Ch 9 paperless

Chapter 9 -- A pathway to good paperless practice

9.1 Introduction

This chapter will provide guidance for practices on how they can change their business processes towards "paperless" working.

We will include discussion of the grades and requirements for paperless working as an outline pathway for change, and explore the risks and benefits of this method of working. The chapter will have safety and governance at its core; ensuring practices are supplied with the information they need to achieve these changes safely and without compromising continuity. Practical advice will include how to create and maintain a high quality electronic record; guidance for clinicians on how to consult using computerised records; how to record encounters; how to manage scanning of documents, both current and historical; document retention and shredding; standards for achieving and maintaining approval from governing bodies; practical aspects of messaging to and from the clinical information systems; business continuity; and where to obtain further support and assistance. The chapter will conclude with the recommended process for practices to gain and maintain their paperless accreditation status.

9.2 About this chapter

The term 'Paperless Practice' is widely used to refer to various grades of working with electronic records instead of paper. At its simplest this means 'working without paper notes', where 'paper notes' refers to the Lloyd George or A4 clinical cards traditionally used to record narratives of patient encounters. The term 'Note-less' is used for practices that record the day-to-day encounters on the computer record system (and not on paper), but may still be using a paper repository of correspondence. Similarly, the term 'Paper-light' describes practices, which, in addition to working note-less, also employ a scanning, or "Document Management System" (DMS) to handle paper correspondence and other files associated with patients' records.

Inevitably all practices will have to continue to manage paper documents at some level, both received by and sent from the practice, thus working entirely without paper is impossible[^1]. There are, however, areas of general practice business historically reliant on paper workflows that can be operated more usefully, efficiently and safely by employing information technologies. Practices planning to move to 'Paperless' working must decide which functions of their practice business they wish to change and why, and consider the impact of these changes on other areas of the practice and upon the people who work for it.

In common with all business changes supported by or dependent on information technologies, the biggest challenges will arise from managing the change for your practice team and supporting them in these new ways of working.

9.3 From paper to paper-free

It is today very rare for a UK general practice to operate without any clinical information system (Clinical Computer System). The introduction of the Quality and Outcomes Framework (QOF) in 2004[^2] has resulted in the vast majority of practices using their clinical information systems to capture some clinical data in a structured way. As a consequence of this, and other business requirements, all practices working for the NHS should have a clinical information system containing at least demographic data and basic electronic clinical records as required to meet QOF reporting.

Many practices that have partially evolved their use of computers for managing clinical data will find themselves in a mixed economy of paper and electronic records. This change has not been without difficulty and may not always have been approached systematically or with care. Some practices may only be using the minimum required functions of their clinical information system to support the demands of the contract, whilst others may have systematically moved towards paper-light working.

9.4 Pre-requisites

9.4.1 Motivation

Practices should consider the reasons they wish to move to paper-light working, the challenges involved and how these will affect individuals in the organisation. Having the support of the whole practice team is ideal, but most organisations will find people who are reluctant to change to new ways of working. Consensus amongst the management team of the practice and a clear statement of intent can assist with this. Describing the benefits to your team may also help, as well as an awareness of where there will be difficulty and recognition that some staff will require more hand holding and support than others.

In order to work paper-light all practice staff must be prepared to change. Clinicians may find their consultation style and methods of managing their work changes substantially. Uncertainty about skills capability, perceived threats to roles and autonomy can lead to resistance to change as well as attempts to disrupt it. A stepwise approach in an achievable time frame to adapting consulting techniques and learning new computer skills can help alleviate concerns and build confidence. Consider how the technology will change roles and responsibilities for practice staff, and how this may impact upon the relationships and existing structures in the practice.

Practices may wish to reflect good information practice in their practice training material, induction packs for locums, GPRs and other temporary staff and even in their partnership agreements and employment contracts.

Practices should be cautious about moving to paper-light working as a mechanism to fix a dysfunctional system in their practice. Information technology can be used as a tool to support a business process, but if that process is already suboptimal then it is less likely that computerising it will result in success -- do not computerise a problem.

9.4.2 Infrastructure, Hardware and Software

A review of the practice's hardware, software and network infrastructure should be undertaken to establish requirements for improvements needed to allow the practice to work paper-light.

Your PCO will be responsible for ensuring your computer systems meet the minimum requirements to allow you to manage practice business. Practices should contact their IM&T department for support in this regard.

Figure 9.4.2a Hardware

Your PCO will supply standard equipment only, to a minimum recommended specification for the applications the practice intends to run. Negotiation of changes or improvements to these specifications is a matter for individual practices. Workstations Aim for one per consulting room; adequate numbers in administrative and patient facing areas; meeting rooms; laptops to support remote working

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Printers Dual bins in consulting rooms, also useful in administrative areas Monitors Larger monitors allow for more information to be shown; a rotating base and inbuilt speakers or USB hubs are also useful Input Devices Keyboards, mice, and other devices such as trackballs are a matter of individual choice. Providing specific piece of hardware in this regard can ease the transition for members of the team who may be struggling

Software

General Practices should always check the constraints for local software installation with their PCO as policies may restrict or even forbid the installation of software to servers or workstations by practices.

Users working in remote desktop environments will similarly find that their ability to install specific software tools will be constrained. Depending on the hosting service, and the clinical system in use, an approved list of third party applications may be available.

Approved NHS GP systems in England are listed on the NHS CfH website^3

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Figure 9.4.2b Software

Clinical Information System All NHS approved GP systems are able to support paper-light working. Changing your clinical system should not be undertaken lightly and only where there will be clear functional or practical advantage.

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Document Management System For scanning correspondence and other documents, an essential component of paper-light. Office Software Word processor and Spreadsheet programs, often with other applications included as a suite. Microsoft Office is commonly installed on workstations in the NHS. Other Software Practices may wish to use specific software packages for a variety of purposes, but care should be taken when installing other software. Check with your PCO IT department.

Figure 9.4.2c Network Infrastructure

Network Access Points Ensure adequate numbers in locations suitably positioned to avoid running cables over floors and desks. Consider also for power outlets.

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Branch Sites If the practice has a branch site then a solution must be found to link all the sites to the clinical database. Remote Working Working from home or from other locations, if required, then a method of access must be supplied and configured by the PCO or system supplier. Bandwidth Adequate bandwidth into and out of the practice will be needed as the practice starts to use more NHS on line services.

9.4.3 Continuity Planning

'Continuity planning' refers to the procedures and actions you employ to reduce the risks associated with loss of access to your computer systems.

As you move practice functions to the clinical information system it becomes increasingly difficult to manage the practice without them. Events such as fire, flood, theft, power cuts and technical problems can all result in at least temporary loss of access to the system and occasionally loss of data.

It is also a Data Protection Act requirement to store records safely (see also chapter 4.2.4)

9.4.3.1 Backups

Backup is essential for all practices that store any important business data locally. Practices working on centrally hosted desktops should have their clinical data, and any other data they store there, backed up by the service provider. This will be part of the service level agreement (SLA) that your PCO holds with the system supplier.

Where practices have locally stored data they must establish a backup schedule, and periodically have that backup verified to ensure data could be restored in the event of loss of the original. Remember any data not stored on servers such as any personal files on the local workstation. Users should be encouraged to store critical business data on backed up drives and be warned that locally stored files are at risk.

The costs of data loss include:

• The cost of continuing without the data

• The cost of recreating the data

• The cost of notifying users in the event of a compromise

Practices have a responsibility for data governance commensurate with their role as custodians of confidential medical records. It would be hard to defend against losing patients' medical records through negligence or omission.

9.4.3.1.1 Backup Media

Your PCO IT department will be able to advise on the best backup medium for your circumstances.

Tape Backups Commonly employed, large capacity, cheap, re-usable, established practices and software.

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Optical backup DVD, limited capacity, rarely suitable for full data backups, BluRay not widely employed. Removable Drives Large capacity removable hard drives can be used effectively for backup, more economical in recent years. Network backup On line backup services are not yet approved for NHS use due to encryption, storage location and bandwidth.

Whatever medium is used for backup the data must be encrypted if the backups will be taken off site.

9.4.3.1.2 Backup Schedule

A rotating back up schedule is typically used, normally with a nightly backup stored on site, and a weekly backup, suitably encrypted, taken off site. An alternative to off-site backups is to use a fireproof safe, but this is unreliable and may not protect your data in a severe fire or flood and, of course, could be stolen.

Practices should include the responsibility for the management and checking of system backups in the job description of a member of staff, often the practice manager. It should be made clear that failure to do this task will be a disciplinary matter, potentially resulting in dismissal.

9.4.3.1.3 'Live' local copies

Some clinical systems allow for a local copy of the system and data to be hosted on a workstation, which may then allow for limited access to the data in an emergency.

9.4.3.2 Working without the computer

9.4.3.2.1 Planned downtime

Most systems and networks require upgrading and maintenance, which will occasionally result in temporary loss of access to your system. These events can be planned for, and may be able to be completed outside of normal business hours.

Where downtime is required during the working week, practices should schedule it for quieter periods of the day and re-schedule tasks that make intensive use of the computers to a different time.

9.4.3.2.2 Unplanned downtime

• Single machine --------------

Practices should create a checklist for use if a single workstation or printer in the practice stops functioning as expected. This will enable non-technical staff to work through a troubleshooting process. Such checklists should always include the contact details for IT support. A checklist need not be overly complicated and can, of course, only be as comprehensive as the technical expertise in the practice will allow.

For example:

Is the power lead plugged in and the machine switched on?

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Try turning the computer off, and then back on again. Contact Tracy on ext 2134 If Tracy is not in phone IT Support on 01236789876

Where the problem cannot be rapidly fixed, it may be useful to have a 'swap out' machine -- a workstation that is functional but not in use, that can be substituted at short notice if needed.

• All machines ------------

Where the network fails, or the server develops problems, you may find your practice abruptly and unexpectedly without access to the clinical system. This is never an easy scenario to manage and how you do so will depend on the practice's own circumstances.

Consider the following:

• Delegate the task of contacting IT support and have this done immediately

• Have staff trained and aware of how to handle patient requests and contacts without the computer system -- a temporary paper system backup.

• It may not be unreasonable to move to 'emergencies only' working until the systems are returned to normal. It is potentially unsafe to do routine consulting without access to the clinical record.

• Inform patients in the waiting room of delays and the reasons for them.

• Consider how manually collected data handwritten during periods of downtime will be retrospectively entered to the system.

9.4.3.3 Fire, flood and Theft

Major data loss disasters, which may also result in damage or destruction of the practice infrastructure, are thankfully rare. In the event of such an occurrence you will rely on the latest data backup to restore your practice system, but repair of premises and other material damage is outside the scope of this document. Contact your PCO and system supplier as soon as possible; use their advice and help. Paper-light practices can be reassured that their patient data should be able to be restored from backup, once systems are operational again. Practices that remain reliant on paper notes will perhaps not be so fortunate.

9.4.4 Training

This document assumes that the practice has in place an approved clinical information system and, consequently, that a level of skill and knowledge of use of the system already exists within the practice. Nevertheless, assessment of individual and team training needs should be undertaken and a plan drawn up for addressing these needs. Readers should refer to Chapter 12 of these guidelines.

9.5 Benefits and risks

It is important to recognise that whilst there are many positive gains to paper-light working there may also be some losses. For example, loss of 'coffee time' chats, where clinicians traditionally meet to read and discuss incoming mail can change the dynamic of communication in the practice. Similarly, someone whose role was to maintain a paper appointment book may find a substantial part of his or her job changed or even removed from them.

9.5.1 Benefits

The biggest gains of paper-light arise from having a large volume of high quality data. High quality data will support the practice and the NHS by providing better information with which to treat patients and plan services.

• Patient records available from any workstation

• Patient records backed up

• Improved legibility

• Flexibility in presentation of clinical information

• Computerised Clinical Decision Support for prescribing and disease management

• Computer generated reporting for audit and analysis

• Computerised appointments

• Support for contractual requirements such as QOF target areas

• Templates and protocols for disease management to improve care

• Access to NHS services such as electronic prescribing

• Provision of shared records for unscheduled care

• On line access by patients to practice services, including records access

9.5.2 Risks

• Changing staff roles can be threatening, may be a risk of redundancy

• Risks of non co-operation or sabotage by practice personnel

• Loss of informal communication space

• Abstraction of record to computer may change meaning

• Working outside the practice requires a technical solution

• Changes to consulting style can be challenging

• Requires significant learning and sometimes re-learning of previously familiar tasks

• Risks to confidentiality imposes an increased responsibility for data governance on the practice

• Risk of duplication of recording onto computer and paper during transitions

• Risk of missed information due to not referring to appropriate resource during periods of concurrent systems

9.6 Data quality recording standards

Much of the value of paper-light working comes from good data. It is therefore important that all members of the practice team understand how to record data on the system correctly.

Data quality means capturing information from interactions with the patient as accurately as possible in a way that is usefully computable. How much 'computability' you require, or can achieve, will depend on individual practice requirements and the clinical information system in use.

Although the primary purpose of the record is for patient care, other uses such as clinical and process audit, research, education, service planning and contract delivery are also important.

PRIMIS^4 and GPRD^5 have been instrumental in defining standards and procedures for improving data quality in Primary Care in the UK. Chapter 6 of these guidelines provides detailed advice on high quality records.

9.6.1 Recording Data

To support paper-light and note-less consulting data recorded should be:

• Complete

• Accurate

• Relevant

• Accessible

• Timely/Current

Chapter 6 deals with this in more detail.

9.6.2 Processes for data capture

Data capture cannot be left to any one individual person in a practice -- it is a job for the whole practice team.

Support Patient Care - The primary purpose of the medical record is to support the care of the patient. Consequently everyone in the practice has a responsibility to ensure the record is complete, accurate, legible, comprehensible and maintained at the time.

Every one participates - All clinicians must take part in recording data to ensure the whole practice population is covered. It is not acceptable for some clinicians to record electronically whilst others continue to record only onto paper notes. Such duplicate systems run the risk of disparate records, which can confuse patient care, increase the risk of error and be medico-legally indefensible.

Every encounter - Procedures must be in place to ensure that every clinical encounter is recorded on the computer system. This includes encounters in the practice and those that may occur outside on home visits as well as encounters with temporary staff such as locum GPs.

All prescriptions - A complete, chronological medication record is essential for paper-light working. All medication records must be added to the computer system, and all deletions, cancellations and amendments also recorded by updating the computer record. Prescriptions that may have been handwritten will need to be added back to the computer as handwritten on return to the practice. . Similarly, where it is known that a patient has taken OTC medication this should be added to the computer system and where it is known that a patient has been issued medication from another organisation, e.g. as part of a discharge, this should also be added to the computer. Most GP systems allow these other types of medication issue to be recorded alongside that issued by the practice and having all of a patient's medication history can prove to be extremely useful. It may be prudent when visiting patients, if possible, to delay issuing prescriptions until return to the surgery when the prescribing can be completed using the computer system. This ensures decision support and avoids transcription errors and, with the introduction of ETP, may not inconvenience the patient or carer.

Agree coding standards - Every practice and every clinical information system is different, and the requirements of how granular the coding level is within a practice will depend on what the practice wants and, within the constraints of the clinical system, what is possible. Practices should agree which data is recorded in a structured way, which codes or groups of codes will be employed and how that data may be best entered. The requirements will be based on variables such as contractual necessities; practice population; special interests of the practice; secondary uses of the records; competence with the systems; requirements for audit and research and clinical safety.

Use templates and coding lists - Practices can encourage standardisation of coding within their local organisation by using clinical system provided code subsets, formularies or 'favourites'. For specific disease management and contract areas bespoke or centrally distributed data entry and review screens can be employed that mandate structured data entry to an agreed code list (e.g. picking lists or synonym lists).

Review and Audit - Policies for data entry must not be static -- they need to be flexible to adapt to changed requirements, to respond to errors or refinements. Practices should be able to audit and review their data entry using reporting tools from the clinical system, or external analysis from organisations such as GPRD.

9.6.3 Coding systems

Computer systems have great difficulty in analysing freely typed narrative for significant meaning. As computers are very good at processing numbers, for clinical data entry to be useful the data we enter must conform to some type of numbering, or clinical coding, schema. This attaches 'codes' to clinical terms -- terms are textual descriptions of clinical concepts such as symptoms or diseases. Chapters 6 & 7 of these guidelines provide more information.

GP clinical systems will conform to a coding system approved for NHS use and allow users to enter a coded item in a variety of ways. Commonly a coded clinical term is added with an attached 'free text' comment. Subsets of the codes from a terminology may constrain the immediately available terms to the user depending on the context of the task, or their role or organisation. By reducing the number of available terms this can make it easier for a user to find an appropriate code.

In practice the conversion of clinical encounters to structured coded data can be quite difficult, especially for non-technical users used to working with handwritten narratives. Systems try and make the task of finding clinical terms easier using a variety of user interface and functional techniques and it is rare with today's systems for users to have to enter data using the clinical code directly -- most systems are able to locate appropriate terms using text searches. Because any coding system is an abstraction of real clinical practice there will always be occasional difficulties finding a clinical term that exactly captures the clinician's meaning. New users can find this frustrating and unless provided with guidance and strategies may find workarounds that hinder data quality.

9.6.3.1 What is a Structured Record?

Clinical information systems aim to provide clinicians with a place to record clinical data. To do this they must apply a model of clinical practice into language that the computer systems can utilise.

When users write a clinical note they also apply 'structure' to it -- they note the date of the encounter, the type of the encounter and who they are. Within the clinical narrative users make use of clinical shorthand and convention to denote, for example a blood pressure reading. A blood pressure reading has values such as Systolic and Diastolic. If a user records these as free text then the computer will have no way of identifying that the user has entered a blood pressure, nor what the respective values for the readings are. To get round this problem clinical modellers create a representation of a blood pressure in the computer record. This will have a place to record the Systolic value and the Diastolic value and a label, perhaps a clinical term, which identifies it to the system as a blood pressure reading. In other words, it is stored as a 'structured record'.

Clinical information systems all differ in their clinical models, the extent and scope of the models and how the users access and use them.

9.6.3.2 What should users be taught?

It is helpful for clinical users in particular to be given a basic understanding of the clinical terminology in use and the logic behind the system's clinical model and structure. Whilst this sounds complicated, it will generally be covered in training sessions from your PCO or supplier, and need not be very detailed. If users do not understand why the clinical system makes them record data in particular way, nor the various levels or meanings of clinical terms they will struggle to record data accurately or perhaps at all. (see also to Chapter 12).

9.7 Moving practice business to paper-light

Many practices have adopted computer use in a piecemeal fashion and may be operating a mixed economy of paper and electronic records. There are significant risks associated with this type of working as well as inherent inefficiencies and risks.

Finding information By operating two or more repositories of patient information clinicians may miss important information by not knowing where to look, or that the information was there.

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Loss of records Paper records risk being lost and mislaid Mixed prescribing records Running two prescribing recording systems is inherently dangerous. Legibility Typed records are normally more legible. In mixed record systems it may not be clear which written entry corresponds to which computer record. Duplication Dual recording of information from the same encounter on paper and computer is not only inefficient, but risks the creation of conflicting records. Efficiency It is inevitably more efficient to use a single record system, and the always on, networked nature of the computer system favours it in this regard.

The practice should plan to move their core business functions to the computer system. Functional areas to consider include:

Demographic / Registration data A patient Age / Sex register

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Scheduling and Appointments Appointment books for clinics and surgeries, as well as general practice calendaring and scheduling. Prescribing Moving to entirely computer based prescribing, with our without electronic transmission of prescriptions. Clinical Data Recording 'significant' medical history provides useful summaries, but the aim should be to record all encounters electronically. Test results Transcription or direct import of test results to the computer. Document Management Use of scanning software to store all incoming and outgoing paper transactions. Referrals and Discharges Ensuring all referrals and outcomes are captured on the computer system. Transfers Managing patient transfers to and from the practice. Remote working Working with patient records from outside the practice.

9.7.1 Demographic / registration data

Demographic data provides the base for managing a paperless practice. Without this data, comprising items such as names, dates of birth, addresses and NHS Identification numbers, the practice cannot begin to use its clinical system. To use the system to manage patients, you must be able to clearly match the record you are working with to a unique patient.

In all parts of the UK, health authorities now hold registration data centrally. Most practice computer systems synchronise locally held demographic data with centrally held data. In England the Personal Demographic Service (PDS) requires checks on the synchronicity of the locally held data before allowing access to national services such as "Choose and Book" (See Chapter 8a).

Practices are required to continue to manage registrations and transfers using their local systems, and to ensure the data they hold is accurate and fit for purpose. Some general rules to maintaining this data include:

Avoid abbreviations For example, abbreviating 'Road' to 'Rd' or 'Rd.'

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Use full postcodes Some systems provide a post code / address lookup service Include phone numbers with area codes Collect different types of phone number and ensure they are correctly labelled, e.g. 'Mobile' and 'Work' Include e-mail addresses
Employ 'Known as' and 'Sounds like' fields For short names and pronunciation. Train staff on consequences of mismatched records Can slow or prevent access to national services. Use NHS Numbers Single unique NHS Ids such as NHS Number and CHI Number are essential for safe delivery of care Always create a medical record for every patient Even for single encounters, and always before the patient receives clinical care. Family and Household linkage If your clinical system supports it, this can be useful to maintain making address changes easier and identification of household members possible. Do not operate two registers For example, for private and NHS patients. Clinical systems normally have methods of identifying patients with different registration purposes without having to create a separate list.

9.7.2 Scheduling and Appointments

Electronic appointment systems offer huge efficiencies in general practice. There may be a large overhead in work in setting up an electronic system in the first instance, and at least one member of staff should be trained and competent to do this. Migration of large numbers of paper based appointment books and forward filling the electronic system with future appointments may take several days, depending on the size of the practice. An incremental approach can be useful, but should be time limited with a clear endpoint for becoming fully electronic.

Advantages include search and audit tools, multiple appointment types, accessibility from all workstations, clinical staff able to manage own schedules, patient remote booking by phone or internet and enabling self service check in terminals in waiting rooms.

9.7.3 Prescribing

Prescribing is more efficiently and safely managed by an appropriate computerised system, and was one of the first functions of early general practice computing that was widely accepted (See Chapter 8f).

Moving from paper to computer prescribing is normally beneficial for a practice, and can encourage reluctant clinicians to start using their computers. Advantages include:

• Legibility

• Standardisation of drug names, packs and formulations

• Decision support for adverse reactions, contra-indications, interactions and duplicate therapy

• Specific controls on high risk medication such as Methotrexate and controlled drugs

• Medication costs provided

• Generic and brand switching, with prompts for appropriateness

• Standard settings for commonly prescribed items

However, there are risks associated with electronic prescribing (e.g. errors caused by incorrect use of drop-down menus, picking lists or predictive text) and care must be taken to ensure proper training and use of these systems.

Prescribing systems in the NHS in England must now conform to the Dictionary of Medicines and Devices (dm+d), a terminology for therapeutics^6. This change has been to support the Electronic Transmission of Prescriptions (ETP), and aims to standardise drug descriptions across systems improving interoperability.

9.7.3.1 Electronic Transmission of Prescriptions

ETP in the UK is different in all four home nations, but all use the same premise of sending or providing an electronic version of the prescription to the pharmacy, either with or without a bar-coded printed prescription (See Chapter 8f).

New models of prescribing are also being introduced which are intended to improve the efficiency of repeated prescribing. The 'Electronic Repeat Dispensing' prescription model in England aims to provide the patient with a prescription, which may be dispensed over a period of up to 12 months, with dispensing instances handled by the pharmacist without a further prescription from the GP. The Electronic Chronic Medication Service (eCMS) in Scotland is similar, but includes a schedule of review messages and dispensing information for the prescriber. Use of these new prescribing services should be safer and more efficient for general practices, but to obtain the benefit all prescribers in the practice must be using the computer system.

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Figure 9.7.3.1 - What is required for paper-light prescribing?

Access rights All prescribers must have logon rights to the prescribing functionality of the system and, for ETP, credentials to allow logon to NHS services.

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Competence with prescribing functions Prescribers must know how to access, search for and select items from the system's drug dictionary Prescribing models Prescribers must understand how and when to use the system's different prescribing models Review prescribing history Users must be able to view past and current medications Know how to stop, cancel and delete items To maintain an accurate, chronological record Know how to 're-print' an item Where printing fails for technical reasons, without creating a new prescription Understand decision support warnings These can be complicated and some training is required, users must know how to respond to them appropriately. Printer problems Some training in troubleshooting simple printer problems, such as re-loading paper or fixing jams. All prescribing is computer based All handwritten or amendments to computer prescriptions must be captured on the computer system All staff aware All staff must understand that all prescribing is now computer based. Capture third part prescriptions Decide a policy on capturing prescribing by other organisations, such as Out of Hours, to maintain a more complete prescribing record. Record indications A QOF requirement, practices must decide how they will identify an indication for Repeat Prescriptions Drug Formulary Who will maintain this, and how will users access it. Can they prescribe 'off formulary'?

9.7.4 Retrospective Data Capture and Clinical Summaries

Under the 2004 GP contract one of the quality measures is that clinical case notes are 'summarised', based in part on the advice of the GPC / RCGP document 'Good Medical Practice for General Practitioners (2008)^7.

If your practice has no clinical summaries then this is a large volume of work that needs to be addressed. More commonly today, in light of the 2004 contract, practices have a substantial number of their records summarised, processes in place for updating these as new events occur, and for refreshing or creating summaries for new patients as they transfer in.

9.7.4.1 Decide what you want to code

Practices should consider coding only 'significant' conditions when doing retrospective data entry. What a 'significant condition' is will necessarily vary from practice to practice, as each summary is written primarily for local use to support decision-making and clinical care. Consideration should also be given to other purposes that a general practice summary may be used for. For example, the Summary Care Record in England intends to use significant items from the GP record initially for unscheduled care use, and the patient may also access summaries.

SCIMP provides guidance on clinical summaries and a recommended code list for Read Version 2, 5 byte^8. PRIMIS advice is also useful in this regard.

Items practices should consider recording include:

• The reasons for admissions to hospital -- the presenting symptom or, if available, diagnosis

• All chronic diseases

• All significant infections

• All operations

• Fractures and other serious injuries

• Important primary care conditions such as back pain, depression, hypertension and skin conditions

• Immunisations

• Adverse reactions and intolerances.

• Pregnancies and births

• Significant investigations and their outcomes, such as CT scans and endoscopies

• Last blood pressure, smoking, alcohol, height, weight

• Cervical cytology

• Occupation

9.7.4.2 How to summarise records

A practice can approach this by engaging a 'clinical coder', someone who has been trained to use the clinical system and the terminology it uses and is able to identify the items the practice wishes to include in its summaries.

Alternatively practices may elect to have medical staff complete the summaries, but again they must be familiar with the terminology and protocols in place. A GP should be available to lead on this process, and for a clinical coder to consult for queries. Audit of the summaries is important to ensure the standard required is being met.

Summaries are generally established by reviewing paper records for the patient, which may be the original NHS records including correspondence and results or could be a printout from another practice.

If the practice has card based disease registers then the data from these can be transcribed to the computer system.

When there is an electronic prescribing record, running searches for drugs used in specific conditions can help identify patients who should have these conditions recorded.

Ensure that 'Event Dates' are used correctly when entering historical data. Consider using a Problem based recording for 'Active' and 'Inactive' conditions if your system supports this, or using a marker for importance of the condition such as 'High', 'Medium or 'Low'.

Estimate the time required for this process by averaging the time taken for a sample number of summaries, and multiplying by the number of records you need to summarise. This can assist in planning the number and type of personnel who need to be involved in the task.

Simply summarising a paper medical record does not mean that the original can be safely destroyed. This should only be considered after a document has been securely scanned to a robust document management system - See also chapter 10.

9.7.5 Processes for Prospective Data Capture

This has two main facets: Coding of new clinical data received from third parties, such as hospital correspondence; and secondly, coding of consultations and encounters at the time.

9.7.5.1 Capturing data from correspondence

Practices must have in place processes for maintaining clinical summaries by capturing new or changed data received in correspondence from other agencies, typically hospitals. Clinicians may use a system of highlighting text on letters that can then be added by coding staff, or elect to do the coding themselves. With experience and training, clinical coding staff can identify relevant information from correspondence independently and enter this into the patient record without a clinician's prior review.

As a minimum, coding of significant morbidity and investigations from hospital correspondence is recommended, but letters frequently contain other data that can be usefully captured. Where this capture is automated via a document management system, practices must ensure that the process correctly identifies patients and accurately maps code translations.

9.7.5.2 Recording at consultations

Practices must have in place procedures to ensure every clinical patient contact is recorded. Data is commonly recorded during and immediately after the consultation. The cardinal rule is to write it up at the time, before moving onto the next encounter.

The content of the EPR should be at least as complete as the equivalent written record and must record the history as relayed by the patient, the nature and extent of examination, questions asked and responses, etc.

Clinicians should be encouraged to add at least one clinical code per encounter. The clinical system will normally capture the Clinician, the Date and Time of the encounter and perhaps the Type of encounter, such as a Clinic or Routine appointment, thus providing some structure to the encounter record. It is dependent on the clinician to provide the clinical context and code relevant data.

In general the chosen clinical term should represent the main purpose of the consultation event. If there is more than one, then a clinical term should be added for each. This may be a presenting complaint, a diagnosis, procedure or administrative term. Users must understand the basic structure of the clinical terminology in use in order to make an appropriate choice, or the system must be explicit about the intended context for the clinical term. In general practice most encounters are managing chronic diseases, thus using symptom, examination or monitoring codes is often more appropriate than trying to enter a diagnosis.

Clinicians would normally then qualify any clinical term with narrative free text that places the coded information within the context of the patient's story.

This basic method has different implementations in different systems. For example, some systems will accept pure narrative without any additional coded terms, whilst others will try and identify code-able information from the free text narrative. Others mandate the selection of at least one clinical term before any free text can be added (See also Chapters 6 & 7)

• Contractual Requirements

The QOF requires that certain data items are captured and recorded to demonstrate the practice's achievements in clinical areas. Clinicians should record contract codes and values as they capture them during consultations. Clinical systems provide templates and guidance to assist with this process.

9.7.5.3 Indirect Data Capture

It is always preferable to have anyone using the system and seeing patients add their own clinical record. On occasion, however, temporary staff or visiting clinical staff may not be in the practice for long enough to become competent and familiar with the practice processes.

Practices need to consider how to handle these circumstances depending on their own requirements. Use of paper capture forms and subsequent manual transcription by staff may be the only viable solution in some instances, but practices should consider the safety issues of allowing staff not competent to examine the electronic record to manage their patients. It is always preferable to supply a minimum training for data view and entry, even for unplanned visiting clinicians. The use of simple printed guidance, computer templates and protocols can help with this.

9.7.5.4 Data Linkage -- Problem oriented records

Some systems allow clinicians to use a Problem Oriented approach to recording or vewing clinical data.

This is the provision of functionality to allow the creation of 'Problems' in the record, normally a label or clinical code for a condition that is then used as the header for all associated data. For example, a patient may have an 'Asthma' problem. The practice would record all encounters and data related to Asthma linked to the 'Asthma' problem, making it easier to filter and view the data together. Problems commonly have attributes of 'Active' or 'Inactive', implying whether a problem is current, resolved or in remission. This allows for a further structural level of 'episodes of care'. For example, 'Back Pain' as a problem may be active or inactive many times during a patient's life.

Problem orientation requires the practice to actively maintain the problem lists and associated data over time to maintain data quality and utility. Consequently while this may represent an additional overhead on data maintenance and training for the practice, it is likely to significantly improve the quality and utility of the patient records.

9.7.6 Diagnosis refinement and amendment and deletion

Practices need to be able to handle diagnostic amendments to ensure that patient records are accurate.

There is a difference between a diagnosis that is refined over time as it becomes clearer, and a diagnosis that is recorded inaccurately or subsequently found to be incorrect. They should be handled as follows;

• Diagnostic improvement. In this case, a patient presents on several occasions and the diagnosis is refined over time. New morbidity codes would be added over time as the diagnosis 'emerged' but there would be no need to amend the initial diagnosis, as it was not factually incorrect.

• *Amendment. There is no ethical difficulty with removing or correcting inaccurate or misleading information, or making a clear addition to incomplete information. It is important that records do not contain information, which may mislead another health professional using them. Indeed, the Data Protection Act 1998 gives patients a right to have inaccurate records amended. It is inadvisable to remove medically relevant information from patient records. It is important that notes provide a contemporaneous record of consultations and information gained about patients. Removing relevant medical information may give the impression that the notes have been tampered with, and may make later treatment and care decisions seem unsupported. It follows that doctors should take care to ensure that the records show all significant aspects of care, and clearly identify any decisions that were later found to have been inappropriate so that in the future carers do not misinterpret the patient\'s medical history. *

If there is dispute about the accuracy of information, for example that was recorded in the past by a previous GP, doctors should take reasonable steps to ascertain the accuracy of information in the records. If this is not possible, a note explaining the patients\' views should be appended to the records. This allows health professionals using the records in the future to be wary of placing undue weight on disputed information.

Practices must be able to change or remove data in a medical record when appropriate to do so.

9.7.6.1 Data is incorrect

Where a record is known to be incorrect it should be deleted or changed. A record should be made of who changed it, why, what the original record was and when the change was made.

Where data has been entered into the wrong patient's record, this data should be removed in line with the guidance above and should be copied to the correct patient's record. Care should be taken to protect the confidentiality of both patients by ensuring no identifiers are retained or transferred between the two records unless there are clear clinical reasons to do so.

9.7.6.2 Data is misleading, or has changed over time

In the course of managing a patient the diagnosis may change as more information becomes available. This may mean that an originally recorded diagnosis is now known to be wrong, and in this instance it should be changed or removed as above.

Expressing an 'opinion' is different from recording a 'diagnosis'. Opinions represent clinical formulations based on knowledge at the time, and are thus normally correct in context. They also inform management plans, and thus subsequent actions. In general where an opinion is subsequently found to be incorrect it should not be altered or removed if it was correct at the time of recording. In electronic records one should distinguish between opinion and diagnosis based not just on the free text but on the Clinical Code or Term used for the record. An incorrect Code may be associated with free text that is opinion, for example:

E23..00 Alcohol dependence syndrome: "I suspect drinking to excess but denies it."

This is opinion but the effect of the Clinical Term used is to give the patient this diagnosis. Care should be taken to use appropriate codes when expressing opinions, for example symptom or examination codes rather than those for conditions. In the example above, assuming the patient did not have the condition, it would be appropriate to change the clinical code but retain the free text

On occasion there may be differing clinical opinions regarding a diagnosis. Electronic records can handle this by qualification, attribution and linkage of data. That is: by adding free text explaining the difference of opinion; by ensuring the attributes of any diagnostic data make it clear who made the diagnosis and when, by expressing any appropriate qualifiers regarding certainty that may be available in the terminology; and by linking diagnosis to any associated clinical data (as occurs in a problem orientated record) so the diagnosis may be viewed in context. Where the patient disagrees with the diagnosis (or opinion) it would be appropriate to record this.

9.7.6.3 Requests for data to be removed or altered

This may occur where there is dispute about content of the record by a patient or third party. If the record is known to be incorrect, then it should be changed or deleted as above. Otherwise, changing or removing data from the record is not recommended as it will obfuscate the subsequent actions of health care workers who have since used the record.

Completely removing data from an electronic medical record is not possible for end users -- all approved clinical information systems in the UK have an 'audit trail' which will record all changes to a record, saving the original data so that it may be used for medico-legal purposes if required. Where patients request removal of data from the record and this is agreed they must be made aware that the changes will be stored in the audit trail.

More guidance on these topics is available from the National Information Governance Board[^9]

9.7.7 Consulting with Computers

Many clinicians find the change to working paper-light challenging. As well as the learning curve required to become familiar with the clinical information system; they also have to learn how to interact with the computer in the consulting room, in effect adding a new participant to their consultation (see also Chapter 12)

9.7.7.1 Keyboard Skills

At present all GP clinical systems rely on keyboards and mice for navigation and input. Although voice control can be implemented for some systems, it is not immediately useful, requires training of the computer and the user and cannot replace the requirement for typing skills. Using voice for data entry or navigation may not be appropriate during a consultation.

Clinicians do need to learn keyboard skills to use computers. Methods of learning include internet-based or computer-assisted programmes, as well as specific face-to-face classes. Users should learn keyboard skills, not just typing, as being able to use the shortcuts and functions of a computer keyboard will aid their navigation and use of systems.

Touch-typing is not a necessity, although can be an advantage.

9.7.7.2 How to sit

As the computer becomes more important to the clinical interaction, and the primary source of information about the patient, it is important that it is accessible to the clinician without requiring them to turn away from the patient. Placement of the computer monitor, keyboard, mouse and printer should take this into account.

Placing the patient-doctor-computer in a triangular formation is considered the most appropriate configuration -- this is called 'triadic consulting'[^10].

This allows the GP to refer to the screen without turning away from the patient, and also facilitates shared screens, where the computer display may be shown to the patient.

Care should also be taken to ensure the screen is not viewable by third parties attending with the patient, unless it is with the patient's consent. Similarly, care must be taken to ensure the record shown on the screen relates only to the patient and no others. For example, appointment books and reports from aggregated records may include names of other patients.

The configuration of some consulting rooms, the distribution of network access points and power points is not always conducive to this type of arrangement, but attempts should be made using extensions and replacement of access points to try and move towards this. Configurations where the computer monitor is behind the doctor should always be avoided.

9.7.7.3 Multi-tasking

In general it is not possible to try and talk to or examine a patient at the same time as trying to enter or even read data from the computer. Clinicians should keep their attention on the patient, or the computer but not both together.

9.7.7.4 Transfer Attention

Techniques to indicate to the patient that the clinician is now looking at the record are useful in managing the consultation.

• Signposting - The clinician says to the patient that they now need to look at the record. "I'll just have a look at your last blood pressure reading".

• Informal chatter - The clinician continues to chat to the patient to maintain rapport whilst referring to the record, but not about any specific clinical issue.

• Re-direct attention - If the patient is speaking, turning away from the computer and directing attention back to the patient to maintain rapport.

9.7.7.5 Shared Screens

It is useful to be able to share the information on the screen with the patient. This may be to confirm the information is correct, to reinforce a piece of advice or to provide explanations and advice. This is a learned skill, and not all clinicians are immediately comfortable with showing parts of the record to the patient. Providing specific 'patient friendly' displays of clinical data, such as blood pressures, can make this easier.

9.7.7.6 26 weeks to computers

A staged, iterative approach to educating clinicians on using their computers can be effective. No clinician should feel they must be able to do every task from the first day of using their computer system. Any learning and adapting skills requires time, and this must be accommodated into the working day.

For example, SCIMP publish a guide titled '26 weeks to Using Computers in the Consultation'^11. This can be adapted to suit specific systems and clinician's needs.

9.7.8 Results

The management of the receipt of results in the paper-light practice has three main solutions:

• Transcription with paper review - Where clerical staff manually enter a subset of results to the computer record. This may only be for abnormal or significant results as identified by the clinical staff, or results required for contractual purposes. The paper result is filed to the paper notes and remains the definitive record used for processing purposes.

• Scanning with transcription - Where clerical staff manually enter a subset of results as above, but the paper result is scanned to the DMS and associated with the patient record. The scanned document is then the definitive record, and is used for processing via the DMS and clinical system.

• Electronic Data Transfer or 'Pathology Links' - Where the results data is received electronically by the practice's clinical information system and filed directly to the patient record using appropriate clinical terms and data areas. The clinical system will have results handling functions to manage clinical workflow.

The latter process is generally the preferred scenario. Transcription of results increases the risk of data entry errors. Provided the result used for processing is the original record, transcribing the results from paper can be a useful interim measure on the pathway to paper-light.

Pathology Links can be enabled with agreement of your system supplier, PCO and local laboratory service. Training should be provided for administrative and clinical staff and the practice needs to consider how to fit the new processes safely into the practice workflow.

Results from other tests such as spirometry and ECGs can sometimes be integrated into the clinical system directly via software that links the device making the measurement with the clinical information system. There is no standard solution, and each clinical system tends to provide integration with various third party suppliers.

Whatever the approach adopted, practices must have a robust system in place for taking appropriate action on incoming results and reports.

9.7.8.1 Test Ordering

In some parts of the UK it is now also possible to request tests from laboratories using an electronic service integrated with GP systems.

9.7.9 Document Management

An essential part of paper-light working requires the practice to utilise a Document Management System (DMS) to handle correspondence. This is often referred to as 'Document Scanning' and will consist of a document scanner and associated software, which stores the scanned images and allows them to be viewed on the computer monitor.

Once backed up, the original documents may then be shredded, within some safety and legal constraints, saving space and removing the need to file the paper into a patient record. There are two main types of document scanning -- concurrent scanning, where documents are scanned to the record as they arrive thus, over time, reducing the need to refer to archived paper correspondence in the paper notes; and archive scanning, or 'back scanning', where the paper notes are scanned to the DMS to make the full historical paper record available from the computer.

9.7.9.1 Preparing for Scanning

Commonly scanning of incoming and outgoing correspondence is a stage undertaken after practices have moved to note-less recording. Practices must have in place methods for summarising notes and up to date summaries recorded on the clinical system. The practice should consult with their PCO and the system supplier to assess which DMS is available for them to employ.

The PCO and the DMS supplier will be able to assist with a site survey, and recommend a particular hardware and software implementation. Even small practices should consider having more than one scanning device to cope with technical faults in their main scanner. Larger practices may require several scanning locations and devices through their sites.

DMS providers should also provide training in use of the software, and appropriate filing procedures.

Practices should ensure that all staff and clinicians who need access to documents and correspondence in the practice are provided with logon credentials for the system; are able to view, navigate and workflow documents; and are aware of the practice's new policies.

9.7.9.2 Document Workflow

'Workflow' in this context refers to the processing of incoming and outgoing correspondence. The movement of paper around practices is complex and widely varied -- practices all work to systems suited to their own requirements. Moving to scanning documents will constrain some of this workflow within the functionality available from the DMS.

Practices should at least ensure:

• Documents are uniquely filed against the patient to whom they apply

• All people who need to view and read a document can and will do so

• Documents can be marked as read

• Actions required from documents are achieved and confirmed. For example:

• Appointments made

• Results communicated to patients

• Prescriptions provided or changed

• Clinical codes and data is captured

• Exceptions are managed safely. For example:

• Staff absence -- planned and unplanned

• Who will manage an absent users documents?

• How will a user returning from absence manage a backlog of > documents?

• How will documents that cannot be scanned be handled?

• A process for managing misfiled items.

Practices moving from a paper based mail management system to an electronic one must consider how they will workflow the documents. A DMS will provide workflow and routing functions. Practices should investigate these prior to accepting the deployment to ensure the functions provided will allow for a safe and workable system in their organisation.

The practice may have a social function associated with reading the mail, and this will perhaps change. Consideration should be given as to how informal communication between clinical staff can be maintained.

9.7.9.3 Scanning Processes

Normally the practice will train and engage clerical staff for this process. Clerical staff must be aware of the importance of filing documents accurately and chronologically, and complying with any folder structure. Staff must review scanned documents at the time to ensure they are legible and complete. Where a document has failed to scan practices must have a policy for handling this.

Practices normally scan documents in Black and White or Greyscale. Where a document is in colour and the colour is important to its meaning staff should know how to change the default scanning process to create a colour scan.

Optical Character Recognition is a process whereby a scanned document image is analysed to extract the text. This text can then be used for other purposes, such as indexing and searching. This can be a useful function to employ, but has implications for storage and speed of processing.

9.7.9.4 Data recording

A method of capturing data from correspondence is required as simply scanning the document is not adequate from a data quality perspective; clinical codes and data should still be recorded from documents.

In general, a scanned document associated with a patient will be recorded in the DMS but should also be linked to the clinical system's patient record either directly by the systems or indirectly via a text description of the location of the file. An appropriate clinical term should be entered into the system to indicate that correspondence has been attached to the record.

9.7.9.5 Other practice documents and attachments

Practices may consider scanning other received mail to the DMS, for example guidelines and protocols, local service information and so forth.

Files other than scanned documents may be attached to the DMS. For example, clinical photographs, PDF files, word processed documents and web pages. (See Chapter 10 of these guidelines for more information).

9.7.9.6 Scanning Historical Records -- "back-scanning"

This process has been undertaken by some practices that wish to have the entire historical primary care record stored on their DMS. This may be of value where the practice wishes to be able to archive the paper records, perhaps returning them to the Health Authority, thus freeing up space in the practice; it can help with paper-light working by removing the requirement to refer to the paper records for old correspondence. It may improve clinical safety, by making the records more accessible, and in some instances may be cheaper than establishing a paper records filing store.

Practices should examine the business advantages to this process against the financial cost. Various companies offer this process as a service, and practices should examine what is offered and consider if the methods used will increase the utility of the record. In general it is good practice to scan archived documents into the DMS using some type of filing structure, to distinguish between the various sections of the medical record. Scanning the entire record to a single, multipage image file may risk losing some of the inherent structure and utility of the paper notes and should be avoided (See also 9.7.5.1 above).

Comprehensive advice on scanning historical records is available from the SCIMP website^12.

9.7.9.7 Shredding

Paper-light practices employing scanning should establish safe processes for the subsequent destruction of the original documents (see also chapter 10). In general this applies to documents attached to the record rather than the original record itself (e.g. Lloyd George envelope contents).

Documents can be shredded after they have been scanned, confirmed as legible, backed up, and that backup has been verified (confirmed local tape read-back). Practices should ideally employ a crosscut shredder, although there is no NHS required standard. In some areas PCOs provide a secure document destruction service, and commercial operators also exist.

9.7.10 Referrals and Discharges

9.7.10.1 Referrals

Moving referral systems to an electronic interface has become increasingly common in recent years with the advent of on line referral services from the NHS such as 'Choose and Book' in England and 'SCI Gateway' in Scotland, which is expected to be adapted for use in Wales and Northern Ireland.

These systems have been integrated with GP systems such that the referral process and correspondence this generates is captured into the patient record. Much of the content of the referral will be automatically generated by merging data from the patient's clinical record:

From Choose & Book guidance:

"The electronic referral letter will automatically be populated with Problems, Consultation, Medication, Allergies, Family History, Investigations, Values and Social information from the patient's record."

The accuracy and relevance of the merged information will rely on the quality of the practice's summaries and merged referral data should always be checked by the author to ensure that the data is correct and appropriate. This may include the need to remove inappropriate sensitive patient information or other information the patient wishes to be withheld.

Other facilities may also be available such as the ability to attach external documents (see Chapter 9); or to request information and guidance alone, short of a formal referral.

The referral is then sent electronically to the hospital and the appointment may be arranged directly by the GP Practice, or organised by the medical records department.

The increasing complexity of these systems makes it advisable for the GP practice to have at least one member of staff and clinician who is properly trained in their operation. It is particularly important that any workflow features of the system are safely integrated into the wider context of practice communications handling. For example: checking for unsent referrals, ensuring interim messages back from providers are actioned, and that the system is not disrupted during spells of absence by clinical or administrative staff.

9.7.10.2 Further guidance:

Choose and Book

• Chose & Book website^13

• BMA website^14

SCI-Gateway

• SCI website^15

9.7.10.3 Mail Merge

If a practice does not have access to an online referral service, the practice should still consider using their clinical system to generate referral letters -- clinical systems normally have the functions to generate mail merged letters and to save these linked to the patient record. In some situations it may be required to create paper letters and then scan these back into the DMS, although such workflows are usually transitional workarounds for practices en route to paper-light.

9.7.10.4 Discharges

Receipt of discharge details from hospitals electronically returned to practices is now available in a few locations. This can take the form of a document that contains 'metadata' about the discharge, allowing identification of the patient, the event and clinical data. It may allow direct import of the document into the DMS with appropriate attribution as well as provide mechanisms to file clinical data to the patient record.

9.7.11 Patient transfers

9.7.11.1 Transfers from the practice

When patients transfer out of the practice the practice needs to prepare the record for forwarding to the patient's next practice. In paper-light practices there are various methods for achieving this. The principle requirement is that the full medical record is transferred, thus the practice must ensure that the clinical record from the clinical information system and the document record from the document management system is sent (See Chapters 8b & 10).

Print - Clinical information systems contain functions to allow reporting on the full medical record in a structured and readable way for sending on. The practice should familiarise itself with these functions, and ensure staff responsible for registration management in the practice are able to use them. All clinical documents should also be printed from the document management system.

GP2GP - In some areas of the UK 'GP2GP' allows for electronic transmission of the patient's record in the clinical information system to the receiving practice. This also allows for attachments to the record to be sent, with some constraints of numbers and file size. It will not necessarily send the documents from the DMS and, because of different methods of naming documents, it may not be immediately clear to the receiving system what the document is, requiring it to be re-filed. It may, therefore, be necessary to print the documents from the DMS and send as paper copies.

In Scotland the DMS in use (PCTI Docman), has a function to allow electronic document interchange between practices on transfer, thus a receiving practice will receive all the previous practice's documents for that patient with their original filing attributes. A process by which the patient's clinical record is printed to a file, which is then attached to the Docman record, is used to provide a readable version of the clinical record with the Docman transfer (More information on GP2GP is available in Chapter 8).

CD ROM - A process for sending the records to the receiving practice using data downloaded to a CD is in use in some parts of England. Please refer to Chapter 10 of these guidelines.

9.7.11.2 Transfers into the practice

Paper printouts - Practices receiving paper printouts or records only for a new patient must decide how much of the information they wish to integrate to their electronic systems, and in what way. Processes will be in place to review paper records and ensure the medical history is summarised. A decision should be made on which parts of the record, if any, are scanned to the practice's document management system.

GP2GP - Practices are required to review incoming records from GP2GP to validate the data, and to 're-shape' it to fit into the practice's clinical system. Practices may find that some data from the sending practice is converted to free text comments, this is the result of the data on the sending system having no similar container on the receiving system.

Critical to this process is validation and authorisation of medication records, and care should be taken to ensure safety and accuracy.

9.7.12 Remote Working

Practices have requirements to be able to work with patients or their records and practice data outside of the practice premises. This requirement arises through clinical staff visiting patients at home, carrying out 'ward rounds' in care homes, and taking administrative work home. With internet technologies and telephony the prospect of being able to conduct telephone or tele-health surgeries from locations other than the practice is becoming more realistic.

9.7.12.1 Asynchronous Remote Access

The use of portable computing devices (Pocket PCs, Laptops) in conjunction with specific software applications can allow a clinician to carry a version of the practice's electronic records with them outside the practice. Typically these devices carry only a subset of the data from the practice system, and will not provide full the functionality available in the main system. On return to the practice the device is then synchronised with the practice's clinical system.

In some instances it is possible to copy the practice data to a standalone computer, which can run the clinical application. As with all removable data, this requires strong encryption. In this scenario, the data is for 'read only' purposes, and any changes will not be written back to the practice's main data.

9.7.12.2 Synchronous Remote Access

In this scenario the clinician accesses the practice data live, remotely from another workstation external to the practice's local area network. Commercial companies do provide this service for the general public (e.g. 'logmein.com'), but the use of such services for the NHS is subject to approval from your PCO. Risks of using a non-accredited commercial company include potentially inadequate encryption and the location of servers, which may be outside of the UK. Such services normally require a computer in the practice remains switched on and is used for the remote worker.

The approved methods of obtaining access remotely to the practice system varies in different PCO areas, some providing an electronic 'token' to access the practice network through the national NHS network (N3) with a home computer, others require a specifically configured and purchased PC to be used. As the security risks are real and the configuration of remote access systems is complex, practices should not consider using a bespoke implementation for this task.

Accessing the practice data live and remotely from the patient's bedside remains experimental at present in all but a few cases, but the technology (such as high bandwidth connections using cellular telephony 3G) does exist to enable this. The use of wirelessly networked smart pens, combined with data entry forms, has been employed in some areas for specific care functions.

9.7.12.3 Printouts

Using reports from the clinical information system, clinicians should be able to carry a summary of patient data on paper for the purpose of home working or home visits. This is not always satisfactory as the data may be incomplete but is often a pragmatic solution when no electronic option is available. Care must be taken, of course, when carrying records outside of the practice.

9.7.12.4 Data downloads

Exporting patient data to a mobile storage device may provide another method of using the data remotely. Practices must check with their PCO with respect to the encryption requirements for this to be approved. No electronic patient data should be removed from the practice premises unless it has been securely encrypted.

9.8 System user groups

GP computer systems often have User Groups, which can help and advise from other practice's experiences of using the system for paper-light working.

CSC SystmOne http://www.tppusergroup.co.uk/

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EMIS LV and PCS http://www.emisnug.org.uk/ ACS Crosscare ??? INPS Vision 3 http://www.nvug.org iSoft Synergy and Premiere http://www.isug.co.uk/ Microtest ???

9.9 Accreditation of paperless practices

9.9.1 Introduction

In October 2000, the then NHS Executive changed GPs' terms of service to allow them to maintain part or all of their patient medical records on a computer system if they so wished. The change in regulations covers GPs working under both GMS and PMS contracts. Advice and guidance was issued to health authorities (working with their local medical committees) to develop mechanisms to allow the efficient discharge of their responsibility to approve requests to introduce electronic record keeping. With effect from 1st Oct 2002 and in accordance with Schedule 5 of the NHS Reform and Healthcare Professions Act 2002 (supplementary, consequential etc. provision) this function has been transferred to Primary Care Organisations.

9.9.2 National guidance

The changes to GPs' terms of service are permissive, allowing practices to keep computerised patient records instead of paper records. PCO approval is required when practices plan to keep computerised patient records in whole or in part. The legislation also applies to practices that were paperless before 1st October 2000.

Practices need to apply for paperless status when they propose to keep some or all of their records in electronic format only. Approval is permissive -- practices maintaining EPRs can still maintain paper records if they so wish - but a practice may only maintain wholly electronic records if approved. Keeping duplicate paper and electronic records introduces the potential risk of the two record systems losing synchrony, information held on one not always being transferred to the other.

There are no mechanisms for penalising practices that are "paperless" but not approved although this would not be a wise position for a practice to find itself in. GPs who maintain EPRs must be able to generate a paper printout of the entire patient's records (including any scanned or linked documents) to be forwarded to their PCO on request.

Although the PCO cannot make any determination as to the content or adequacy of the record, it has an obvious duty to satisfy itself that any EPRs are being properly maintained and held securely.

GPs and PCOs should try to ensure that clinical systems are fit for purpose within the overall NHS strategic direction outlined in Chapter 1 of these Guidelines. (e.g. those systems that are approved under the GP System of Choice (GPSoC) framework^16).

9.9.3 Implementation -- PCOs and LMCs

Existing guidance to PCOs makes clear that "individual practices will decide how to implement electronic record keeping locally". PCOs have a key role in satisfying themselves that practices are ready to safely maintain EPRs, but there is no requirement for them to use any pre-determined process before giving consent. Indeed, PCOs are strongly advised to agree suitable processes locally with their LMCs. PCOs do not have any requirement to monitor ongoing standards of record keeping in practices but they can withdraw consent in exceptional circumstances. Once again, a procedure for dealing with this situation should be agreed between the PCO and the LMC. The PCO's main role is to approve appropriate applications and to ensure that practices receive the support they require to safely make the transition from paper to electronic records. Experience to date strongly supports the development of a joint approach to practice approval by PCOs and LMCs.

9.9.4 Generic schema for the approval process

• The PCO (or its successor organization) to implement, in consultation with their LMC, the mechanisms to provide written approval in response to requests to introduce or continue electronic record keeping in general practices.

• The PCO to implement, in consultation with the LMC, the procedures that will operate should they wish to remove their approval to allow a GP(s) to maintain electronic records.

• The PCO to identify a senior officer who will have responsibility for approving requests to maintain electronic records.

• The practice makes a formal written request to the health authority to be paperless All the GP partners (PMS and GMS) should sign the first application. The lead IT partner should sign subsequent requests to maintain paperless accreditation

• The designated person at the health authority reviews the application.

• Where there is no doubt as to the readiness of the practice to become or remain paperless, based upon the information known to the PCO, approval should be granted.

• This acceptance is then formally acknowledged by the practice that must also agree to inform the PCO of any future changes that could affect the approval.

• Where the PCO has any doubt as to the readiness of the practice to be paperless, based upon the information about the practice known to them, they should consult the LMC.

• If, after input from the LMC, there is no doubt as to the readiness of the practice to be paperless, approval should be granted as above.

• If, after input from the LMC, doubt remains as to the readiness of the practice to become paperless, an accreditation visit should be arranged. The purpose of such a visit is to address any concerns the PCO may have.

• If the LMC and PCO are satisfied, following the accreditation visit, approval should be granted as above.

• If the LMC and PCO are not satisfied following the accreditation visit, the PCO should work with the practice to make any necessary changes to enable it to seek approval at a later date.

• If at anytime after approval has been granted the PCO has reasonable concerns as to the practices' ability to maintain adequate EPRs, the PCO should notify the practice and the LMC immediately, that it is reviewing approval and provide details of any concerns to the practice and the LMC. The PCO should bear in mind that withdrawal of approval is appropriate only as "an extreme course of action".

9.9.5 Implementation -- practices

Practices need to understand that the decision to become (and remain) paperless must be supported by the whole practice team and that all clinical team members will require access to the practice clinical system and appropriate education and training.

Practices will need to carefully consider and plan for the transition from paper-based to electronic patient records as outlined in this chapter.

Practices should continue to provide the full patient record to their PCO as now, with the existing Lloyd George envelope and a printout of any electronic records that make up the totality of the patient record if requested to do so by the PCT. This requirement will be reviewed in the light of technical developments.

[^1]: Persistent Paper: The Myth of "Going Paperless", Richard H. Dykstra et al, AMIA Annu Symp Proc. 2009; 2009: 158--162.

[^2]: Quality and Outcomes Framework Guidance, 2004 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4088693.pdf

[^9]: NIGB http://www.nigb.nhs.uk/about/guidance/amendrecords

[^10]: Information in the Consulting Room, final report 2002; Nick Booth, Judy Kohannejad, Paul Robinson; SCHIN, University of Newcastle

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