Electronic patient records are the essential prerequisite for a modern, digital NHS.

Never has it been more important to learn the requirements for summarising medical records, following the recent announcement from the Health and Social Care Secretary who has set out his priorities for health care by harnessing the power of technology at the Health Service Journal Digital Transformation Summit.

He announced ambitions including for 90% of NHS trusts to have electronic patient records in place or be processing them by December 2023. This move underpins the Government’s drive that the NHS should be using technology to improve productivity, reduce costs and ultimately enhance patient care.

In announcing the launch of a new data in health strategy at London Tech Week’s HealthTech Summit, the NHS app is set to become a central point of access for GP appointments, prescriptions and hospital records. The app will also make it easier for patients to get hold of their GP records. Improvements to the mobile app to make it easier to request historic information including diagnoses, blood test results and vaccinations are set to be rolled out by the end of next year.

Good training in summarising medical records not only ensure that electric data is accurate but can help to achieve QOF targets. All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one. The information held in the Summary Care Record gives health and care professionals, access to information to provide safer care, reduce the risk of prescribing errors and improved patient experience. The Summary Care Record contains basic information about allergies and medications and any reactions patients may have had to medication in the past. Some patients, including many with long term health conditions, have previously agreed to have additional information shared as part of their Summary Care Record. This additional information includes information about significant medical history (past and present), reasons for medications, care plan information and immunisations.

Currently, the app has 28 million users, around half of England’s population. The rollout plan has a target of 75 per cent of the adult population to be registered to use the NHS App by March 2024, with the overall aim for the app to be a “one-stop shop for health needs”.

The Health Secretary also promised in February to speed up the digitisation of the NHS, with 90 per cent of patient records to be held electronically by next year.

Summarising medical records is not without its issues and good training provides an understanding of how confidentiality can become compromised during summarising

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Which is better: online learning or face to face?

medicologic - client feedback

We’re hearing a lot about online learning currently and its recent prominence has highlighted some of its many advantages. Online learning has been used as an educational tool for decades. When information is presented online, it becomes accessible to those who might have found it difficult to attend classes in person. On the other hand, face to face learning also offers a number of advantages. Collaboration – sharing discoveries and debating questions – is easier, and students are more likely to establish interpersonal relationships. Teachers can also tell more quickly whether students are engaged with the material. Both approaches when presented well appear to be equally effective

In a review of 19 studies, Queens University Belfast found online teaching of clinical skills to nursing students was no less effective than traditional face to face approaches.

One of the most important factors in learning is motivation: whether delegates want to engage with the material . The National University in San Diego and the University of Massachusetts asked more than 4,000 students what they wanted from their course of study. Their top priority, whatever the mode delivery, include relevant and engaging course material, teachers who are able to connect with and motivate students, and a mixture of approaches when delivering course material; especially methods that encourage student- instructor interaction

Whatever the mode of delivery, students want enthusiastic teachers who present interesting material and prioritise student engagement

This is an extract of an article from Linda Blair, clinical psychologist that first appeared in The Daily Telegraph in August 2020

The full article can be read here


Online Medical Terminology Training

COVID-19 has proved a catalyst for online training. E-learning has been around for several years now, often through impersonal computer based training packages offering online self-paced courses. With the onset of COVID-19, distance learnings has recently taken on a completely new dimension. Given the current social distancing requirements, and the fact that significant percentage of learners prefers virtual classrooms, real-time workshops are effectivity being used to deliver online medical terminology training.

A viable alternative to on site delivery

The current range of technology and platform choices has made it easier for organisations to access online medical terminology training remotely without a huge investment in technology. Zoom is one of several solutions that can be used on laptops, desktops, tablets, smartphones, and even desk phones, giving delegates several ways to access the training workshops. If there are bandwidth limitations, Zoom will modify its transmission to ensure that delegates are able to have as smooth a training session as possible. Where other applications will begin to act sluggishly and take seconds to load a single frame, Zoom does everything in its power to ensure that delegates do not experience any delay in presentation. Simply because the next slide won’t load on participants’ screens, even if it has to resort to cutting down slightly on the resolution.

Zoom workshops provide trainer / delegate interaction as viable alternative to on site delivery. These are shorter and more digestible real time classes with the same live trainer that would normally deliver on site.

Delegates and trainers interacting in real-time

For organisations like Medicologic it has been easy to immediately integrate ready-made, high-quality courses into Zoom online medical terminology training packages which that can still be delivered in house. Delivery in person through Zoom allows an easy switch between web cam and screen-share content. With delegates and trainers interacting in real-time, the sense of presence is enhanced when everyone shows their face via their web cam. Simply, it is easier to engage with the group if trainers can see the group, notice non-verbal cues and gauge the level of engagement in real time.  Trainers can then make adjustments to the way, and the pace at which, they deliver the workshop in order to make sure they are getting through to everyone. Indeed delegates themselves are more likely to pay attention if they know they’re on camera.

For online medical terminology training, delegates are still provided workbooks and manuals, and simply join the course from a location that suits them.

These trainer led real-time virtual workshops are the closest equivalent of physical training room in the digital world, but without the need to travel or book rooms. What started as a short-term response to a crisis, this shift to remote training will likely become an enduring digital transformation for the whole of the training industry

COVID-19 and Digitalising Medical Records

Twenty years ago the NHS began the process to take paper records and create digital summaries. Collating relevant data and standardising it is a complicated task, but when done properly, the current COVID-19 pandemic has provided a great example of just how invaluable digitalising medical records really is. We have seen a stream of reports published on the impact of COVID-19. This has helped policymakers better understand the demographics of those that have been affected. The primary care digitalising of medical records has given the country a database of patient records including such categories as  age groups and pre-existing conditions. From this analysis can work out which patients are most at risk, where to focus containment efforts, where the healthcare system will face strain, and which interventions can best mitigate the crisis.

Trained and experienced primary care staff have been central to the summarising and digitalising of medical records. In order to make better predictions on the spread and impact of Covid-19, more data from reliable sources is needed. Patients’ medical records are just one example of where life-saving information has been used to and gather valuable insights, which in turn

One strategy for reopening the economy before a vaccine is developed could involve monitoring the contacts of newly infected people, and knowing the individuals who are most at risk would make this a powerful and effective strategy. The more complete the data, the more effective this solution could be.

However there are still plenty of notes still sitting in practice cupboards, so this rich source of data still has some way to go before its exhausted. The primary care task now is to make the time to make it a key objective to finish the task, so that patients across all GP practices are given the benefit of having their risk profile considered as part of a risk management strategy in managing social distancing and for the greater public good.

While diseases can spread fast, verified data and knowledge can spread even faster, and that is where the focus needs to be. The importance of having a logical approach to summarising medical records and getting this data in the hands of analysts has never been stronger.

Woman given erectile dysfunction cream for dry eye in prescription mix-up

basic understanding of medical terminology and medicines

The importance of a basic understanding of medical terminology and medicines is as important as it ever was, and has been highlighted recently by this example of two medications with similar spellings – but for completely different complaints

A patient, had to be treated in hospital after she was given the wrong medication due to a mix-up.On attending the emergency department of a Glasgow hospital, the patient was found to have conjunctivitis and a defect on her cornea. However, the erectile dysfunction cream that was dispensed to her had a similar name, Vitaros, to the eye lubricant she was actually prescribed – VitA-POS. The patient suffered with blurred vision, a swollen eyelid and redness and discomfort immediately after putting the erectile dysfunction cream into her eye.

Experts have said GPs must use block capitals when writing prescriptions after a woman was mistakenly given erectile dysfunction cream for a dry eye

Eye doctors from Glasgow’s Tennent Institute of Ophthalmology, who treated the woman, have now written an article on the case in BMJ Case Reports, the medical journal

“It is unusual in this case that no individual, including the patient, general practitioner or dispensing pharmacist, questioned erectile dysfunction cream being dispensed to a female patient with ocular application instructions.

“We would like to raise awareness that medications with similar spellings exist,” the report said.

Importantly, doctors noted that one in 20 prescriptions were estimated to be affected by a prescribing error.

The original report can be read here

Training non-clinical staff in Primary Care

non-clinical staff in primary careOver the last 16 years I have delivered face to face training to non-clinical staff in primary care. In light of easy access to technology and information on the internet, what are the training needs today for non-medically trained professionals working in close contact with the medical profession?

What’s required of the role?

The class of 2016 are involved extracting and imputing key medical data from medical notes. Often referred to as note summarising, they scan medical reports onto IT systems and link them to a problem title. Then once this has been done read codes are attached to each medical diagnosis, operation or problem. This process requires clarity and key medical knowledge; it is not enough to record a patient as having had a hysterectomy (uterus removed). There are at least 10 different codes or ways of having a hysterectomy, and it must be correctly coded.

The non-clinical team also update medical summaries as letters arrive from hospital departments. Staff are expected to work with other agencies and need background information to deal with patients, doctors and other multidisciplinary staff.

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