service?• What will be the impact of these changes?

…..and the service provided by others

• What services are available?• What are the interests and expertise of the provider?• How well does the service perform?• What are the waiting times?• What is the procedure for referral?• What should I tell the patient?• How do I seek advice without referral?

The patient also has needs…..to

• Book a timely convenient appointment• Know what to expect when seen• Have confidence in the service and the

practitioner• Know that their beliefs and concerns are

understood• Avoid unnecessary repetition of information • Look up and have confidence in further

information about their diagnosis or procedure

During a recent RCP pilot of an audit template, the records of149 acute medical admissions in 5 hospitals were evaluated….

Audit of records and communication

Entries

2292 entries from records of 149 admissions 8% - not signed 9% - not completely legible 11% - undated 57% - failed to record the time 73% - no author’s name in capitals 83% - most senior person present not

identified

Discharge Summary

Of 87 printed discharge summaries present in the notes, omissions included: 17% - diagnosis 19% - procedure 21% - follow-up arrangements 75% - information given to patient

Validity of Hospital Episode Statistics: procedures

Validity of Hospital Episode Statistics: procedures

• 6 million operations were recorded last year on HES for England, but only 61,833 anaesthetics

• We have compared PEDW with local data on gastrointestinal endoscopy activity in Wales in 1992, 1996 and 2000

• Missing procedures were 33%, 21% and 7%

Why these problems?Why these problems?

• Medical Record“Accurate coding requires the

active involvement of doctors in defining precisely what services were provided”

Setting the Record Straight A Study of Hospital Medical Records Audit Commission HMSO 1995

What’s inside the folder? A case note study…...

Based on the notes of a one time NHS patient in Wales

Forms - Administration

• HMR 1 (W) 83/undated Identification sheet/summary• HMR 1 W (IP) undated Identification sheet

(casenote copy)

• HMR 250 WKX undated Admission form

• WQN 2001 undated Personal possessions

Sheets for clinical recordings

• HMR 4(a) WL History sheet - one• HMR 4 b (W) Continuation sheet• HMR 100 W Standard mount sheet (gummed)• HMR 111 (W) In patient medication• HMR 6 (W) Anaesthetic record• HMR 302 (W) Nursing preoperative check list• HMR 200 (W) TPR & BP sheet• HMR 5A1 (W) Operation consent by patient• HMR 210D (W) Diabetes chart• HMR 210A (W) Daily intake - output chart

Locally generated forms

• Neurological observation chart

• Trauma chart

• Gastroenterology outpatient form

• Rectal bleeding form

• Physiotherapy assessment form

• Incontinence assessment

• Dietetic assessment

• Theatre form

A few request forms:

• Consultant opinion

• Physiotherapy treatment

• Removal of sutures

• Follow-up appointment

• Appliance request

• Occupational therapy

• Self injury referral

• Referral to social worker

• Request for radiology

• Microbiology

• Histology/cytology

• Chemical pathology

• Special test

• Blood transfusion

• Haematology

• Special diet

• Drugs to take home

Forms for the transfer of care

• GP referral letter

• HMR 2D (W) Discharge summary

• Transfer of care form A

• Transfer of care form B - check list

• Formal discharge summary

• Physiotherapy report

• Outpatient letter

In summary: A plethora of forms

• 47, all different

• Many loose & not in date order

• No integration of perspectives

• All need demographic details

• 26 ask for clinical information

• 9 request a diagnosis

There are many issues to be addressed if this is to be achieved, including…..• Culture change

• Education and training

• Professional consensus

• Patient involvement

• Standards - clinical and technical

• Confidentiality and security

• a single record for each patient - common screens, technical and clinical standards

• patient focused information• clinicians taking responsibility for clinical data

validity• local information laboratories where information

can be extracted in a secure, skilled environment• a single national information agency for

aggregate data requests and reports• a common sense approach to confidentiality• built in evaluation as progress is made

The vision in Wales…

Summary

• An exciting strategy

• Potentially huge benefits

• Many hurdles, but

• Achievable and worth the pain

• Status quo is not sustainable