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Making information technology work for hospital juniors

Section 2 - Issues in current practice
Clinical information and risk
Rapid changes in the working patterns of doctors and in hospital bed management mean that continuity of care no longer arises simply as a feature of long, continuous working hours. With insufficient means of handing over quality information, patients are increasingly put at risk.

Availability of patient information
When a patient presents to A&E or an acute receiving unit, the receiving clinicians often do not have the patients’ hospital notes available until several days post-admission, leading to the potential for harm and inconvenience to patients through:

- Misdiagnosis – or not taking account of co-morbidity
- Admitting patients who may not need admission (and vice-versa)
- Repetition of unnecessary, and potentially harmful investigations
- Repetition of referral to other specialties, when already referred with pending appointments.

Coping with shift changes and sharing information
New working patterns of partial- and full-shifts, mean a doctor taking over from a colleague at a shift change may find themselves with responsibility for often up to 100 in-patients – the vast majority of which they will not have previously cared for.

Changes to bed management practice mean that responsibility for a patient may change between consultant-team several times during a patient’s stay, and the patient’s location moved between wards (without the clinician necessarily being aware).

To ensure the safe continuity of information at changes of duty, there must be a comprehensive yet succinct handover. There is need to:

- Highlight patients who are unstable, and need review
- Have access to summaries of all other patients’ clinical problems
- Be aware of outstanding clinical tasks which need completion
- Be alerted to abnormal results that become available, even if requested by a different doctor during a previous shift.

The previous reliance on ‘continuity of care’ has meant that robust mechanisms to meet these requirements rarely exist. In most hospitals the patient administration systems are unable to produce a list of currently admitted patients under a doctor’s care, and lack the flexibility to recognise the way clinical teams work (ie often with several consultants).

Many doctors have thus had to resort to typing their own patient lists (often stored on a home computer or carried on a floppy disk), to allow essential information such as patient locations, clinical summaries/active problems and outstanding tasks to be shared with colleagues. This could mean:

- Flouting current data protection legislation
- Risking patient confidentiality when, as often happens, these paper lists are mislaid around the hospital, or at other patients’ bedsides
- Perpetuating the dichotomy between a ‘medico-legal’ record in the case notes, and a working clinical problem list informally handed around that is not properly recorded/available to other staff.

Practice scenario
Mrs M presents on Sunday to A&E with pleuritic chest pain. The on-call medical team (Team A) diagnoses pulmonary embolism, and commences IV heparin, with a plan to perform a V/Q scan on Monday and to check her level of anticoagulation in four hours time.

She is admitted to one of Team B’s wards. The doctor hands over care to the on-call doctor covering the wards. This doctor loses his jobs list when it is mistakenly discarded on the ward, and the patient is not handed over to the night SHO. The patient continues on the heparin without her clotting levels being checked.

The next day, when Team B returns to work, they are unaware that a new patient has come under their care. The V/Q scan is not booked, and it is not until the heparin infusion runs out that night that the patient’s anticoagulation level is checked 21hrs later. The V/Q scan is then booked for the next day -– and turns out to be negative.

She may suffer harm from her anticoagulation not being checked and her hospital stay is unnecessarily prolonged due to the inadequate system of handover.

Clinical support systems
Many trusts now publish local guidelines and policies on their intranets which are readily available throughout the hospital. There has also been the establishment of the National Electronic Library for Health, as well as a plethora of commercial/non-for-profit web-sites offering on-line information.

While the development of these systems is a step forward the types of information being developed are not necessarily in the most appropriate form.

In an acute or emergency setting, doctors need:
- Readily available information, avoiding convoluted search strategies
- Consensus information on diagnosis, investigation and management.

This may best come from a respected textbook.

Improving efficiency – thereby reducing working hours
Clerical and administration tasks, including multiple form filling for orders, transcribing and physical collection of results, are neither appropriate nor efficient use of doctors in training. Advances in information technology can potentially provide mechanisms to address the pressure to reduce junior doctors’ working hours and intensity.

Ordering, results reporting and prescribing… at the point of care?
There is widespread acceptance of the benefit of electronic results reporting and ordering, and the development of electronic prescribing. This is already implemented to varying degrees across acute trusts.

However, even in the most successfully implemented systems, the path usually falls short of reaching the point of clinical care (ie the bedside).

This results in doctors wasting time copying results into flow charts or patient notes, or chasing round the hospital looking for x-rays to have information available for the ward round. It is also a potential opportunity for error, when results have to be transcribed from electronic devices to notes.

Similarly, not being able to order at the point of care means having to wait until the end of a ward round (which may take a whole morning/afternoon) before being able to order the requested investigation or prescribe a drug. This results in delays in the scheduling of tests (leading to real delays in discharge) or potential omission if the task is forgotten.

Devices and security
In addition to the need to provide the patient record at the point of care, issues around authentication need addressing to avoid delays or short-cutting of security systems.

In the ward setting, multiple users are likely to access the same machine, with frequent switchovers. Currently what often happens is that applications are left running with the previous user logged-on. Subsequent users continue to order tests/view records on this ID, and the accountability of the record is lost. Current mechanisms of logging-on, with the time delay of restarting the application and losing the browsing point for the user, encourage this.

Interruptions
Most trusts still rely on the ‘bleep’ system for communication between staff. This is highly disruptive for all concerned. For the initiator, it is necessary to call switchboard to obtain the bleep number (often with long delays before answer), page the doctor, and wait by the telephone until the doctor is able to reply. The doctor may have to interrupt an examination or consultation to answer a ‘bleep’, which can be especially frustrating if it is non-urgent.

On-call from home
If a doctor is on-call from home, they are often able to provide advice without needing to see the patient. However, they may need access to investigations such as ECGs or radiographs to make meaningful decisions.

The ability to access full information and imaging at home would give a faster expert opinion (avoiding travel time) and reduce unnecessary trips to the hospital for the doctor.

Communication within the NHS
Doctors in hospital are working increasingly complex rota patterns, and often across multiple wards or sites. Reliance on the bleep system cannot provide a satisfactory level of communication.

Trying to contact the responsible clinician
The doctor responsible for a patient will change several times over the course of a day. Patients may also change consultant several times during their admission. It is increasingly difficult for the ward staff, and indeed fellow clinicians, to know which doctor to call first about a patient. Bleeping the last bleep number in the notes is often fruitless.

As a result of this, patients are put at potential risk when:
- A doctor is needed to urgently review a patient urgently, and time is wasted trying to find out which doctor to bleep
- Laboratory/radiology staff are trying to communicate abnormal results to a doctor and are unable to find out which physician is responsible at that time.

Trying to contact an individual
There are many occasions when a colleague needs to contact an individual doctor either about their clinical responsibilities (for example, the GP wishes to speak to the doctor who saw the patient in clinic, not the on-call doctor), or for non-clinical reasons (eg relating to administration or training).

The process is frequently hampered by:

- The doctor having a shared bleep
- The doctor being off shift – and the system having no mechanism for leaving a message
- The doctor changing bleep number frequently as they move around departments.

Email
Email has been employed successfully in some trusts for internal communication on non-clinical matters. For junior doctors, however, progress seems to have been slower than for other staff, due to a perception that there is less need to register juniors or list them in internal directories because they are ‘only in post for six months’.

If email is to be developed then, for the reasons above, the doctor needs to be able to be identified both in their clinical role, and also as an individual. In addition, a need for rapid authentication and log-off on shared machines is critical if email is to be checked regularly.

Education and training support
There has been concern in some quarters that reduced duty hours will lead to a reduction in clinical experience and poorer training. It is the Junior Doctors Committee’s (JDC) belief that if better working practices and structured training are implemented this will not result. There is a need for proper information systems to support this, and these are often not in place.

Training Records and Data Protection
Trainees are required by their colleges to record data on case exposure/practical experience for purposes of appraisal and assessment. Many doctors currently record this through paper or electronic log-books.

Potential problems lie in:
- The accuracy of the record – with useful experience being unrecorded as it is not entered at the time
- Information contravening the Data Protection Act.

Supporting individual learning
It remains difficult for the doctor to track a patient’s progress once care has been handed to another team, resulting in the loss of a valuable learning experience. This is a particular problem for doctors staffing A&E or admission units, and as patients pass more frequently between different teams’ care.

Supporting teaching
Patient cases provide a wealth of learning experiences. The opportunity to share this information with colleagues is often missed due to difficulty in obtaining case-notes/images in retrospect, especially if the doctor has moved trust.

Informatics training
Although informatics is now well placed on the medical school curriculum in the most part, there is a significant cohort of doctors in training who will not have received any formal training in informatics or IT systems. These groups will also have a poor knowledge of current legislation and their responsibility for clinical data.

The opportunities and benefits of an IT strategy will be lost if the user groups avoid using the new systems due to inadequate training, or a poor understanding of new information pathways.