A Few of the Wrinkles of the Shared Electronic Health Record.

A really interesting article and more than one useful comment came to my attention a few days ago. The topic was an issue close the heart of your blogger – just how complex and hard it might be to make a shared EHR actually work in the real world.

Does Lorenzo mean the end of GP electronic patient records?

15 Apr 2008

GP computing has been one of the great success stories in patient care and the use of IT in the NHS.

Since its earnest start in the early 1980s, GP records have gone from paper based narratives held in A5 Lloyd George envelopes to fully interactive records, capable of handling the complexities of modern patient care, including the Quality and Outcome Framework (QoF) used for performance related pay and its central reporting mechanism, Quality Management and Analysis System (QMAS).

Without the universal use of electronic GP records throughout the UK, neither the targets introduced in 1990, nor the 2003 new General Medical Services contract, would have been achievable.

In the North, Midlands and East (NME), the area where Computer Sciences Corporation (CSC) is the Local Service Provider (LSP) under the National Program for IT (NPfIT), CSC is planning to introduce Lorenzo, which is understood to incorporate GP records, by 2010.

At present, CSC are supporting TPP SystemOne as their official alternative GP solution, with a view to incorporating it fully into Lorenzo by 2010.

Managing shared records

A great deal has been written about access to medical records held centrally, including the Summary Care Record (SCR) and the risks of unauthorised access. However, as far as I am aware, little or no attention has been paid to the management of the record itself. Has full consideration been given to the management of how such shared records should be arranged?

Lorenzo is planned as an early manifestation of the SSEPR (Single Shared Electronic Patient Record), defined as “a single electronic patient record for each individual patient used by, and contributed to by, all the organisations caring for that patient”, and scheduled to be introduced within two years.

Regardless of the access controls (and who controls access permissions), there are problems in managing a SSEPR which should concern everyone – and for which at present, I believe, no-one is claiming responsibility.

According to board minutes, Yorkshire and the Humber SHA is currently introducing a new shared record system to local NHS organisations, using a GP system with an integrated community module. The approach used within the TPP SystmOne SSEPR is understood to only let records be amended by whoever made the original entry.

The rationale for this is that the record also belongs to the organisations outside the general practice and only the organisation making the entry can change it: GPs can alter GP entries, community can change community entries and so on.

But using shared records that can only be amended by the service that made the original entry may present some worrying hazards.

Take the example of the patient who is sent to chiropody and returns with a diagnosis of diabetes mellitus, which the GP knows to be wrong; the entry on the records can then only be amended by the service that made the wrong diagnosis originally.

Currently Diabetes Mellitus gets picked up quickly thanks to the searches developed for QOF, and it is expected that patients with the diagnosis have the disease and should be managed appropriately.

Much more (and at least 8 comments) here:

http://www.ehiprimarycare.com/comment_and_analysis/309/does_lorenzo_mean_the_end_of_gp_electronic_patient_records_tcq

This is really a very important discussion as it raises the complexities and questions that sit beside the choice to develop a Shared EHR.

Among these questions are:

1. Does it make sense to deploy a Single Shared EHR (SSEHR) with all the patient information held in a single record – or is it more sensible to share just extracts as envisaged in HealthConnect? As soon as you go down the latter path you face the question of what data you hold where and how access to the detail is controlled.

2. Who is the owner of the record given it is built up from the contributions of many? This then leads on to all the questions about who can edit, change etc and how much trust can be placed in the record. There are also real medico-legal issues that arise as soon as any actual editing of the record becomes possible – if indeed it is permitted.

3.What access should each professional class have to the information in the record. Is there any value in having the pharmacist know about an abortion that was carried out 30 years ago?

4. Who has full access to the record – sealed containers and all. The GP, the patient, relevant specialists or who?

5. What access is the patient to have to the record and under what circumstances should information be held but not disclosed to the patient.

6. If sealed containers are to be permitted – are they totally invisible to others – or are they flagged as existing with a note to contact the individual authorised to open them? This goes to the issue of trust in the completeness of the record.

7. With virtually all EHR’s having considerable amounts of free text, how can highly sensitive, but un-coded information, be properly protected with any consistency.

8. Is there a good benefits case for sharing any more than a basic Continuity of Care record – at the very least in the first instance. Seems to me it makes sense to learn to walk before on tries to run!

These and many other issues are raised in the article and the comments. All worth a very careful read.

Until sound workable policy and work practices can be developed to address ALL these issues we need to hasten slowly down this road in my view. The time to address these issues is earlier than later in the Shared EHR development process. NEHTA are you listening?

David.