Hubris

Designing GP Clinical Systems

Index

Never mind the computer, how about paper notes?

Posted to GP-UK Wed, 27 Aug 1997


Simple working interchange formats for computerised medical records are much to be desired, but many excuses are raised for our current inability to go to the Practice computer in Practice A and take out the record of a patient, post it to Practice B and have it put into their filing system.

However, one of the excuses not raised here so far has been a comparison with what has not been done in the same area with paper records.

How much has been done to make Practice (uncomputerised) C's records assimilable by Practice D? And how much should be done.

In the specific area of ante-natal records a common interchange format was worked out long ago. The triptych card, 6* A5, was a model of design of an appropriate record, with fields and tables for the appropriate minimum data set, and with enough formatting to make the handwritten contents of each field usually decodable from context.
Although there have been regional variations in how the record is used in general any user in the UK, and most in the world could pick one up and continue using it, with benefit to the next recipient and the patient.

Some groups of travellers have been given minimum dataset records to carry, and generally look after them well.

Designing partial records along these lines would have been a reasonable approach, another lost opportunity.

GMS Notes

Many special purpose cards have been designed, and the good ones tend to spread in use. Again, in general, a card from one practice used for FP, anticoagulation, immunisations or whatever can continue in use in another practice, or if not, the information from it can be transferred reasonably well from one version to another.

None of this seems difficult to duplicate with a computerised record.

The Future

There is a spreading move toward sharing records, with the Diabetic nurses handing records toDiabetics to carry which duplicate our records, the paediatricians dispensing immunisation record booklets, in fact everyone seems to be handing out records which should simply be printouts of our long-ago-agreed rough and ready minimum transfer record format.

Inevitably the results are inferior in effect, and require considerable duplication (or in most cases reduplication and sometimes triple entry) of effort, maintaining effectively two record sets at each encounter.

We get to do most of the avoidable excess work, and we have been let down by those responsible for maintaining our IT in this respect.


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