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Nicholas Lee, FRCS, FRCOphth,
is a Consultant Ophthalmic Surgeon
and the co-author of the ABC of
Medical Computing BMJ.
His specialist interests are medical
retina including diabetes and
diabetic screening, and age related
macular degeneration including
photodynamic therapy.
Figure 1: Picture of Practice Manager from screen This displays
the
demographics on the patient from which the diagnosis, letters, notes
etc. may be created. The display is very large and easy for both
Doctor and patient to see. Navigation is aided by large buttons where
possible and short keyboard cuts for the most popular
selections.
Figure 2: Vision chart The visual acuity part of the Electronic
Patient
Record (EPR) in Practice Manager. Vision by entered by LogMar or
Snellen and is also displayed graphically. This graph may be
incorporated into the patient's letter if required.
Figure 3: Patient information screen This is menu for printing
out
information for patients on their eye conditions. New handouts
can easily be written and incorporated or updated as information
changes.
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Introduction
Computing has evolved a long way since the first
computers of the 1980s and to some extent doctors have been left behind.
The National Health Service is recognizing this and investing large amounts
into Information Technology and one notable improvement is placing a computer
on every consultant's desk. This gives the opportunity for doctors to
use IT more in their clinical practice. However it is naïve to think that
merely putting a computer on a doctor's desk will bring benefits; it is
a far more complex issue: Factors to consider are:
1) Availability of programs to do the task - Are
these well written and mature, from companies that are going to be around
for the long term?
2) Are they supported by a good IT help desk?
3) Is the program linked to the PAS (Patient Administration
System) system for demographics or able to exchnage data with other Electronic
Patient Record (EPR) programs?
4) Doctors are very mobile - can the programs be
used elswehere off site?
5) How is the data backed up?
6) Is the data secure and confidential?
This article looks at how IT can assist in the
decision making process in Ophthalmology.A good source of the way the
government views IT is the Department of Health (DOH) website: www.doh.gov.uk/ipu/develop/
Information for Health (1998) document sets out the strategy to change
the way the NHS uses information. Many of these initiatives will fundamentally
change the way we work whether in the clinic on the ward or in the community.
Many of these changes have begun and the level of IT knowledge that we
all are required to know is increasing as we get involved in ever more
sophisticated projects.
Electronic Patient Record
(EPR)
The government Electronic Patient Record (EPR)
scheme has a number of stages but the early stages are more to do with
appointments and management aspects than clinical. The plan by 2010 is
to have all of a patient's clinical information available from where ever
the patient is being seen or has been seen in the past, be this in the
GP setting, community or in the hospital available at your terminal. GP's
have had EPR for many years, all be them quite old systems but do contain
a wealth of information and it certainly would be useful for secondary
care to have access to these records. All aspects of the clinical record
will be computerised from the notes, investigations, Xrays, images, letters
etc, producing a truly complete electronic clinical record. The patient
too will have access to his or her own record via "Yourhealth"
web pages. This is the single largest IT project to be launched in the
UK costing £1.3 billion and will undoubtedly affect the way we all
work. The project started this year and contracts for the companies overseeing
the project are to be awarded later this year and discussions with clinicians
on designing these systems have already started. Many hospital systems
still run on old patient administration systems which are in many hospitals
coming to the end of their lives and being replaced by more modern solutions
which it is hoped will evolve into true EPR as medics view them. Currently
most systems are limited to making appointments, logging procedures performed
and auditing times of operations as well as financial data, however the
newer systems have the capability of doing much more. Our Wyse dumb terminal
based system, supplied free with the hospitals PAS system at the Western
Eye Hospital, runs a basic EPR using simple screens for data entry which
are customisable for speciality and allow the GP/optometrist record to
be printed off immediately. As the clinical data is stored it is possible
to create reports on activity as well as patients with particular diagnosis
etc. It is functional and quick but not as flexible as windows-based EPR
schemes.
Central to the EPR is the demographic database
of the patients; usually know as the PAS (Patient Administration System).
Ideally this data should be able to be shared with other programs, this
often needs an interface which can be costly to set up but does ensures
data entry is not duplicated and data quality maintained. There is no
one program that is everything to everyone, thus bespoke programs have
evolved to meet particular needs and thus in ones practice it is necessary
to use a range of programs.
Modern alternatives for EPR exist. One we use at
the Hillingdon Hospital, and is the largest EPR in private practice, is
Practice Manager (DGL - www.dglit.co.uk). This is a modern windows-based
program which act as an EPR which has evolved over 12 years and thus is
very mature and very extensive. It is also highly flexible being able
to adapt to individual needs. At Hillingdon this uses the PAS demographics
database to collect the basic information on a patient and with the new
PAS will perform a live two-way link.
The front screen of Practice Manager Presents the
demographic information on the patient, their GP, and importantly logs
the optometrist and other linked clinicians. Currently in hospitals, few
write to the patient's Optometrist because they are not recorded. Both
our Clinical Data Capture (CDC) and Practice Manager has a database of
all our local Optometrists and once this is attached to the record, reports
can be copied to them at the same time it goes back to the GP. The biggest
complaint Optometrists up and down the country have is that they rarely
(12-17% of time in Whittaker et al's survey1) receive information about
their patients. There is really no excuse for this as it puts the optometrist
in a very difficult situation when the patient returns asking questions.
With increasing shared care this is becoming more important. However entries
in Practice Manager do not have to be patients but can be companies, company
representatives, meetings, friends etc. Letters, articles, papers can
be scanned for easy future reference and useful notes section for recording
conversations and call log numbers which IT help desks always require
you to note down. Practice Manager is a superb front end for Word, which
is the word processor it is linked to, making letter writing very easy.
All the old correspondence is stored against the patient entry for easy
access later.
Practice Manager can be stand alone, but comes
into its own in being able to be both networked and has an
import/export facility for laptop users enabling the data to be synchronised
with the main server either by connecting to the network or even by modem
connection. This helps in outreach clinics or multi-site situations enabling
access to the EPR at any time or place. Practice Manager has sections
for recording diagnosis in Read 3 format, procedures, management, visual
acuity, refraction, investigations, intraocular pressure (IOP) and medication.
The diary and theatre modules can be used for not only to book patients
but also to schedule meetings and staff holidays. Practice Manager can
have any number of different consultant or clinic data sets, so for instance
my laptop has a training mode, main NHS clinic, diabetic screening service
and a private copy. Every aspect of my professional and person life is
managed through Practice Manager and even my son has a copy to manage
all his school work!
EPR Entry
Vision may be entered in two formats, Snellen or
LogMar, but is displayed in both and may be incorporated into the letter
in both formats. By recording or going back in the notes and entering
the information on the vision you can build up a picture of what has happened
to the patient's vision more quickly next time. The graph is a useful
way of displaying this to you and the patient. Similarly there is an intraocular
pressure (IOP) section enabling fast evaluation of IOP trends. With combined
notes in hospitals it can take quiet some time to look through all the
readings when interspersed by general medical notes, where as in an EPR
these are all collected together and it is thus far quicker to understand
what has been happening to the patients vision or IOP. Having entered
the relevant information, the system enables production of request forms
for investigations eg. Fundus Fluorescein Angiogram (FFA), Xrays, admission
forms etc. The patient's details are merged with Word templates which
are completely customisable, my system has over 800. For the FFA request
form the program prompts the doctor to enter in which eye the run should
be done on, why the FFA is being done and any allergies. This ensures
a complete request form every time. In addition the form has the patient
information to give the patient. As these are printed with the request
they are available every time. Similarly with waiting list forms, the
electronic form ensures that all necessary information is entered and
not left out, with plenty of information for the patient to take away
with them.
Patient Information Sheets
Kessels2 showed that most patients forget up to
80% of what they are told as soon as they leave the clinic. Nearly
half of the information they do remember, they remember incorrectly. It
is well know that patients forget 80% of
what you tell them. The article recommends backing up spoken advice with
written or visual material.
Written information has the obvious benefit of being able to be read and
reviewed later. Practice Manager has a
patient information section enabling unlimited storage of patient information
sheets in a variety of font sizes suitable
for the vision of the patient. These can be printed off when they are
needed, my view is that every patient should be
given information about their condition to take away. You just cannot
keep enough pre-printed leaflets on all the conditions that exist to do
this, nor can they be easily updated as new information comes along. A
computer and a printer are essential to achieve this.
Medication Screen
The commonest complaint from the pharmacy is that they cannot read the
prescription. Modern pharmacy systems
are available for hospital wide systems enabling electronic prescribing
from the doctor's terminal, which is passed to
pharmacy electronically and in one place even activates a robot to select
the drugs and restock. However few hospitals have succeeded in achieving
this. Practice Manager has a medication module that aids the doctor in
selecting the drugs by providing advice and then by printing the prescriptions
with the name of the doctor so there can be no confusion. This is set
to work with the hospital system, FP10's and private prescriptions. This
is greatly appreciated by the pharmacists.
Letter creation - Transcription/Voice
Dictation
Of vital importance is then to create the final
report to send to both the GP and the optometrist as well as any
other linked clinicians there may be. An EPR program like Practice Manager
stores and orders these letters for easy retrieval by anyone on the network
or even remotely on merged laptops. Computers have encouraged senior staff
to perform keyboard typing tasks that were previously the domain of the
secretaries. The question of whether this is appropriate use of senior
personnel is an interesting one. For those with high level of keyboard
skills this is an attractive option as letters and emails are sent with
out the need for proof reading in a much shorter time frame.
However if your keyboard typing skills are slow
the answer may be voice dictation. The dream of being able to
talk to your computer and it will miraculously obey your commands and
type has progressed but is by no means
perfect. It requires significant discipline to use and achieves around
95% accuracy which sounds high, but
means five words in every 100 will be correctly spelt, and thus not picked
up by spellcheckers, but just the wrong
words, spotting these is far more difficult unless you have the dictation
play as you proof read which is time-consuming. However for the finger
typist this is a solution worth trying. Future developments to increase
the accuracy are looking at incorporating lip-reading to the speech recognition.
Transcription on the other hand has been available for some time, but
not integrated with EPR software as of yet. Here you dictate directly
onto the PC and the voice files are then sent to your secretary or via
email to anywhere in the world for transcription (there are several companies;
www.ten-percent.co.uk, www.essentialsecretary.co.uk, www.london-secretarial.co.uk).
The human ear has the unique ability to decipher your dictation from background
noise, remove the 'ers' and 'ums' and any other irrelevant comments. Given
the volumes of letters generated in medicine it is surprising this technology
has not been utilised more. In due course the reports will be emailed
rather than mailed to the GPs and Optometrists. Though with the availability
of encryption for email, the technology to achieve this is here now.
Scanning & Image
Storage
Few hospitals have yet taken the final step to
discard their paper records despite the technology being cost-effective
and available. Virtual CaseNotes (Summit Health) integrates paper-based
records with data from other computerised information systems. Paper-based
records still provide the mainstay for recording and review of patient
information but these can be scanned and stored for later use. The advantage
of electronic stored images of notes or data is that it can be available
to several users at the same time where as paper records can only be in
one place at one time. While computer inputting of data will become more
common, the nature of medicine still requires writing of notes at times
but these can be scanned and archived later. In time, no doubt, we will
see this technology in hospitals. Current software like Practice Manager
can scan and store (encrypted) records reducing the need to store paper
records. This has huge advantages for your personal or private practice
as a filing cabinet of records can be stored on one CD with obvious spacing
saving. This can either be done by your own secretary, staff or DGL themselves.
Digital photography is becoming the standard for ophthalmic photography
in the clinic and for diabetic screening. Radiology is similar progressing
towards digital Xrays.
NOTE: This article originally appeared in
the August/September'03 edition (Vol 10, No.2) of EyeNews and is re-printed
with the kind permission of both Mr Lee and EyeNews. The author has no
financial interest in any of the products mentioned in this article. The
full, un-abridged version of this article can be downloaded
here (requires Adobe Acrobat Reader)
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