The primary care electronic health record: who's righting the software?

Guidelines and deficiencies

The EHR should be ‘clear’,4,8 ‘accurate,’4,6,11 ‘complete’ and timely',6 and convey ‘narrative’.6 Vision's Problem Pages list problems in alphabetical order without dates so there is no sense of chronology; other pages default to reverse chronology so that, especially for entries occupying more than one line, the narrative is lost. In Vision I'm unable to code fit frequency in the recommended Structured Data Area without a comment on aura, or to record ‘currently teetotal’ without selecting ‘lifelong teetotal’ or ‘ex drinker’. Recording drug allergies in such a way as to trigger subsequent computerised warnings requires a precise Read Code although that's often unknown. In Vision, the field offered for date of last menstrual period becomes the date under which the note, with any free text, is listed in Journal View. In Vision, entering ‘URTI’ leads not to the most general ancestor code for URTI but to an end-node ‘not otherwise specified’ code which excludes all other types of URTI.

In the Read Code hierarchy (currently Quarter 3 2010) ‘male homosexuality’ (E2200) is a child of ‘sexual deviations or disorders’ (E22).

Entries made via Contract+ or ESCRO appear in Vision only after the patient's notes have been closed and re-opened. In SCCRS a date for last menstrual period has to be entered even when it's unknown and I'm unable to combine a normal cervix appearance with a referral or an abnormal appearance with no referral.

The EHR should avoid ambiguity, ‘personal shorthand’,6 ‘meaningless phrases’ and ‘unnecessary abbreviations or jargon’.8 In Vision, ‘Hepatitis_B Stage: B Given Special Risk Group’ means that a hepatitis B booster was given, although it could be mis-read as indicating a second immunisation. The Vision screen displays field names and data in various combinations and permutations such as ‘Height 1.62 metres O/E – height’.

EHR ‘standards should facilitate not hinder the process of writing, communicating and retrieving clinical information,11 so that information is ‘accessible’6 and care is safer and more efficient’.11

In Vision an oral contraceptive note entry defaults to ‘first service’ even for subsequent entries; recording pulses leads to windows which add by default that other pulses or heart sounds are satisfactory; recording immunisation requires that the vaccine name be entered twice; and clinical information in the ‘remarks’ field of the Med3 window is invisible when the window is closed.

When drugs are reissued in Vision, ‘notes for patient’ and ‘instalment dispensing’ are visible on screen only when those respective windows are opened.

Our previous system, Synergy, had the facility of interval-specific prompts for, say, a hepatitis B booster 12 months after the third dose: Vision Guidelines have no facility for this. In Vision, changing dispensing arrangements for a patient needs to be done individually for each drug rather than once for all drugs.

Reading Docman documents requires a minimum of 1 click and 1 curse per page; and each Microsoft letter requires 3 clicks to enter, often at least 1 curse to read and 2 clicks to exit – if you forget to exit, you get an unresponsive screen with no explanation.

Entering a ‘problem’ in Vision requires two windows with multiple fields and can be completed without Read Coding so that disease registers are incomplete.

Prescribing systems ‘should cross check prescriptions for any sensitivities or interactions where appropriate’ and ‘provide an audible/visual warning for the prescriber’.3 In Vision, depending on patient factors and user settings, warnings are so non-specific that the same number of clicks is needed to prescribe aqueous cream as to prescribe warfarin, drugs with quite different safety profiles.

Prescribing systems should ‘provide a facility to record that the medication regime has been reviewed and confirmed’.3 In Vision, prescriptions are divided into repeat and acute drugs. Coding a review of a medication regime indicates that the list of repeat drugs is correct, but drugs might be added to or removed from this list subsequently without this being apparent to the next doctor. Acute drugs are not reviewed at all.

‘Prescribing systems should display the appropriate generic name(s) with the trade name … and list generic drugs first and branded products after’ to reduce ‘the possibility of mis-selection’.9 Vision defaults to a single alphabetical list of generic and proprietary drugs.

Prescriptions should be printed in ‘11 pitch’3 (11 characters per inch). Prescription dosages are printed in 15 pitch (15 characters per inch), which is smaller than 11 pitch; so, dosages are in smaller print than drug names and therefore harder to read.

Responses by software and guideline writers

Suppliers have made two relevant changes. In Contract+, the prompt to prescribe a beta-blocker for ischaemic heart disease in asthmatics used to be accompanied by a warning icon: it's now accompanied by a warning statement. In Vision, the only ‘Journal’ page available included a record of all prescriptions issued making it hard to discern the clinical notes: this is still the default journal but a second page called ‘My Journal’ has now been added – this excludes the record of prescriptions issued which makes the notes easier to read, but it also excludes other entries such as medication reviews along with any free text attached to them.

I've had many interesting discussions with unfailingly courteous computer experts. In fact, I found some to be so kind that I think they were concerned for my wellbeing. These experts tended to emphasise the need for more training. On further discussion, however, they proposed that, when systems were being set up, the trainers should customise the software to suit the individual practices and users before leaving the building.