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Tuesday 25 October 2016
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Linking records

The joining of primary and secondary care records is a long-held ambition for the NHS. It is to many imperative for patient safety that an ambulance or hospital has timely access to a patient’s medical records

The integration of medical records has long been a holy grail for the NHS. Millions if not billions have been spent in pursuit of this goal, but why is it so elusive? In North Oxfordshire, general practice is currently struggling to integrate the primary care clinical systems of INPS’ (In Practice Systems) Vision and EMIS (Egton Medical Information Systems) in order to deliver seven-day week opening across organisational boundaries. We are finding that it is fraught with difficulties. Why is it apparently so difficult to implement what is after all a cutting-edge technology of the 1960s in order to improve the care and safety of patients? We should ask why is it that we can use credit and debit cards in ATMs on the far side of the world and see the transactions reflected in our bank accounts within nanoseconds, but yet secondary care cannot inform GP surgeries of when their patients are admitted and discharged from hospitals? The international banking system demands information on transactions in real time. The NHS should expect nothing less.
Part of the chief executive of NHS England, Simon Stevens’ Five-Year Forward View for the NHS is the avoidance of unnecessary hospital admissions by improving the care of the frail and elderly in the community. Part of this improvement in care requires that general practice is able to resume the care of patients, seamlessly, on discharge from hospital. The avoiding unnecessary admissions enhanced service makes it clear that general practice has an obligation to contact the patient within three days of discharge from hospital. On the face of it, this sounds like an eminently sensible and easily achievable objective. In practice, it is quite the reverse. Quite often the first indication that general practice will have that one of their patients has been admitted to hospital is when it receives a discharge summary, of variable quality, often some weeks after the discharge of the patient. Linking primary and secondary care record systems would make it far easier for general practice to be informed of both hospital admissions and discharges. It would also make the audit of the timeliness and accuracy of discharge summaries far easier.

Simple linking
The linking of secondary and primary care records is not too complicated. All medical records should be identifiable by the use of the NHS number. Any dataset using the NHS number as a unique identifier, is capable of being linked to any other dataset using the NHS number in a similar way. This is at the very heart of relational database theory using the one-to-many relationship. One patient may have many episodes of care but one episode of care relates to one patient.
All patient episodes of secondary care are contained within the secondary user service (SUS) and service level agreement monitoring (SLAM) datasets. Both of these datasets use the NHS number as the unique patient identifier. Both of these datasets provide information on admission and discharge dates for episodes of care. They also provide information on complications coded in secondary care. These complications could include diabetes, hypertension, stroke, coronary heart disease and a number of other long term and transitory conditions. It is generally accepted that the primary care records are the best and most complete of the various fragmented patient care records within the NHS. It is therefore surprising that there is no validation of these complications noted in secondary care against the primary care record.

Clinical commissioning groups (CCGs) and their commissioning support units (CSUs) are developing ways of monitoring the timely transmission of discharge summaries and other clinical letters without referring to primary care records. This ignores the fact that communication does not consist merely of transmission. True communication is a four stage process, including: transmission, receipt, decoding and comprehension. Linking primary and secondary care records would enable a whole system audit of the discharge summaries to be performed. An episode of care in SUS/SLAM data should correspond to a discharge summary or clinical letter received in the primary care record. The date of discharge in service, compared to the receipt date in primary care gives a clear and accurate record of the delay in issuing these documents for use in quality monitoring systems.
Discharge summaries transmitted by secondary care but not received in primary care represent a significant potential danger to patients and must be addressed. It can only be addressed by looking at both primary and secondary care data. Many GPs are also frustrated with the late receipt and quality of discharge summaries. Linking record systems would enable secondary care departments routinely issuing late discharge summaries, or no discharge summaries, to be identified. It would also allow for GPs to comment on the quality of the discharge summary as they read it, rather than having to enter a clinical reporting system, such as Datix and complete the reporting form. This is not pitting primary care against secondary care. It is rather putting the interests of the patient first to ensure that general practitioners have the information they need to provide high quality and appropriate care to patients recently discharged from hospital.
These complications, included within the SUS and SLAM data have significant budgetary implications for CCGs and acute providers. Recent reports by both the Audit Commission and Capita indicate an average 4.5% over coding including complications in favour of secondary care, equivalent to £1.4 billion per year. The Health and Social Care Act 2012 expressly forbids the use of clinical information for invoice validation. Perhaps in these straitened times, the government should revisit this restriction on data use in order to ensure that CCGs only pay for the services delivered by secondary care.

A much needed vision
So why is it that the NHS is content to tolerate a fragmented clinical information system? Some believe it is the lack of an overarching vision for the future of medical record integration. The absence of central vision leads to the expectation of local development of local IT integration solutions by CSUs. This in turn leads to further fragmentation of medical care records as local systems fail to be able to communicate across CCG and CSU boundaries. The NHS currently has numerous IT groups duplicating at their effort to solve the same problems. A vision for medical record integration in the NHS is a system where:

  • Relevant clinical information from the primary care record is available to community and secondary care clinicians, with appropriate information governance, for the purpose of delivering safe and effective care to patients.
  • Information concerning care being delivered in the community and/or secondary care should be available to general practice on demand and in realtime.
  • Coding of complications in secondary care should be based on information stored in primary care datasets.
  • Admission and discharge information from secondary care is notified to the usual GP by a system generated electronic document transfer (EDT).
  • Discharge summaries and clinical letters are generated with a minimum of delay with system generated breach reports going to CCGs for contract monitoring.
  • Significant documentation, such as admission avoidance care plans, are available and obvious to all interested health professionals, including A&E and ambulance services.
  • Any future IT system commissioned within the NHS must be capable of being integrated, both vertically and horizontally.

An integrated medical record system is not only an achievable objective, in the interests of patient safety, it is essential. Being aware of the flaws in the current system and nor insisting on change we are accepting a system that we know to be unsafe.

Andrew McHugh, manager of a GP surgery in Banbury, North Oxfordshire.