Clinical EDI in General Practice A GP s Guide to the Use of Electronically Transmitted Pathology Reports

Transcription

1 Clinical EDI in General Practice A GP s Guide to the Use of Electronically Transmitted Pathology Reports Version 3.0, July 2001 Dr Richard O Brien East Quay Medical Centre Bridgwater Somerset

2 CONTENTS CONTENTS...2 PREFACE...3 SUMMARY...4 INTRODUCTION...5 The purpose of this pamphlet...5 The evolution of Clinical EDI...5 The future of Clinical EDI...5 You don t have to go paperless...6 AIMS AND ADVANTAGES OF CLINICAL EDI...7 A common aim for the use of Clinical EDI...7 Advantages of Clinical EDI...7 HOW CLINICAL EDI WORKS...8 Reports are sent to your computer...8 Matching and filing the reports...8 Adding comments and taking actions...8 Electronic lab requests...8 YOU CHOOSE HOW MUCH YOU USE CLINICAL EDI...10 Minimum use of Clinical EDI...10 Maximum use of Clinical EDI...10 An example of maximum use...10 What do you do with the paper reports?...11 ACHIEVING THE MINIMUM USE OF CLINICAL EDI...12 Training your practice EDI administrator...12 What help is available?...12 Transmission failures 12 Reports not matched to patients 13 Reports not matched to doctors 13 Results without a Read code 13 Failures of filing and archiving 13 Increasing your use of Clinical EDI...13

3 PREFACE Pathology messaging in various technical guises has been available for a considerable time, and as a result a large body of experience has grown. The current national roll-out of pathology messaging has taken advantage of this experience in designing a standardised approach that deals with identified issues. This document has been written by Dr Richard O Brien, an experienced user of pathology messaging, and a practising GP in the Somerset Health Authority early adopter community. It provides a highly informative introduction for primary care staff as to what pathology EDI can offer, and how clinical messaging of the future can support patient care. It also provides recommendations and suggestions on how practices can take advantage of pathology messaging. The current national roll-out of pathology messaging introduces a range of new capabilities, for example the use of encryption to protect privacy and confidentiality of messages in transit. To support the introduction of those new ways of working the project has, in collaboration with professional representatives, produced detailed Good Practice Guidance for practices. This and other detailed guidance information is available via the Pathology Messaging web site: Pathology Messaging Implementation Project July 2001

4 SUMMARY EDI (Electronic Data Interchange) is already a fact of life in primary care, and it will become increasingly important in the future. It has clear advantages over current paper-based systems in terms of speed, accuracy and reliability of communication, adding up to improved patient care. The vast majority of computerised practices already have registration and item-of-service links with their health authorities, but a growing minority also receive clinical data, such as haematology, biochemistry and microbiology results, from local laboratories. Future developments in Clinical EDI will include the transmission from hospitals to GPs of radiology and histopathology reports, as well as hospital out-patient and in-patient reports. In the other direction, from GPs to hospitals, Clinical EDI developments will support referrals (including rapid cancer referrals) and pathology and radiology requests. These developments depend on the ability to exchange electronic data between the transmission systems and your patients computerised records: the first step is to incorporate pathology results into your patients records, and an important aim is to achieve this in every surgery. GPs with an interest in computers adopt EDI with enthusiasm and a hands-on approach, but the future of EDI also depends on those who have little interest in, or even an aversion to, information technology. They may be reassured that they can become part of this future without substantially changing their current working practices, and it is hoped that this document will provide the necessary reassurance and perhaps even stimulate their interest.

5 INTRODUCTION The purpose of this pamphlet This paper will help you derive benefits from electronically transmitted laboratory reports. It is not intended to tell you how to organise your working practices; it is aimed more at helping you to adapt Clinical EDI (Electronic Data Interchange) to suit the way you work. It will show that Clinical EDI can be set up on your computer with a minimum of fuss, and that you can have as much or as little to do with it as you like. Pathology reports are just a start in the evolution of Clinical EDI (to be clear, in this context a report is a collection of results), but once the mechanism is in place to incorporate them into your patients computerised records, future developments in EDI will be able to follow. In this document, the term Clinical EDI will therefore refer to pathology reports, but it will encompass a wider range of applications in the future, as described below. The material in this document applies to all GP medical computer systems. Details on how to set up particular systems are included in the suppliers manuals, and there will be opportunities to receive training in the use of your system from your software supplier and/or health authority. Some Primary Care Groups/Trusts (PCGs/PCTs) will also have mentors, experienced GPs who can offer help and guidance in setting up your system. The evolution of Clinical EDI EDI has been around for several years. If you have computerised registration links or item-of-service links with your health authority, then you have EDI. Clinical EDI has been available for nearly as long mainly for haematology and biochemistry results but only a minority of surgeries have so far chosen to use it. There are various reasons for this. Getting the most out of Clinical EDI involves a relatively high degree of computerisation, and until recently only a few surgeries have had the resources to install the necessary hardware. It has also depended a great deal on having one or more partners who are particularly interested in computers and able to deal with their idiosyncrasies. In the early days, Clinical EDI did not always run smoothly, and often tested the patience of the most dedicated enthusiasts. The situation is different now. Almost all surgeries have a medical computer system, and many are now connected to NHSnet either through a single standalone computer or via their medical system. Most GPs have a computer on their desks: all are connected to their medical computer system, and many are also connected to NHSnet through that system. Therefore, most surgeries now have the capacity to receive Clinical EDI messages. The future of Clinical EDI Clinical EDI started with haematology and biochemistry results because they are the easiest to transmit, but it has recently been extended to include microbiology results. Future transmissions will include transfusion results and text-based reports such as radiology (already working in some areas), histopathology and hospital correspondence (outpatient clinic reports and discharge summaries/letters). You will then have an electronic patient record that can be seen from any terminal in your surgery. This record won t be lost, will automatically be kept up-to-date and sorted, and can be sent to a patient s new practice if they move. Imagine receiving a new patient s record that doesn t have to be summarised, sorted or tagged. The next step is to complete the circle, with Clinical EDI flowing out of the practice as well as into it. Electronic requesting of lab tests is already being tested (see below), and this enables the report to be matched to the request, so you know when all the tests you requested have been done. Hospital referrals can be sent electronically (cancer referrals are already in the pipeline), and the subsequent outpatient letters and discharge summaries will be matched to the original referral.

6 You don t have to go paperless A computer-based vision, as outlined above, is not to everyone s taste. Many surgeries have an efficient notes-based system and see no reason to change nor do they need to do so. Most doctors did not study medicine with the intention of becoming computer boffins, and those who maintain a healthy scepticism must have their concerns respected. Clinical EDI reports can be incorporated into patients computerised records with a minimum of intervention and can run alongside, or complement, a paper-based system. The process does need a small amount of supervision, but this can be accomplished easily by non-medical staff with a little training. The extent to which you are computer- or paper-based is entirely up to you, but you will have the choice to move to a more computer-based system at the pace you choose, and at a time that suits you.

7 AIMS AND ADVANTAGES OF CLINICAL EDI A common aim for the use of Clinical EDI Given the implementation of suitable systems within NHS trusts, pathology reports can be reliably transmitted to all but a small proportion of surgeries, and we are at the stage where we may state the following as an aim that can apply to all computerised practices: Pathology reports can be incorporated into the patients computer records in every computerised surgery. This aim is not difficult to achieve it is no more challenging than the registration and item-of-service links already working in most surgeries and there are all kinds of help available to assist you in achieving it. Nonetheless, it is an important step because it will form the foundation for future developments that will further enhance and streamline the exchange of clinical information. To corrupt a well-known saying: it s a small step for a surgery but a giant leap for clinical communication. Beyond this aim, it is not intended to impose any particular working methods on your surgery. If you wish to continue receiving paper reports you may do so, although you may eventually ask your local laboratory to cease sending paper reports to your practice when all parties are happy about using electronic results. To give it another sound bite: the evolution of EDI in the National Health Service is a culture change, but it needn t be a culture shock. However, it is hoped that you will see the benefits of Clinical EDI for your practice and your patients, and that you will be inspired to develop its use within your surgery. Advantages of Clinical EDI Currently, the main advantages of electronically-transmitted lab reports are in terms of time: Electronic reports usually arrive a day before paper reports sometimes on the same day that the sample was sent. Practice staff do not have to sort and stamp the reports. Adding comments and taking action are usually quicker. The reports are filed in the electronic patient record with very few keystrokes (much quicker than for paper records, giving a big saving in staff time). Results can be viewed quickly on any computer terminal in the surgery, without the need to find the patient s notes. Results can be automatically incorporated into referral letters and summary printouts. Searches and audits are easy and fast. In the future, other laboratory-based reports will be received more quickly via EDI, and text-based messages such as radiology reports and hospital discharge summaries will reach you soon after they have been typed. Eventually, you may feel that there is little point in filing reports in the patients notes since they will go straight into the computer record with little effort think of how much filing time that will save your staff, freeing them for more rewarding tasks. Another important advantage is that EDI messages are rarely filed incorrectly they go straight to the correct patient record. This will become even more reliable when the cycle is completed by the transmission of requests and referrals from your computer to the lab or hospital, so that reports are matched to requests. All these benefits of EDI add up to one thing: improved efficiency of patient care.

8 HOW CLINICAL EDI WORKS Reports are sent to your computer When a blood sample is received at the laboratory, a technician reads the request form and types the details into the system controlling the analysers. The instructions to the analysers are thus linked to the demographic details of the patient, to the requesting doctor, and to the surgery. Beyond that stage the analysers are fully automated, and when the results are produced they can automatically be sent down a telephone line to your surgery s mailbox. The mailbox may be in your surgery s main computer (the server ), but in some systems the mailbox is held on a computer elsewhere, and your server automatically dials it and transfers the results into your system. Matching and filing the reports Your EDI software looks at the names of the doctor and patient attached to each report and matches them to the doctors and patients on your computer. The reports are now put into the EDI inbox for the relevant clinician, as stated on the original request form. That clinician, if he or she wishes, can look at them, add comments to them, ask for action to be taken and file them in the electronic record of the relevant patient. Each result in the report has been sent by the hospital as a Read code, together with the rubric (official meaning) of that code. The computer stores each result in coded form in the relevant electronic patient record: this means that the computer can easily search for and process the results because they are in a coded ( structured ) form that the computer can understand. After filing in the patient s record, the report is removed from the inbox and archived. Laboratory mailbox report matched to patient doctor s inbox [viewed/comments/action] results filed in patient record report archived In some primary care computer systems, this entire process can be automated. In theory, you won t have to do a thing if you prefer to deal with the paper reports and don t want to look at the computerised reports in your inbox you just skip the step shown in brackets above. In the past, this facility has been used to automate the filing of results that fall within the reference range for that test: but this practice is strongly discouraged and, as a safety measure, some medical systems require the reports to be archived manually. Moreover, there are occasionally reports that are not matched accurately to a doctor or a patient. These problems are straightforward to deal with (see later). Adding comments and taking actions If you want to, you can get the system to do a little more work for you, as shown above. Before the report is archived you can add a comment to it (eg Kidney test OK ) so that when the patient phones for the results the receptionist can look up the report on the computer and read the comment to the patient. With some systems you can also send an instruction to the receptionists, such as Ask patient to repeat test in 1 month. These comments and instructions are no more than you probably do with your paper results at present, but they can speed things up: standard comments and instructions can be kept on the computer so that you just pick them from a list much quicker than typing or writing. Electronic lab requests A further development already being tested is the electronic requesting of tests, in which a barcode is attached to the sample. This two-dimensional barcode is about 5cm square and contains the patient s registration details and all the other information normally put on the request form. You enter your request on your computer, which prints the barcode on a sheet of A4 (details are printed in words alongside the barcode in case cross-checking is needed). The sheet is sent with the sample to the lab.

9 The lab technician simply scans the barcode instead of typing in the details from the request form. Matching the sample to the patient is faster and more reliable, resulting in fewer mismatches and a quicker turnaround time in the lab. Your computer will also be able to match the results to the request, so you know when you have received all the results you asked for.

10 YOU CHOOSE HOW MUCH YOU USE CLINICAL EDI The extent to which you can use Clinical EDI covers a wide spectrum, and you can choose where you want to be within that spectrum. At one end of the range, minimum use can, in some systems, function without the GP s involvement: the electronic results may be filed in the patients computer records and the GP uses the paper-based system to read, comment on and request actions on results. At the other end of the spectrum, with maximum use, the paper reports can be dispensed with if you wish. Minimum use of Clinical EDI Minimum level of use for practices with basic IT provisions, eg just a server: EDI pathology results are filed in the patients computer records. The doctor continues to use paper records in the consulting room. The surgery continues with current arrangements for filing paper results, informing patients and taking action. What you do to maintain this level of use is described below. On most systems it will take your practice EDI administrator, who can be one of the administrative staff, about one minute per doctor per day to administer. The next step up from this minimum use might be for a doctor to view the filed results on his/her own terminal during a consultation. A further step up would be for the GP to deal with the results on his/her clinical EDI inbox, rather than in the paper format. Maximum use of Clinical EDI The maximum level of use for surgeries with full IT provision, ie terminals for doctors, nurses and receptionists: Doctors look through the incoming reports on their personal clinical EDI inbox, rather than looking at the paper results. (The reports are automatically matched to each doctor so they don t have to be sorted manually.) Doctors file EDI pathology results in the patients computer record and then remove the reports from the inbox by archiving them. An indicator may automatically appear on the consultation screen to show that EDI reports have arrived if you so choose. Comments can be put in the report so that a receptionist can read it to the patient when they phone for the result. Instructions ( actions ) can be sent to the staff in the form of an task list. Results can be viewed on any computer terminal in the surgery. Special provision can be made for dealing with absent doctors reports. Access to filed pathology reports can be gained from links on the consultation screen. You can choose to deal with the results by any means between these two extremes, and you can develop your use of the system as gradually as you like. An example of maximum use In our surgery, which uses EMIS (currently Version 5.1), each doctor deals with his or her own patients results. We have set up our system so that the results are automatically put into the patients records as soon as they arrive, but they need to be seen by the GP so that any necessary comment can be made or action taken. It takes three keystrokes to get from the Main Menu to the list of patients for whom there is a report. Another keystroke opens a report, eg a set of haematology results. On this, results which fall outside the reference range are usually clearly marked (although this feature should not be relied upon to determine whether a report is normal or not). We usually put a comment in the report by pressing F : this gives us a list of standard comments from which to choose, and these need just two keystrokes, but we can

11 instead put in a comment as free text. F also marks the report as having been viewed. If we don t want to make a comment we just press X. Most reports require no action to be taken by our staff, but if a particular report needs to be acted on we press N, which opens a Practice Note (a kind of message) to which we can attach an instruction. Again, standard instructions (eg Ask patient to make/keep appointment ) are kept on a list and can be selected rapidly. The Practice Note is sent to all the receptionists computer terminals. This adds about five seconds to the time taken to deal with a report. One further keystroke moves us to the next report. We could set the system to put references or links to the reports on the consultation screen, but we don t because they clutter it. Dealing with a report containing only normal results takes less than ten seconds add thinking time if there are any abnormal results. We have a buddy system, so that if a GP is away another designated GP takes care of their EDI reports. On average, each doctor spends less than five minutes a day dealing with lab results. It can even be done from home, as all our partners can access the system from their home computers. When a patient phones for a result, the receptionist looks in the patient s record (in the Patient Notes section) and reads the comment to the patient. The receptionist doesn t have to leave his or her seat. The Practice Notes the receptionists task list for action to be taken are available wherever a receptionist is logged-on to a terminal. If a receptionist has a spare minute he or she looks at the task list, selects a message, and performs the action requested, such as telephoning the patient to make an appointment. While the receptionist does this, that particular message is removed from the other receptionists terminals to prevent duplication of effort. When the action has been completed the message is removed from the task list. To make sure the job is done on busy days, one receptionist is delegated to check the task list twice a day in any event. What do you do with the paper reports? Surgeries that make minimum use of Clinical EDI can deal with the paper reports exactly as before. Some surgeries that use Clinical EDI to its maximum extent have asked the laboratory not to send the paper reports, cutting down considerably on administration. Our surgery does make maximum use of Clinical EDI but we have chosen to receive the paper reports as well, mainly to give us a back-up if the system breaks down. This has not happened for a long time, and we would probably dispense with the paper except for the fact that when a hospital consultant asks for a copy of a report to be sent to us it is not yet transmitted electronically. However, future versions of the software will enable reports on tests requested by a hospital consultant to be copied to the GP at the consultant s discretion. One of our staff members looks through our paper reports every morning, picking out those that are unlikely to have been transmitted, and enters the data on the computer by hand. The other reports are kept for three months then shredded.

12 ACHIEVING THE MINIMUM USE OF CLINICAL EDI Surgeries that have the wherewithal to use EDI to its maximum extent will already know how to achieve their ends. This section is for those to whom minimum use, or something close to it, has more appeal. As stated above, the aim is for pathology results to go into the patients records in every surgery. This requires at least one person in the surgery (not necessarily a doctor) to monitor the incoming results on each working day to make sure that: Reports have been received. They are matched to doctors and patients. They are filed in the patients records. They are removed from the inbox (archived). This is much less onerous than it may appear. It will only take a few minutes each day and can be done by someone with no more computer expertise than the ability to use a simple word-processor. This is because: Most of these processes are performed automatically with no errors or mismatches. Transmission failures are easily spotted and rectified. The vast majority of results are correctly matched to patients. Those that aren t (eg misspelling of a name) are easily spotted and matched by hand on the computer. It is most unlikely in future that results will not have the correct Read code attached. This is because laboratories will use reliable electronic matching tables between their internal codes and the Read code equivalent Failures of filing and archiving are easily spotted and rectified. Training your practice EDI administrator The practice EDI administrator is the person responsible for supervising the incoming reports. He or she will need some training to understand how the system is set up, how to monitor the incoming reports, and what to do if there are problems. Such training will not take more than half a day, and is usually organised through the software supplier or the local health authority. If action messages are ed to the receptionists it is a good idea for the practice EDI administrator to check that all the messages are dealt with if a patient can t be contacted the practice EDI administrator can talk to the GP about what to do. What help is available? Getting your Clinical EDI system working in the first place involves obtaining a software upgrade from your supplier, setting up the mailbox, and making sure that the lab transmits your results and that your server receives them. This can be done by your software supplier, often with the help of your health authority s IT department. Your system has to be set so that it can work automatically ie with a minimum of human intervention. This is done with the help of the software supplier. Your software supplier will provide you with a manual that tells you how to set up and use the EDI system, but not everyone gets on terribly well with these documents. Fortunately, other help is available. Transmission failures The practice EDI administrator will normally check the system once or twice a day. If there are no reports it may be that there has been a transmission failure. The practice EDI administrator will need to know how to check this and how to initiate a transmission manually; the software supplier will help with this. If it turns out to be a problem at the laboratory end, a telephone call to the hospital usually sorts it out, and reports can be re-transmitted.

13 Reports not matched to patients Your system will tell you if a report cannot be matched to one of the surgery s patients. This is usually due to a misspelling of the patient s name or address, or an inaccuracy in their date of birth. Your system will help you match the report to the patient manually, and will often offer a list of likely matches for you to choose from. If you are unable to make a match you will need to call the hospital s pathology department. Reports not matched to doctors This is unlikely, as the partners names will have been entered on the EDI system as part of the initial setting-up procedure. If it happens, your software suppler will help. Results without a Read code All results should be sent to you by the laboratory as a Read code, together with the official meaning (or rubric ) of that code. The laboratory may have its own in-house code for a particular result, but these will be mapped to the equivalent Read code by the laboratory, before transmission to the GP using reliable mapping software. Very rarely, you may be sent a result by a laboratory for which no Read code exists. All the investigations in common use in general practice have Read codes but, when new investigations are performed by laboratories, there will be a delay before a Read code can be allocated to that investigation. Your software supplier can help with this. Failures of filing and archiving Your system will warn you if a set of results is not filed. If a report is not archived, it stays in the inbox, which is of course easy to spot. Either problem can be fixed easily, if necessary with the help of your software supplier. Increasing your use of Clinical EDI Once your system is working smoothly you may feel like making more use of it. For example, you will probably find that you can look at the results on your computer more quickly than you can find them in the notes. On some systems, they can be viewed in the form of the original report, which is easier on the eye than a list of Read codes, and is more like looking at a paper report. There may come a time when you are ready to deal with the incoming results on your computer rather than the paper reports, but the settings on your system will need to be changed so that you can view them. The supplier s manual will tell you how to do this, or their help line can support you. However, this might be the time to think about what you can get out of EDI and how you can tailor the system to your needs a kind of systems analysis. It is worth talking to other practices about how they use their systems, and some PCGs/PCTs are drawing up lists of mentors. These are GPs experienced in the use of EDI who can spend a few hours with you showing what is possible and how to achieve what you want.