‘Integration is the way ahead.’
My whole career I have heard this. Sometimes as a request, other times as a plea, but always as a proposed solution. The problem to be solved has evolved many times but has always been about tools we use — mainly note-keeping systems — and rarely about the people using them. Sometimes not even the patients for whom they exist were part of the equation either.
My training practice was awash with paper, chaotically covering desks, corners, shelves. The supermarket basket into which the notes for each surgery were loaded was always correct and ordered though. Prescriptions were written by hand, of course. There was a computer that generated repeat prescriptions when patients came only for those, but that was all it did.
That early use of a computer to automate what was otherwise a time-consuming task was a boon but opened the door to today’s problem with polypharmacy. Generating a long list of repeats would never again be limited by the doctor’s willingness for the task. Every upside holds its own flaws.
Without email or voicemail, teamwork required direct communication. Which in turn meant we necessarily knew those others seeing our patients.
The paper record we used was itself integrated as a system. After qualifying I worked in a practice that still used Lloyd George cards, the entirety of them contained in two boxes. They came on visits on the back seat to ensure ready access in case of unscheduled care needs arising. Everyone’s complete record was available anytime.
The quest for integration has led us progressively away from reliance on paper files. Soon we had countless different computerised note systems, none of which could inter-relate. We are only just emerging from that downside. With every practice move, data were printed out only to be duplicated in the next printout, and the next, and so on. Those paper notes have steadily disintegrated as a useful source despite the heroic efforts of countless practice secretaries.
Now, paper notes being considered a storage problem only, we are again moving on to new concerns. We are seeking to have more professionals use the same set of electronic notes. Where I work, we have a curiously random mix of services using them and the files themselves no longer reside on a server I can locate. Whoever controls them, it is no longer the practice.
And we are all beholden to the rise of the algorithm. Checklists and automated prompts mean that pop-ups and alerts pepper the experience of accessing patient notes. Templates that can extend beyond the edges of the screen make finding particular information increasingly difficult.
Still more integration is called for. Lately, it is about adding in hospital services too. A shared laboratory reporting system means that patients are already being directed to us to find out and discuss the results of tests ordered in outpatients. Shared notes will hardly lessen such problems.
As 2020 begins, the upsides remain all that are visible. A single health and social care dataset remains the logical endgame. The possibilities for further integration thereafter — think immigration, tax, and benefits for a start — are dystopic but entirely plausible.
Integration always could be something different though: professionals coordinating better for the benefit of patient care. It’s a no-brainer. But it needs actual human relationships to work well. So it’s not about the notes.
- © British Journal of General Practice 2020
