‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each instalment is based on one of the 12 RCGP competency domains, this month’s being:
7. Primary care administration and IMT: the appropriate use of primary care administration systems, effective record-keeping, and information technology for the benefit of patient care.1
‘Successful high-reliability organisations are characterised by mindfulness — that is, an ever-present awareness among staff of the possibility of error and to the ongoing measures that must be taken to minimise it; over-reliance on technical systems may erode this.’2
INTRODUCTION
General practice infrastructure exists in order to enable the doctor to consult well. Behind the scenes, business management organises the resources, research provides evidence, call-and-recall systems bring in the patients who wouldn’t otherwise consult, and audit safety-nets.
The electronic health record should represent the final outcome of intelligent design. Instead it is in a process of evolution; clinical decision-making and prescribing aids may offer advantages or lead to harm; and the e-lephant in the consulting room needs firm handling by its mahout, the doctor.3
HARMING
Making the patient serve the needs of the doctor, and the consultation the needs of the organisation. Looking not at the patient but at the computer. Fossilising a person in code.4 Assuming that the computer’s always right and running call-and-recall programmes without clinical moderation.3
HEALING
Concentrating for some of the consultation exclusively on the patient. While writing the clinical note, continuing to revise the diagnosis, and retaining something of the person. Ensuring organisational continuity of care.1
ATTITUDE
Regarding the computer as a sheepdog that, once trained, will do the running around for you.
KNOWLEDGE
Patients want more information than they receive in consultations. They have limited health literacy5 and have difficulty making sense of the information they get in spoken or written form.6 Provision of accurate well-presented literature makes patient choices more informed7 but of the many resources available it is unclear which are useful in which situations, particularly for patients with multimorbidity.8 Most symptoms, signs, and test results have low predictive value for disease so it’s important to have access to data and decision aids to help weigh benefits and risks;4,9 and this needs information technology. Biomedical science is beneficial at both individual and population level. For instance, of reduced ischaemic heart disease deaths, about 42% are prevented by treatment of individual risk and 58% by reduction in population risk.10 Telemedicine in asthma, diabetes, heart failure, and hypertension has a weak and contradictory evidence base11 but in chronic obstructive pulmonary disease reduces hospital admission and emergency hospital attendance.12
SKILLS
Reading and writing the computer record fluently. Using free-text, coding selectively, entering diagnosis late in the process of recording clinical notes, and configuring data entry screens to make this possible.3 Keeping the consultation open-ended by directing the patient to selected decision aids13 and information leaflets.14,–,16 Storing websites as favourites on the computer for rapid access during the consultation. Accessing sources of information and help. Checking drug interactions and side-effects.4 Having, or having access to, adequate computer skills.3 Using NHSmail.17
Supplementary information
The internet footnotes accompanying this article can be found at: http://www.darmipc.net/first-do-no-harm-footnotes.html
- © British Journal of General Practice 2012