Building an Electronic Disease Register: Getting the by Alan Gillies;Bev Ellis;Nick Lowe

By Alan Gillies;Bev Ellis;Nick Lowe

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Managing the process of change • 41 Risk Accidental damage Deliberate damage Inherent risks Risks due to errors Risks due to ignorance Opportunity risks Paper Computerised • Files deleted in error • Records filed incorrectly and • System destroyed by lost fire • System destroyed by • Records flood destroyed by fire • Records destroyed by flood System stolen • Records stolen • Records destroyed System destroyed by arson by arson Linked • System destroyed by fire • System destroyed by flood • Physical damage to communication links • System stolen • System destroyed by arson • Deliberate damage to communication links • Threat from viruses • Threat from viruses • Records • Threat from Year 2000 • Threat from Year physically problem 2000 problem deteriorating due • Threat from external to age access ('hacking') • Data input errors Data input errors • Transcription • Errors due to bugs in Errors due to bugs in errors computer system computer system • Errors in assigning • Errors due to problems Read Codes with external communication systems • Lack of knowledge of • Lack of knowledge of • Failure to detect system system information through • Integrity problems due • Integrity problems due to failure to implement to failure to implement ignorance of common coding common coding record contents standards within and standards within without practice practice • Failure to fully • Failure to fully implement strategies to implement strategies minimise other forms of to minimise other risk forms of risk • Even greater human and • Difficult to get • Failure to reduce risk financial resources data integrity information for devoted to running the problems through health promotion system • Difficult to get electronic communications management • Human and financial information • Difficult to resources devoted to running the system implement coding Summary of risks identified within risk analysis matrix.

Therefore, with practices such as this it is necessary to implement a long-term action plan to bring their information to the level required by the PCG. Each year, a GPIMM audit will be needed to check progress against the plan. Managing the process of change • 31 The plan for this practice, audited in 1999, is shown in the table below. Year GPIMM level 1999 1 Tasks to be carried out • • • Persuade doctors and other PHC workers to use system in consultations Train PHC team in use of system Establish new working practices based around use of the system 2000 2 • • • • • Persuade all staff to use Read Codes Train all staff in use of Read Codes Discuss scope and nature of coding within practice Liaise with PCG over coding standards Implement codes within agreed scope 2001 2* • • Implement PCG coding standards with training Implement practice defined protocols for diagnosis and prescribing with training Implement computer based health promotion policy with training Implement real-time audits with training • • 2002 4 • • • • 2003 5 • • Move all records to electronic form Agree coding standards with external bodies Ensure system meets requirements for connection to NHSNet Make paper records for legal requirements Carry out audit to ensure that Level 5 is reached Implement a culture of continuous monitoring and improvement *To meet the requirements of Level 3, the practice would have to have implemented computerised repeat prescribing by this year.

Entering codes on the computer will improve the results of an audit report but the codes are worthless if they do not represent effective clinical activity. It does not seem realistic to expect clinicians to record data without a clear clinical benefit. If the benefit is not apparent the data is not likely to be recorded. This critical approach to data collection is encouraged - most clinicians do not wish to be swamped by priorities of recording data over listening to and caring for patients. The four PCGs in NW Lancashire have been discussing the issues around collecting data at regular meetings over the last two years.

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