Parliamentary Briefing on the Electronic Patient Record
Westminster Hall Debate on Thursday 21 February 2008
Introduction
The RCN agrees with the House of Commons Select Health Committee Report on the Electronic Patient Record that stated: "Achieving the widespread uptake of the DCR [Detailed Care Record] systems is therefore the single most important advance that the NHS can make towards the provision of faster, better integrated, and more patient-centred care" (Health Select Committee, 2007, The Electronic Patient Record pg. 77 para. 228). The RCN supports the direction of travel of the national programmes in all four countries of the UK, including the English National Programme for IT. As was pointed out in the recent Royal Society report Digital Healthcare: The impact of information and communication technologies on health and healthcare that, “the single most important factor in realising the potential of healthcare ICTs is the people who use them” (Royal Society, 2006, Digital Healthcare: The impact of information and communication technologies on health and healthcare. London. Royal Society. http://www.royalsoc.ac.uk/displaypagedoc.asp?id=23835).
Nurses are the largest group of healthcare professionals in the NHS, and because of their particular role in co-ordinating as well as delivering care to patients nurses are already major generators of patient information and will be major end-users of the electronic patient record. It is therefore, vital that they are fully involved in the development of the e-health programmes, and have the appropriate knowledge and skills to obtain, hold, share, use and store sensitive information, whether paper-based or paperless, about patients.
Incorporation of clinical interventions to properly reflect the patient journey and ultimately improve the quality of patient care
• In order to achieve co-ordinated multi-disciplinary care, the record must not be limited to medical data but must include the parallel clinical data from all disciplines, including nursing.
• This means that nursing diagnoses, interventions, and outcomes must be recorded alongside medical diagnoses, interventions and outcomes.
• The system should allow users to record all actions prescribed by the plan of care, including progress notes, flowcharts, critical paths and other forms of nursing documentation.
• There are recognised and well researched classifications of nursing diagnoses, nursing interventions, and nursing outcomes, and the terminology to be used to describe them in the patient record is already incorporated within SNOMED-Clinical Terms, which the NHS has already decided should be the standard terminology for use in electronic records
• Nursing data standards (including Nursing Minimum Data Sets) are in use in many countries; in the UK national agreement on standards for nursing record content and nursing data is urgently needed
Secondary use of EPR can improve workforce planning and patient outcomes
• Secondary usage of EPS has the potential to enable the identification of patient outcomes and best practice but also to demonstrate the effects of staffing levels and skill mix which has a direct impact on patient satisfaction and clinical outcomes.
• The Healthcare Commissioning report Ward Staffing (Healthcare Commission (2005) Ward Staffing: London) found that patient satisfaction and clinical outcomes such as the incidence of pressure sores relate more to the number of experienced and skilled registered nurses employed by the Trust than total numbers. Independent research in the UK by Professor Anne Marie Rafferty, University of London, reveals that for surgical patients in 30 NHS acute hospitals mortality increased by 12% to 49% in hospitals with the lowest registered nurse to patient ratios. Put another way, patients are more likely to die in the surgical settings studied when there were fewer registered nurses on the ward.
• Determining the threshold or ideal equation of registered nurse to patient ratios is complex, such as seriousness of patient illness, case mix, treatment and so on. Therefore, the application of secondary uses to benefit long term planning and patient outcomes would only be possible if nursing data is appropriately included in the EPR.
A focus on user training and development to ensure take up and proper use
• Those that are using EPRs are generally more favourable towards it than those who have not. This achievement requires greater investment in the engagement and education of nurses
• Surveys conducted annually by the RCN show that the introduction of the EPR seems to be welcomed by the majority of nurses, even by those who have no experience of it
• Only a minority of nurses are currently using EPRs
• Lessons learned from previous large Governmental IT projects suggest that where the end-users have “ownership” of the proposed development there follows successful implementation and positive outcomes for all
• Whilst the surveys show that nurses overwhelmingly support the overall aims of the Programme they do not have adequate information about or the involvement in the development of clinical IT systems.
• In 2006, 65 per cent had not received adequate information. 74 per cent felt there was inadequate consultation with nursing staff or no consultation at all
• This year’s survey showed that 56 per cent had received a ‘little’ IT training and 55 per cent had received no training at all in the last six months.
• This underlines the need for true clinical engagement supported by Trusts and SHA’s making the Programme and its aims a priority for the NHS.
Recommendations
Connecting for Health and the Strategic Health Authorities to whom responsibility for implementing the programme has now been devolved should ensure that:
• Nurses are fully involved in decisions at local, regional, and national levels concerning the development and use of the electronic patient record
• Adequate resources in terms of money and time, including backfill requirements are allocated to the education and training of nurses to enable proper use of the EPR
• The nursing content of the EPR is nationally agreed and is included in the specifications for all EPR systems
• Connecting for Health should restore immediately the funding to support nurse engagement
• Local employers must ensure that frontline staff have the time and skills necessary to ensure that patient are able to make fully informed decisions about the safeguards and choices related to information sharing and the implications of measures such as sealed envelopes.