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Chapter 12 - Education and training

12.1 Why education and training are important

The use of computers is becoming ever more prevalent in our daily lives. Their design is growing ever more intuitive and in many settings people are used to a 'just get on with it' approach to using a new machine or system. This approach is not appropriate for large-scale initiatives such as using electronic records in health care. This has been recognized for some time, as is shown in this quote from a literature review, commissioned by the NHS Leadership Centre, from the Henley Centre:

The main factors in the success or failure of the introduction of IT-led change initiatives are clearly shown by the evidence to be the human elements. It is not the technical aspects that cause major IT projects to fail but the 'people' aspects. Unless these are tackled from the outset, there is little likelihood that IT projects will be successful. This is true not only in health care systems but also in other public sector enterprises and the private sector, and not only in the UK but also internationally.

- Williams (2004)^1

Similar points are made in UCL's independent evaluation of the SCR^2, particularly in sections *7.3. The SCR: 'Plug and play' technology or socio-technical change? and 7.4. The change model: 'Make it happen' or 'let it emerge'? *

Sadie Williams and Trishia Greenhalgh are referring to 'engagement' and their comments are made in a political and social context. These themes, when expressed as motivation and learning climate, are familiar to educators.

Social and affective aspects of learning are at least as important to a curriculum as is content.

12.2 Learning needs

Aside from these 'hearts and minds' issues there are two particular aspects of electronic health records that demand attention and require specific education and training.

The first relates to the main theme of this version of GPG: i.e. interoperability. This is dealt with in detail in the report from the Shared Records Professional Guidance Project[^3]. Records are no longer written primarily for the benefit of the clinician who writes them and his or her immediate colleagues. Elements of the shared record may be read, and relied upon, by clinicians in other teams in other locations and in other professional groups, often at considerable distance in each of these dimensions. They also may be read and relied upon by the patient. When care is shared in this way the record is a form of communication that does not merely impart data and information. The communication may also convey expectation. For instance, a clinician in a single contact with a patient may prescribe a medication (such as an ACE inhibitor), which requires subsequent monitoring. It is essential for patient safety that this expectation is passed on and understood. It's possible to design systems and care pathways so that the expectation and the need for subsequent clinical monitoring is clear to all users purely from the way the information is presented on the clinical computer system. More commonly, such transfers of responsibility are implicit in the ways of working of local teams: the clinical record is written in the context of this local knowledge and understanding. This requires the clinician to be able to make technically correct coded entries while at the same time being aware of the contexts within which the record entry is written and later read.

The second imperative relates to the way that information, particularly coded information, is displayed by clinical computer systems. Even the youngest and most computer literate of clinicians have been brought up with paper documents. On paper, position on the page and the spatial relationship between different elements of text are part of the context that contributes to meaning. Clinical computer systems re-present items of information in different spatial relationships. As a consequence, things that appear to be clearly understandable on one screen view may not carry the same meaning so clearly when viewed on another screen view. This is particularly true of a coded entry that is qualified by free text. That qualification will not apply if the two items become physically separated. Making a good record does not merely require the correct choice of coded clinical term; it requires a contextual understanding of how the record will appear to the reader. This understanding includes the functionality of their individual clinical systems -- as well as an understanding of the secondary uses that data can be put to.

In addition there are semantic issues to consider. Different professional groups, specialties and sub-specialties are examples of sub-cultures that use language in different ways. They all use language in ways that can be opaque to the general public, i.e. their patients. These issues are dealt with in more detail in the SRPG and Record Access reports [ref these] and chapter 4 of this guidance. They all hinge on properly combining the technical accuracy of the coded clinical term and the context in which it is being used by the writer and the reader.

All clinicians need to know the technical aspects of which codes to use; they all need to understand how contextual factors shape the meanings of records; they all need to be able to use the electronic records as a safe, effective and reliable way of communicating with other health professionals, and their patients.

Similar statements of need can be written for other aspects of practice with electronic health records. In records governance, for instance, there are technical details of how to apply each guidance or statute. These have to be implemented in local and broader contexts. So that the person who is sending an extract from a patient's records to an outside organisation has the following learning needs: to be aware that information about third parties should not be disclosed (i.e. awareness of the principles of the NHS Code of Practice for confidentiality); to have the technical knowledge of what constitutes a third party reference that should be deleted or redacted and the specifics of how to do that; local contextual knowledge of who's responsibility it is to do the check for third party references and to ensure that the task is always done.

This is a recurring theme. Whatever the task undertaken, necessary technical accuracy is not sufficient without considering wide and local contexts. The relation between an understanding of the technical and of the contextual is a fundamental characteristic of health informatics.

12.3 Meeting these learning needs

12.3.1 Training and practice management

Especially in the case of records governance, but to some extent in all areas, some of the local and wide contextual factors may be embodied in practice policies and protocols. So that when the practice receives a request for an extract from records, it is clear that a check for, and deletion of, third party references is required. The practice policy will set out how this should be done; by whom, and how the checking should be confirmed before dispatch. In this example the practice and its systems are taking responsibility for the wider contexts. The employee needs to be trained to follow practice policy and in the technical detail of how to do the check. Equally, the practice managers who write the policies may need guidance with that task.

Up to a point a similar approach can be used with regard to clinical coding. Through the quality and outcomes framework clinicians and managers have come to appreciate the need for technical accuracy in coding and have learnt some of the costs of inaccuracy. The Framework itself contains a limited code set for the conditions it embraces. In other contexts, EHS and SCR for instance, restricted code sets can be agreed and used to limit ambiguity. Their preparation and implementation are matters of management and training.

However, large parts of the primary care repertoire are not so simple. Not all conditions are as well circumscribed as those in the QOF, we deal with many complaints that are not sorted into neat diagnoses while co-morbidity and social and psychological factors add to medical complexity. In these circumstances, business processes and structuring of the record can only contribute so much: the note-writing clinician must understand the communicative aspects of the record as well as being technically proficient in coding.

The important point here is that local ways of working (business processes in the practice, and the way that different local clinical teams work together) have an impact on education and training needs. At the simpler end of the spectrum it is possible to build required understanding into business processes: so that the individual needs only to be trained to follow protocols. As things get more complex, or where business processes are less well developed, so the contextual understanding required of the individual increases.

This means that any learning needs assessment needs to take into account aspects of practice management as well as the competencies of the individual practitioner or staff member.

12.3.2 Context and communication

The intended outcome here is that the individual will understand how their use of a particular clinical records system or application impacts on other users and on patient care. This requires a different approach. While skills acquisition and learning how to do specific tasks lend themselves to a training approach that can be relatively didactic and put into packages that are cascaded out through e-learning or other methods, matters of understanding often require a more discursive and individual approach.

The individual needs to be able to relate their work to the work of other members of their team, and also to understand how their team fits in with the bigger picture. The rich variety of sizes and types of General Practices, and other types of primary care provision, makes it very difficult to achieve this level of understanding by means of pre-prepared material whether delivered on line or in person. A one-size-fits-all approach is inappropriate. Group discussion that allows people to situate their experience in the wider context is much more likely to be successful.

In terms of learning about and coming to understand the use of the electronic record as a means of communicating with other professionals the most useful activity is likely to be meeting with and talking to the other professional groups involved. Much of this can be done within a practice, but as care of one patient is increasingly shared by different organizations so increases the benefit of people from those organizations meeting each other.

As will be shown in the next section, the NHS website offers e-learning support for developments such as Summary Care Record and Personal Demographics Service. While these are invaluable as guidance and expositions of content, they are not sufficient in themselves. Clinicians and administrative staff need to be given the opportunity to apply the material to their own situation, to grasp the implications of using this technology in their work setting and in their communication with other professionals. This kind of work is best done in facilitated groups. This is relatively costly of resources. The cost is justified as these human elements are the key to success of IT-led change: as demonstrated in the quote from Sadie Williams at the start of this chapter.

12.3.3 Clinical and non-clinical staff

Information handling is part of the role of everyone who works in health care and so of everyone who works in an organisation such as a General Practice. The scenario of third-party references illustrates this. Informatics is beginning to be included in the undergraduate curriculum for doctors[^4] and is being promoted for all clinicians in the e-ICE project (see resources below). There is not the same structural support for admin and clerical staff. As mentioned above, this falls into the realm of practice management as an aspect of staff development and appraisal. Ways of working, practice protocols and staff development and appraisal should each complement the other.

Factual guidance and pre-prepared training materials need to be supplemented by facilitated inter-personal learning so that human elements of learning and change can be properly addressed.

12.4 Some learning resources

There are many useful resources available on the internet. The few examples listed below are NHS related and provided by Connecting for Health and PRIMIS+ among others. They include general material as well as e-learning resources for specific items such as Summary Care Record, Patient Demographics Service and Information Governance: all of which are on the CFH e-learning resources site below;

[^3]: SRPG report http://www.rcgp.org.uk/news_and_events/news_room/news_2009/rcgp_shared_record_professiona.aspx

[^4]: Tomorrow's Doctors http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors.asp

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