Quality | 2009.11.14
Patients' medical notes to be made electronic
Doctors hope the £300m move will cut confusion and reduce potentially deadly errors in treatment
The NHS is abandoning handwritten files of medical notes, sometimes several inches thick, and finally introducing electronic records of patients\' conditions, medications and allergies.
More than 700,000 people have already had a computerised personal medical history created and health officials will start doing the same for 7.2 million Londoners this week.
Each will be the subject of a new "summary care record" (SCR). These are secure electronic summaries of a patient\'s history, which include details of their symptoms, allergies, the drugs they are taking and any adverse reactions, the treatment they have received and any wishes they may have for their end-of-life care.
The long-awaited move will scrap the current system, widely derided as hopelessly outdated, under which an individual patient can have up to six separate sets of medical records. Five may be on paper – one each if they are a mother or have a mental health or sexual health problem, a routine hospital record and another from an A&E department – plus the notes kept by their GP, 98% of which are electronic. That number can even increase if they attend more than one hospital.
"The SCRs stop us treating patients as strangers," said Dr Simon Eccles, an A&E consultant in London who is also the medical director of the NHS\'s Connecting for Health IT programme. "It\'s clearly out of date to have a system that\'s so archaic that you can have six or more separate medical records. It also risks the lives of patients – it could lead to a fatal medication error, for example – and is incredibly frustrating for NHS staff, because there are so many different records to keep up with."
The new records are meant to improve quality of care by ensuring that doctors and nurses have instant access to what colleagues have previously written and no longer have to rely on the patient\'s own word. They are based on the patient\'s existing electronic record maintained by their family doctor, but will be updated every time someone receives treatment in any NHS setting by a healthcare professional.
So far 717,106 people in 10 parts of England, including Bury, Dorset and south Birmingham, have a summary care record. The NHS hopes that all 51 million patients in England will have one within two years, at a total estimated cost of about £300m. The elderly, and those with English as their second language, are expected to be among the major beneficiaries.
Eccles said widespread take-up of the records should help avoid a repeat of a death like that in 2005 of Penny Campbell. The 41-year-old journalist died of septicaemia after speaking to eight different doctors from her local out-of-hours service over four days, with each of her calls being treated individually and medics not sharing information. The case provoked outrage and demands for reform of overnight and weekend care.
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http://www.guardian.co.uk/society/2009/n[...]ical-notes-electronic-patients
