Electronic Patient Record Development following GEMSS 2 - Will Lusher
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Sharing best practice on electronic patient records
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Electronic Patient Record Development following GEMSS 2 - Will Lusher
- 1. Sharing Best Practice Electronic Patient Record Development Following GEMSS 2 Will Lusher MS Specialist Nurse Salford Royal NHS Foundation Trust
- 2. GEMSS 2 Highlighted • Our Electronic Patient Record was unable to: – Identify patients with MS accurately – When they were diagnosed – Identify their MS phenotype – Identify which DMT they were on or DMT history – Provide accurate information for the service to assess ourselves against relevant KPI’s
- 3. Action Points • A way to identify patients with MS • A new referral system on EPR • A way to store patient information on types of MS, DMT’s, steroid courses, reviews. • An ability to interrogate the stored information to continually update KPI’s and caseload activity. • To see on EPR relevant information at a glace.
- 4. New Developments • A new contact and referral document • A comprehensive clinical review document that records: – DMT history and reasons for stopping/swapping treatment – Systematic relapse assessment and review – Comprehensive annual review based on Guys model – Steroid treatment – EDSS, 25m timed walk, 9 hole peg test and BICAMS • A clinical tile screen that provides a summary of the patient to provide an at a glance overview.
- 5. Phone calls and referrals
- 7. Relapse Triage and Review
- 10. Relapse Outcome and Steroid Courses
- 16. Reporting
- 20. In Summary • Find out who is your directorates business analysts and befriend them. • Although Information Governance can cause issues it can also be a useful tool as we have found. • Ensure that with any developments you undertake that the IT team undertaking the work “get it”.
- 21. Thank You For Listening • If you do wish to discuss further or get any information please do not hesitate to contact myself here today or at Salford Royal Hospital william.lusher@srft.nhs.uk 0161 2061611
Editor's Notes
- As a part of the GEMSS 2 project the team had to collate a large amount of information. We thought that due to our electronic patient record gathering this information would be straightforward…..boy were we wrong! Rollodexes, cardexes, clinic lists together with a large trawl of the patient records began. This highlighted a number of points that needed addressing as follows
- In discussion with the directorates business analysts we felt that we needed a better way to collate this information in a format that could be more easily interrogated to continue the work we undertook with GEMSS and move forward. The information in GEMSS was a very powerful driver for change and also could be replicated with other specialisms. We identified we needed the following things:
- We approached IM&T to request these changes. Typically this would be a very low priority however as the GEMSS work was being stored just as a spreadsheet and containing the patient caseload we used Information Governance due to the way the information was stored to be able to get these changes as a higher priority due to the sensitivity of the information being stored.
- This is the referral tab. Entering a referral on this page automatically puts an event of MS patient on the system to allow IM&T to identify our caseload quickly. We also use this to monitor ourselves against the 6 week KPI of NICE QS of review following diagnosis.
- This is the contact sheet mainly for phone calls. It allows us to monitor our KPIs on returning calls and logs them to help assist complaints (Typically about timely calls or not being called back, each call or failed call is documented). Also the length of the call and outcomes – Since its use in June 280 calls have resulted in MSSN appointments. It also allows relapse triage if Relapse review is ticked.
- This is the triage form this allows information to be entered about the suspected relapse which will populate a relapse assessment form if the patient is subsequently reviewed in clinic. It also allows the outcomes to me monitored –since June 18 and 19 patients referred to relapse clinic or reviewed by MSSN in their clinic.
- If the patient is reviewed in relapse clinic the following screens are used to document the relapse by the MSSN. This will also be reassessed in the relapse review clinic which occurs in 8-10 weeks to assess if symptoms are recovered.
- These 2 screens document outcome from relapse clinic review (allowing auditing) and also steroid courses both given by the team or reported by the patient if given by the GP.
- These screens are used to record current and previous DMT’s to provide a history of treatments and also reasons why treatments are stopped.
- Used by the consultants to record results pertinent to monitoring and diagnosis.
- These next 3 screens are the nurse assessment which utilises the framework of the NICE quality standards for annual review.
- This is the Guys assessment tool however this is going to be fully developed moving forwards with a further improvement with the questionnaire to be fully completed on the system with the questions and scores automatically totalled.
- These are some of the reports that we have been able to generate so far with the new developments however we may have the ability to get all the information extracted from the EPR system and import this into a further application which will allow us to manipulate and query the data as we see fit.
- They are a useful source of information and can look at things in a way you might not have before and also give you ideas on what you want to achieve IG allowed us to get something pushed through IM&T that otherwise we would be waiting years or may never have happened without it. By Get it understand not only what you want but also the processes behind what you are doing. It helps make what is being designed do what you want it to do not what they think you want but they might have ideas about how you can get things done you want in another way which is actually easier – blood monitoring not just for MS but other DMARDS for other conditions.