Back @ the EPR Arms: December 2017 A Christmas Record

A Christmas Record

Approaching the EPR Arms on a starry, starry (twinkly, frosty) night.

’ ……and a partridge in a pear…’

The door opened and shut again.  I walked closer.

‘……...five gold rings, Four calling….’

Shut again. Lots of comings and goings tonight. Open………

and a partridge in a pear tree’.

I held the door opened and this time heard all the remaining days of the twelve days of Christmas.



Back @ the EPR Arms: September 2017 Finding stuff and understanding it once you have

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 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 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 if I want to know about my patient, I need to read the relevant paperwork.’


‘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.

Back @ the EPR Arms: May 2017 A troubled mind

‘Ay Up lad!’ said Fred as he let me go first to open the door of the EPR Arms, ‘You’ll have tae gee yit a whallop! All tha’ sun then’t rain then’t sun. Swelled it annit!’. 

You don’t need to go abroad to hear another language. I pushed the door and it didn’t budge.


‘A bigger whallop than that yer Jessie!’


I kicked the bottom of the door and simultanously pushed with my shoulder.

‘Tha’s better lad!’


And I was in.


Back @ the EPR Arms: June 2017 Cyber Cyber Cyber

Soggy spring is transitioning into soggy June via soggy May.

May called an election. Shocked us all. We all shocked (collectively) her.

Drama and sadness: London then Manchester and London again.


Back @ the EPR Arms: February 2017 Daisy's Record

When do I stop saying ‘Happy New Year’ I asked Frank in the pub the other night.

‘Well, to be fair I think you’re milking it a bit now were in February’ he said with his usual frankness. Well it would be wouldn’t it?

‘Speaking of milking it, how’s your cows getting on?’ he asked.

‘Two pints of Badgers Crushed Paw bitter please landlord,’ I shouted in the direction of Bill the ever-busy barman/landlord/chef.



‘Yes. Daisy the cow and Jasper the dog’.

‘Is this the start of one of your jokes? A cow and a dog walked into a bar’

‘By ‘eck you’ve lost it big time. Cheers’ he said taking one of the pints from me and heading to a table in the corner. Bustling busy Thursday. Nearly weekend. Nearly. ‘ I saw you do a presentation once about Daisy the cow and Jasper the dog’.

‘OK and now I’m back in the room’ I said, now confident that I hadn’t slipped into a paralell universe’.

‘ A presentation. That was years and years ago.’ I continued pulling the buffet towards me. (Buffet is a Yorkshire stool and is NOT food related.)

‘I know, but it left an impression. Not sure if that was a good or bad one but remind me and I will tell you’.

‘Well ,’ I said licking the froth from the side of the glass. Not a good habit but waste not want not (as they say in Yorkshire.) Frank adds ‘many a mickle meks a muckle’ as the say in either Scotland or Jamaica (depends on where you search on Google for proverb meanings! )

‘Well – it was based on a conversation I had with a farmer - in here actually Frank. And he was called Frank, Frank. Coincidence or what. Back in 2005. Wow! Eleven years ago. Gosh! Anyway, he told me his tale. This tale to be frank:

“In the old days, I used to get up at 4.30am and bring all the cows in from the fields and milk them at 5.30am and then again at tea time.”

“I bet that was hard chasing them all.”

“Well no actually. They want to be milked, ‘cos they get full and uncomfortable don’t they? Their udders is busting and swollen. So now’s I’ve got this fancy milking parlour, they come and get milked whenever they want. 24/7”


“Well, I’ve chipped them all: a little tag on their ear. They know that when they enter the parlour they’ll be fed, so they approach the unit and the unit knows who it is by their chip. It releases the right amount of feed and checks if they’ve already been milked. They know the teat configuration and size (‘cos all cows udders are different), and the teats config has been measured by laser and stored in the unit. It then sterilises the teats. Attaches the milking cup thingy-bobs and milks each teat one by one.”

“One by one?” I asked.

“Yip. Instead of sticking a four teat vacuum thingy-bob on and sucking till all milk has come out, it measures milk flow and conductivity for each individual teat, and stops when the flow stops.”


“Yip. Clever innit? The ‘lectricity flow across the milk is affected by things like infection.”


“Yip. It plots graphs of the milk flow and conductivity of each teat. You can see which teat is infected and it sends me a text message on my mobile. And I’m still in bed!’

‘No way!’ I said.

‘Way!’ he replied.

“And wait for it, and this is the best bit, I end up with an electronic record of Daisys health and stuff.’

‘Health and stuff?’ I asked incredulously.

‘Yip. I have a record of Daisy’s milk yield, weight, food eaten, so I can work out if there’s a problem. I’ve even got her wearing a pedometer so I know how far she’s walked.”

“So why is this the best bit?” I asked.

“Because you’ve been going on for years about your electronic health record, your EPR and how that record should be a by-product and not simply the objective.”

I was impressed he’d latched onto my mantra – oft repeated, mostly by me! “Yes. Support clinicians in what they do and what they’ve done is automatically captured” I repeated mainly for Frank’s benefit.

“It’s the same with Daisy. My aim wasn’t to produce a record of Daisy’s health or milking history. I just wanted to get her milked efficiently. The computer is supporting the milking process and offering decision support and guidance: not too much food today. One of the teats is poorly etc. But you end up with all of it recorded electronically.”

‘Wow!’ So you’ve got an EPR equivalent?

‘Yes sir. Instead of having lab test requesting or your electronic prescribing, I’ve got milking. My milking is supported with technology. The computer directs me to capture the correct information that I need, it offers me guidance and support and it gives me, in return two things.’

‘TWO things?’

‘Yip. An electronic record AND a lie-in!’

Back to today:

‘You see Frank, some folk in our NHS lose track of what EPR is all about. Some think going paperless is the objective but it’s not. Supporting our busy doctors and nurses with computers simply improves their effectiveness and ensures all the right clinical data is captured by them during that episode and makes that available to others to impove their interractions with the patient. The fact that we need less paper is simply a by-product of using these epr type systems to support them in what they do.

‘So those Trusts that are responding to Jeremy Hunt’s vision by scanning their paper casenotes are barking up the wrong tree?’

‘Not necessarily, scanning the old legacy paper has a place in this emerging electronic record. But simply ‘going paperless’ by scanning does not give you the real clinical benefits of a proper epr system.’ I detected that I was losing Frank - he was eyeing up the Guest cask ale hand-pulled pumps and twitching nervously.

‘Frank! Frank. Let me explain: We could take the paper drug charts from the ward and either get someone to scan them every night or type in the drugs/dose etc for each patient on that patient’s EPR. That would give us an electronic record of what drugs had been prescribed and which were administered and by whom and when’.

‘Isn’t that what you want?’ asked Frank frankly losing interest by the minute.

In part yes, but we actually want these clever EPR systems to influence what drugs are being prescribed. We want decision support at the point of care. It’s all very well knowing later that what killed the patients was a dose six times higher than normal. We want to know that while the drug is being prescribed and certainly before it is being given.

‘And you end up with an electronic record of what was prescribed and administered?’

‘Yes- we end up with Daisy’s record!’

So that was where you got your presentation from? And what about Jaspers record?’ asked Frank being Frank again.

‘Jasper is another story for another night. Same again? Your shout!’

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