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Documents and databases for the NPfIT record

paper-records.jpegWilliam Hooper is Senior Advisor, Healthcare, Xerox Global Services and writes as a guest author.

This blog has frequently looked at humans and computers in healthcare. Let us introduce another factor—types of information.

Historically, pretty much an entire acute note has been un-structured. Some forms have been used for transactions such as ordering tests or receiving results, and nurses, as ever, are organised. I have not yet found a fag-packet in notes, but you get the idea.

The National Programme attempts to take a structured approach. GPs have been working this way for years, and it has many advantages. Computers are good at validating entries, when supplied with sensible rules. The advantages in terms of activities such as prescriptions are obvious. They can also be programmed to make sensible suggestions on care given a set of patient conditions. To say that programming these care paths is complex and time consuming is an under-statement.

Databases (which are what underlie the clinical systems of CRS) are good at holding structured observations and measurements. But, it will be many years before they have comprehensively encoded the bulk of medical practice (if ever).

Meanwhile, clinicians today are still adding both free-text and documentary additions to GP and acute notes, to say nothing of psychiatric observations. Paper is being generated too, and a tiny proportion is now being scanned and added to the database note.

A database stores a blood-pressure reading effectively where the care-plan says one should be taken. Documents can store anything and everything from the patient’s mood this morning to a sketch of a planned intervention.

The technology is now available to integrate documentary with data notes. This is to be supplied in most NPfIT clusters. Rather than talking about heaps of paper as being a problem for records managers to sort out, should we not be concentrating on who needs what information to deliver care, and how best to make best use of this?


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Do you think that in some way the management of scanned paper may slow down the adoption of IT by medical staff?

Would you agree that there is less scope for exploiting scanned information than for information in a database?

It seems to me that if staff can continue to use paper and have it scanned in there may be less incentive to move into the digital world?

Those staff that are used to doing everything on a computer will be little inhibited, and will not use scanning much. For them, document management will mean the ability to upload files such as digital photos and WP letters. For those less comfortable with IT, it will accelerate their change by making all the record available through the system, both DB and scanned.

For structured information, where a field is provided it is far better to use it than to write the data on a page and scan it. The totality of patient care includes both this data and unconstrained observations for which a database is a poor receptacle.

The process of helping staff to make best use of the digital record is likely to be a combination of the carrot of rich information processing and the stick of requiring certain fields to be completed. The current state is so far off being able to administer either with any effectiveness as systems rarely cover more than a single department's delivery of care. In the interim, paper is the only option in Acute. Over time, databases will progressively become more pervasive. The best solution comes from using both approaches; each where it brings the best clinical benefit.

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