Medical records, flexible working

Digitising the clinical paper trail: a clinician's tale

As an NHS doctor, deficiencies in how we processed information always seemed pretty evident. I recall how, as a house officer, I would have to fetch x-rays from one department to another. Much of the time the x-rays wouldn’t exist, or they would be hidden away in a secretary's office which was locked, or in storage in another part of the country.

I can remember times when this lack of information caused problems — patient delays, unnecessary transfers and sometimes worse. It becomes obvious in those first formative months that the role of a doctor is predominantly the collection and collation of information to provide good care — from blood results to evidence-based treatments.

I became involved in information technology from a purely selfish point of view. I was stunned that all my years of study had culminated in me copying blood results from a computer onto a flow chart to put at the end of a patient’s bed for the boss to peruse, or that I had to physically walk around the hospital to find out where my patients were.

This, of course, meant getting out of bed earlier, and leaving work later. This was unacceptable. So, in 2001, I devised a PDA programme on an early Palm PDA to download results from the computer onto the device so I could carry it around on the ward round and not have to write it down.

The concept seemed sharp, but there were practical issues — I had no idea about the technologies involved — the languages, patient confidentiality, and the endless committees needed for approval.

As is always important, I found a mentor in a biochemist at Leeds General Infirmary who managed to give me guidance and, most importantly, encouragement to not get disheartened with the obstacles.

He had also been in a similar situations whilst trying to develop new ideas as a clinician but had found paths through. And that seemed to be how it was in 2001. The NHS IT programme (now renamed) was then at its inception, great visions were laid out and huge projects were being born. Mine was a drop in the ocean.

Keen to be part of the process, and deciding that the next big thing in medicine was information technology, I studied full time for a Masters in medical informatics whilst working as a SHO in oncology.

Although this often meant that night shifts would end and lectures begin, I was buoyed by the subject matter (and coffee) and completed the course with a head filled with ideas for more projects.

I developed countless departmental databases/ stroke audit programmes/ networked data-entry programmes and even some medical games for many of the places I worked at since that course.

It was a great remark on the old system of medical education that that kind of flexibility was allowed and it allowed me to develop skills in programming that I would otherwise not have acquired. It was also a great remark on IT within the hospitals that they allowed me to carry out such projects with the view that clinician involvement was tantamount and should be encouraged.

A glaringly obvious gap in the day-to-day working of a hospital was medical transcription. Increasingly, hospitals were being asked to audit their outpatient appointments, or send out letters more quickly, particularly on '2-week wait' patients, whereas in reality the letters would be sent a week after the appointment, leaving the recipients in the dark.

The secretaries were also under an increasing burden as the number of outpatient appointments increased. Why not have a system where the letters for a single clinic were shared out amongst many, and what better model to use than the internet in order to do this?

As such, I became involved in the DICT8 project whose aim was to provide a type of parallel processing of clinic letters. We used a model which allowed doctors to upload letters from their electronic dictaphones onto their online account, without having to install any extra software.

The letters would get typed up by several secretaries online, who were based in the UK and experienced with the doctor’s specialty. All the doctor had to do was then login, check and download the letter.

The turn-around time for typed letters dropped dramatically from weeks to one hour, and often the doctor would have all the letters from the day’s clinic before he or she left the hospital.

The potential for the technology seemed powerful and I was lucky to have been involved at its conception using my background to help develop the technologies and languages that the system works on.

The project has now grown. We are used in several trusts around the country with great success. We have also grown the project. It clearly has great potential and we have designed it to be fully integratable into proprietary trust databases, as well as using the system for clinical and financial audit. The system is also proving to be a good basis for coding of outpatient episodes for 'payment by results', which has become an important information trust requirement.

I would like to think that I was a good example of clinical involvement in the NHS IT programme. In defence of the NHS, it has not been obstructive to any new IT ideas I may have had, just occasionally confused as to whether they should be allowed.

I often hear of criticisms regarding the NPfIT but, from my perspective as a clinician, it seems to be working: I can access x-rays from anywhere in the hospital; I get the flow charts I want on the computer without having to write them out; and I can see electronic discharges from a patient’s last admission.

My contribution has been to recognise the importance of what is happening and to want to become positively involved.

Dr Sebastian Zeki, Gastroenterologist, Ealing Hospital.

Further information

For more information on DICT8 please see www.dict8.com