Another night in the EPR Arms. The sky achieving a darker, dusky hue when another Hugh walked in through the main door.
‘Hugh. Pint?’
‘Yes please. Usual’.
‘We’re sat over there near the window (I gesticulated with my empty glass) – grab a chair I’ll just get these.’
Hugh joined Keith Lamont - the hospital’s Medical Director.
‘Hi Keith. Busy day?’
‘The usual. A bit of stress in the morning followed by a stressful afternoon and early evening. You?’
‘Busy kiddie clinic then ward round. Really struggling with where to find our clinical letters at the moment. We’re moving onto this American EPR system – which will be great once it’s all in there. But at the moment it’s a mess. Finding where my letters are in the scanned record is just a nightmare.’’
‘I once knew a doctor who had a Montblanc fountain pen which he always used for writing in the casenotes.’ said I, depositing three pints of badgers on the table carefully.
‘Montblanc – that’s well posh and expensive isnt it?’ said Keith
‘His was at the cheaper end – only £450 smackerrooners’ I replied.
‘Another world. It’s just another world isn’t it? ’ said the Paediatrician with the Noddy & Big Ears tie still loosly wrapped round his neck.
‘And he used a turquise QUINK ink’
‘Why so?’
‘So, when flicking through the patients casenotes, he’d know which letters were worth reading - i.e. His own!
‘And he used to write in code for him and his mates’ said Keith. ‘But then again, didn’t we all!’
‘NFH!’ exclaimed Hugh.
‘NFH?’I queried.
‘Normal For Huddersfield!’ He explained.
‘TEETH’ said Keith.
‘TEETH?’ I asked.
‘Tried Everything Even Tried Homeopathy’. explained Keith.
Hugh added ‘And in some sad cases AGMI – Aint Gonna Make It! ‘
‘You see, what is recorded in casenotes has to make sense to whoever reads them and they need to know where to find it. And nowadays, that also means the patient, so you have to be very very careful what you write in there.’ Keith summarised.
‘But if you don’t know what the abbreviation means, you don’t know what the abbreviation means!’ said Hugh.
‘For example?’ I asked.
‘Well - WNL – is used for recording vital signs. It can mean “Within Normal Limits” or “We Never Looked! or NAD: No Abnormality Detected OR Not Actually Done. A minefield.
‘And so the colour of the writing helped him navigate through the hundreds of pages of documents to find the note he had written earlier in the episode?’ said Hugh.
‘Exactly’ I replied.
‘But no use to anyone else?’ Keith this time.
‘Exactly so. So, the question is, how will all this pan out when it’s all digital?’ I asked cautiously.
‘That’s a very good point. Unless there is some agreed structure to these digital records, then it will be a real challenge finding the clinical information you need.’ Keiths turn.
‘But in the Trust across the road there, they’ve just implemented a big American EPR system. That will have a structured record won’t it?’ I asked, remembering the news item in the local daily paper.
‘Yes from when it goes LIVE. And that other Trust, 20 miles away will have a completely different EPR with a completely different record structure to it from when IT went live and Junior Doctors will be oscillating twixt the two! And don’t get me started on the scanning debacle’ said Hugh.
‘Go on – tell me about the scanning debacle.’ I pleaded.
‘Just as soon as we’ve got fresh drinks-this may take a while.’ said Keith.
I handed over my empty glass to Keith who obviously was in need of some refreshment to blunt the tired but sharp edges to his day. ‘Badgers. Pint please and some crunchy pig.’ I said.
‘Badgers and some scratchings. Wilko. And you Hugh?’
‘Same for me Keith. Ta.’
Keith was squeezing between the tables and chairs and ‘buffets’ (stools to you and me but not in Yorkshire pubs!) and shouting his order as he approached, ‘Three large badgers and three bags pork bits please.’
‘I am surprised at you Mr MD getting some Scratchings. Shouldn’t you know better?’ I attacked him as he was depositing the drinks and bags of grub randomly onto the table.
‘Actually, hard to believe but this bag of bits is better for me than a bag of crisps. No carbs. Some good fat (and granted some bad fat) but sooooo delicious with a pint. All in moderation of course!’
I couldn’t argue with him over that one, taking my pint and having a quick slurp whilst trying to manfully pull apart the cellophane bag of pork bits. ‘So, Hugh, what’s this scanning debacle then?’
‘Well. There are some Trusts who think that going paperless simply means scanning in the paper record and so have embarked on a very expensive and complicated paper record scanning process’.
‘Well whats wrong with that?’
‘Going paperless should NOT be the objective. Getting rid of the paper will be a natural consequence of using clever clinical IT to do prescribing or ordering labwork, recording clinical histories or even completing profiles or pathways of care.’
‘And?’
‘And the outcome will be less paper. But that is NOT the objective, but the outcome.’
‘So how’s this scanning all going wrong then?’
‘Because there is no national standard or guideline for scanning in paper case notes. Every Trust can invent its own list of document names.’
Keith joined in. ’And it’s actually worse than that. Some Trusts are simply scanning the contents of these huge paper casenotes into a single PDF file. ‘
‘And?’
‘And because they haven’t got an all-singing all-dancing Amercian EPR system, most of the clinical information is sadly still held on that paper.’
‘And?’
‘And if I want to know about my patient, I need to read the relevant paperwork.’
‘And?’
‘And my six letters of consequence are buried in and amongst a thousand other scanned pages with no record structure. As a busy clinician I haven’t time to wade through page after page of a massive PDF file. I didn’t write the notes in Turquoise ink. They were typed and I want to know where to look for a discharge letter or an A&E discharge note. Ideally I want any scanned piece of paper to have what they call ‘metadata’ attached to it that tells me what kind of document it is, who wrote it, what specialty that person worked in and when it was created and then when it was scanned and by whom. And I expect this metadata to be the same in ALL the NHS.
‘And isn’t that what they are doing with the scanning?’ I asked. Seems a bit obvious that you need to know what documents you have so you can file them in a sensible structured record.
‘Sadly not. You see, if you are given a five hundred page, over-stuffed casenote to scan, it has first to be broken down into all the separate documents. They won’t all be filed in the right place. They won’t all be on A4 paper. Some may be lab reports which have to be cut off the backing sheets. Some will be ECG tracings on ticker tape. Then these have to be indexed i.e. a code added saying what kind of document they are. Then put in date order. Then scanned. It would cost the earth to do that level of detailed Indexing, so most Trusts simply scan the paper casenote in the existing casenote sections. At best all correspondence will be ‘tagged’ as correspondence. All nursing notes will be ‘nursing notes’ etc., etc.
I drained my pint quickly and got up to leave. ’To be honest guys, I think this conversation is a four or five pinter so I’m gonna have to go now but why don’t we meet up again in a month and I will get you an update on where we are nationally with this scanning issue?’
‘Good plan. I’ve got to dash anyway’ said Hugh draining the last of his craft beer.
‘Me too. Heavy meetings tomorrow’, added Keith.’See you in a month!’
As we all made our way out, I looked back into the bustling EPR Arms and was reminded of one more casenote abbreviation that was more appropriate in this non-clinical setting; LGFD. Looks Good From the Door.