Life on Marsland on taking responsibility for the Summary Care Record
The idea that everybody should have an electronic health record has been around for a long time. An NHS Summary Care Record is being trialled in three areas and will be rolled out eventually. Iain Marsland wonders if the content will be acceptable and useful to clinicians.
The emerging Summary Care Record (SCR) is generating significant philosophical debate among clinicians and patient groups.
First introduced in the 1998 NHS IM&T strategy, Information for Health, as the Electronic Health Record (EHR), it was intended to include information about patient contacts with their GP and primary care team, as well as summary information about treatment by hospitals.
Today, the SCR is still a central pillar of the National Programme for IT in the NHS architecture. So far, three pilots are underway, with another about to be announced. These early implementations only contain demographics, allergies and medication details. Additional data can be included at the discretion of primary care providers. Eventually the SCR will be sourced from community provider clinicians, as well as acute providers.
“The assumption is that the data it holds is clinically accredited, relevant and accurate. That does not necessarily translate into it being clinically useful or acceptable.”
Nobody has disputed the fundamental reason for the SCR. The efficiency of the health service will certainly be improved through better communication between healthcare professionals and organisations. Few see the benefit of retaining single professional paper records and communicating through summarised notes or referrals.
However, there are plenty of issues to discuss. I don’t want to deal with the security or confidentiality of the SCR or whether patients should give implied or explicit consent for their information to be included in it. Those are subjects of the moment and are being dealt with in depth elsewhere.
I do want to look at whether the current focus on security and confidentiality is hiding a rather more fundamental problem – that of how useful the data contained within the SCR will be. The assumption is that the data it holds is clinically accredited, relevant and accurate. That does not necessarily translate into it being clinically useful or acceptable.
Incomplete data
Most clinical data needs to be context-based to be useful. Recording allergies without their associated reactions can limit potentially useful treatments. An allergy to Penicillin can result in a range of reactions, from rashes and diarrhoea to the more serious anaphylactic response. Clinicians need to know how the patient reacts to allergens.
Recording drugs without condition can be equally unhelpful. Some drugs benefit from further data and explanation. For example, clinicians wish to see the target INR on Warfarin prescriptions. Similarly for pathology results where, for a wider clinical audience, numerical data will need to be accompanied by a pathologist’s report for clarity and safety.
Judgement and opinion
“[The clinician who has precedence over a patient’s care] must become the senior responsible owner of the patient’s SCR and accredit the data held there.”
Medicine is based on judgement which itself is transcribed as professional opinion in medical notes and especially for diagnoses and treatment pathways. The expectation implicit within the SCR is that clinicians will value and act on third party clinical opinion. That premise needs to be tested amongst the clinical professions.
Until recently, referrals were made between clinicians who knew each other and had built up a professional trust of each other’s practice and opinion. GPs, as the key gatekeepers and advocates for patients, are probably the most sceptical, even of their own profession. To expect GPs, nurse practitioners, modern matrons, health visitors and hospital consultants to drop their guard and believe everything they read in the SCR goes against common sense and practice.
Ownership and accreditation
The Royal Medical Colleges and NHS Connecting for Health, the agency that runs the national programme, are developing standard records in support of the NHS Care Record Service, which includes the detailed care records held by individual NHS organisations, as well as the SCR.
This is a necessary and welcome foundation for shared records. Unfortunately no matter how structured clinical notes are, key elements are still based on opinion and judgement. Those core skills that sit at the heart of medical practice may result in a fundamental flaw in the SCR. As the numbers of professions and professionals contributing to the record grows then the level of distrust may also grow to a point where the SCR itself is brought into disrepute.
To begin to overcome this problem, we must answer the question of who has precedence over the care of a patient and hence the patient’s record. This may be obvious for simple pathways of care. Yet even patients themselves are unsure who leads their care for complex and multiple conditions, such as diabetes with renal and stroke complications.
Whoever that clinician is must become the senior responsible owner of the patient’s SCR and accredit the data held there. I do not underestimate the enormity of the change implied in this argument and the challenge that it will present to the caring professions. Unfortunately, the alternative could be an SCR with the credibility of Wikipedia.
About the author: Iain Marsland has been in the NHS for 34 years, most recently as chief information officer for Essex Strategic Health Authority and previously as director of IM&T for acute trusts in Brighton, Sussex and Bristol. He is now an independent consultant.