Patient Healthcare Using SMS Technology Application
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Introduction to Patient Care Using SMS Application
Patients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health care in different locations and other remote areas can be achieved using mobile phone applications .
1.1 Problem Statement
Development of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare; encouraging patient's to use mobile health application and supporting people with long term conditions .
Incredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution [5 6].
* To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à-vis Exchange Server etc
* Main aim of this application is to achieve “greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patient's care “[5 6].
The goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants' care have to be provided. The second is sufficient exchange of patient's information have to be provided.
Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important .
1.4 Existing Systems
The existing system of treatment consists of two different systems. They are as follows:
* Traditional or manual system
* Online application
1.4.1 Traditional or Manual system
The present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process.
* Time consuming
* Patient need to stand in long queues to make appointments
* Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest.
1.4.2 Online System
Online application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. The online systems are discussed below are:
* VISION System
18.104.22.168 EMIS System
EMIS® stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online .
After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information - if practice has set up these features online . This example has been explained in detailed in chapter 2.
1.5.2 Example 2: Vision System
Vision  is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day.
“Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDA's support and incorporated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems” . In this project we are more concentrating on EMIS rather than Vision system.
Incorporated External system
Problem Orientated Views
Community Caseload Search and Reporting
7. Clinical Audit Vision and the National Applications 
Few of the above features are explain below :
This system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patient's data from number of external sources including the NHS Spine or local CPR's to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy.
Vision also manages a range of clinical messages from third party systems to support the patient care as follows:
* Choose and Book Referral's (electronic booking)
* E- Discharge Summaries
* Radiology reports and Encrypted pathology reports
* OOH Summaries
With a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed.
2. Incorporated External System
In the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop.
The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision
3. Patients Appointments
This Vision system allows user full access to the appointment screen. “Using session templates developed by the practice” the appointment books are defined in advance.
The view of appointment book can be defined by user: all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctor's room or leave the surgery, their status is recorded.
Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters.
1.5 Thesis Organisation
In chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages.
The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.
This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained.
In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter.
The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions.
The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained.
Advance system and its features are discussed in this chapter 7. Waterfall Model's activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations.
The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter.
Egton Medical Information Systems
EMIS® and 'EMIS intellectual technology' are trading names of “Egton Medical Information Systems Limited”. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire .
EMIS® head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors .
2.1 Practice Care System Enterprise
Due to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMIS's Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community .
PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly .
2.2 An overview of PCS Enterprise
This edition has been designed to develop EMIS' provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections .
EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system:
2.3 EMIS Primary Care System Practice edition
Health information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use .
Key features of EMIS PCS
* Complete patient record management
* Quick and good prescribing
* Formulary managements
* Incorporated consultation mode
* Incorporated appointments
* Mentor Library
* Integrated with MS Word support
* User defined templates
* Drug Explorer
2.4 EMIS LV Version 5.2
In the PCS market, EMIS Live Version  is the main text based medical system. Approximately 5000 GP's currently using EMIS LV system (which is shown below) in the UK. The system offers GP's consultation mode option, medical record, search and reports option, prescription and booking appointments.
2.5 Population Manager
This system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager  has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system.
2.6 Version 5.2 features
This is the most recent release of EMIS LV. This LV offers users the following key features :
2.6.1 MS Word incorporation
Patient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS.
2.6.2 Referral template for Cancer patient's
If cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks; hence these referrals are named as “two week rule referrals”. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2.
2.6.3 Electronic Insurance reports
One of the most common and time taking medical information requests for GP's is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system.
2.6.4 Scanning and attachments
This module enables to scan corresponding or images and attaches them directly to a patient's record in consultation mode. These documents are instantly available during consultation.
2.7 EMIS Clinical Communication Modules
The following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care .
1 Online Referrals with Booked Admissions
2 Electronic Referrals
3 Incoming Reports including Electronic Discharges
4 Online Results Ordering
With an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below :
2.7.1 Online Referrals and booked admissions
Traditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment.
Requirements: Each EMIS practice must have:
* EMIS LV 5.2
* NHS Net connectivity
* Router access for EMIS
* Version 2 clinical terms (5 byte Read Codes)
The Secondary Care Provider will need:
* An EMIS approved website
2.7.2 Electronic Referrals
This module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant .
The way electronic referrals work
You can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission: answer ‘Yes' and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen.
Each EMIS practice must have:
* EMIS LV 5.2
* NHSnet connectivity
* Router access for EMIS Support
* SMTP or DTS mailbox
* MS-Word Integration
The secondary care provider will need:
* SMTP or DTS mailbox
* Suitable software capable of sending and receiving XML messages and acknowledgements
* SMTP/DTS and EDI code addresses of the practices involved - the trust should obtain these from the health authority or national tracking database
2.7.3 Incoming Reports including electronic discharges
Use this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hour's services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider .
How does the Incoming Reports module work?
Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider.
When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode.
To use Incoming Reports, an EMIS practice must have:
* EMIS LV 5.2
* NHSnet connectivity
* Router access for EMIS
* A DTS address
To use Incoming Reports, a secondary care provider must have:
* A DTS address.
* The DTS addresses and EDI€ codes for all required practices - this information is available from the health authority or from the national tracking database.
* Software to create and send XML messages and receive acknowledgements
2.7.4 Online Test Ordering
Requesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service.
The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results .
Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patient's demographic and GP details are transferred to the laboratory system when you request the required tests.
After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patient's record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before .
Each EMIS practice must have:
* EMIS LV 5.2 or EMIS PCS
* NHSnet connectivity
* Router access for EMIS
* Version 2 clinical terms (5-byte Read codes)
The overall Online Test Ordering process relies on different services and software all working in conjunction with each other: the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas; therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities.
2.8 Storage area network (SAN)
Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run , on which EMIS stores data [Detail explanation in later chapter].
The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.
Drawbacks of Online systems
Although online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example.
3.1 Patient Record
¨ Time required to put all relevant information onto system
¨ Possible security issues
¨ Doctor can focus too much on patient information onscreen which could intimidate the patient
¨ Scanning and entry of data is more time consuming. Important information lost can when overlooking the record.
¨ Medical record print-outs are frequently of poor quality and difficult to understand necessary information
¨ In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable.
¨ Often using computer and paper records together will make patient data look very difficult.
¨ Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data
¨ Patients have to be checked into appointment system by receptionist
¨ Problematic if patient's can't read, or unable to view sign (e.g. blind people)
¨ Relies on drug information being up to date
¨ Aptitude of doctor in using computer effectively
¨ Some times doctors issue hand written prescription; they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required .
¨ Relies on doctor checking their mail daily
¨ Troublesome patients abusing the system
¨ Hospital letters not emailed (would be preferred)
3.5 Security issues
¨ Doctors have to go to bother of signing on and off EMIS
¨ Forgetting passwords
¨ Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable
¨ Leaving computer on
¨ Locum doctors
¨ Experts are need to show computer frauds and misuse 
3.6 Internet connection
¨ Continuous internet connection required
¨ The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5].
¨ System backed up every night onto tape
¨ Two copies:-
- Fireproof safe
- Remote location
3.8 Read codes
Maintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility .
The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2
The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. .
Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesn't always reflect a clinician's view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 .
Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated .
Read/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. “Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners” .
Read codes has been explained more clearly in chapter 4.
3.9 GP2GP Record transfer
The experience of the GP2GP record transfer and the clinical involvement are explained this section.
3.9.1 The underlying principle for electronic GP-GP record transfer
The vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part .
This results from a variety of causes whose main headings are:
* Patient records that are an unpredictable mix between paper and electronic.
* The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore:
* As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities.
* To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications
* To reduce the risks to patients arising from the transfer of confusing records.
3.9.2 The nature of electronic GP-GP record transfer
Electronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of :
* Record encounters; what constitutes a single transaction with the record like a doctor's consultation, a letter received from hospital or outside, an examination result etc
* Names for these encounters; e.g. home visit,
* Headings within these encounters
* Complex clinical constructs
* Read code mappings; such medication codes sets
* Codes and associated text
* Major modifiers of clinical meaning
3.9.3 The Problems of electronic GP-GP record transfer
There are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below .
There are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are:
* The multiple coding schemes used and
* Failure of previous code mapping exercises (see chapter 5 on data transfer).
3.10 The Problem Oriented Medical Record (PMOR)
Electronic health records (EHR) are more used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) .
3.10.1 Limitations of the PO Medical Record
The limitations of POMR are explain below 
* It is very easy to pick up but very difficult to maintain.
* In the strict way of the word not all headings are 'problems'. For example, the heading of 'Immunisation' is used usually to indicate where all the entries related to a immunization history may be found.
* Many different problems may be discussed within a single consultation
* To check scanned documents is very difficult especially when patient record is too big
* Problems are frequently linked in a fundamental way.
* The PO Medical Record only gives a basic measure of the state of a problem.
* Different clinicians, view the clinical record, required different information from the medical record as well as with different views.
* Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again.
Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress .
3.11 Other Disadvantages
* Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms.
* Many screen need to be changes to find results and mouse activity
* Information can be hidden as only the information requested is
* Viewing screen generally takes longer time than scanning visually
* In busy practices information fatigue can easily occurs and while entering all telephone data slows doctors as they practice defensive medicine
* Information and data quality depends on the software using and user skills
* Patients see the doctor as computer centred 
This chapter gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained.
Patient Medical Records & Read Codes
“A medical record, health record, or medical chart is an organized record of a patient's medical history and care”. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal .
A medical record consists of the following:
* Medical history
* Surgical history
* Obstetric history
* Medications and medical allergies
* Family history
* Social history
* Immunization history
* Growth chart and developmental history
A medical record provides a written account of a patient's complete medical history. A whole draft of legislation, standards and guidance on what has become known as 'Information Governance' has been produced in the last few years to cover issues of access, confidentiality and disclosure .
4.1 Traditional Patient or Medical Records
Traditionally, patient records have been written on paper and kept in thick envelopes which classically divided into useful sections either alphabetically or using patient numbers, with new information added to each section ascending or descending order as the patient experiences new medical issues. Active problem records are generally housed at the clinical site, but past records (e.g., those of the dead or the patient who have more than one record) are often kept in different location or facilities .
Problem of Paper based system
Though paper-based records have been in continuation for centuries and their gradual substitute by computer-based records has been slowly underway for over twenty years in healthcare systems. The main problems with the manual records are security, if lost cant be recovered, time consuming. Even computerised information systems have not achieved the same degree of penetration in healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail industries. Those EMR (Electronic Medical Record) systems that have been implemented however have been used mainly for administrative rather than clinical purposes .
4.2 Paperless Practices
With the help of system providers many GPs are developing into paperless practices, which have a completely incorporated Windows-based system including access to full EMRs . “Improvements in information flow technologies, supportive national and local policies, as well as a motivated practice and a local champion with good management skills have contributed to the successful integration of computers. These improvements have subsequently moved many general practices forward towards becoming paperless. Hospital's are not making improvements as general practices in their IT infrastructures” 
The reason why the hospital or the GPs that prevents or discourages doctors from migrating towards becoming absolutely paperless is generally the restricted and uncoordinated development of Information Technology (IT) within .
4.2.1 The reason General practices become paperless
There has been a relentless move with computerisation of practices towards paperless clinical records and paperless practice activity generally. Good quality electronic records, generally, can be used to prompt :
* patient care can be improve
* Better management of patient care between GP and secondary care
* monitoring of the health of populations will improve
* Research based on primary care improves
4.2.2 Advantages and disadvantages of paperless practice
Computerisation has traditionally been seen as enabling improvements in the quality of care given by a practice. A variety of advantages and disadvantages have been cited .
* problems such as delay when transferring paper records and loss or misplacement of paper records envelopes can be overcome
* Time saving and convenient
* It allows information sharing more easily, the practice can reduces internal paper flows using email and intranet communication
* Provides better security and confidentiality
* Using electronic patient records, data quality can be achieve
* Provides more efficient and effective consultations
* collecting/retrieving exact information becomes easy
* Provides transparency of patient data
* Data security is still remain an issue
* managing and scanning documents have proved difficult
* Staff training required and lack of IT principles for GP staff
* Problems such as data backup and sharing information externally between practices
* using Data Protection Act patient may view notes which can have considerable workload implications
4.2.3 Migration towards a paperless Hospital
There are several different document-related activities that can be analysed for investigating the practical implications of migrating towards a paperless organisation. Data entry into electronic format by consultants using the preoperative risk assessment PRA form is tiresome and an additional activity that is required purely for reasons outside the local concerns of the medical professional 
* reduce costs of storage space
* Up to date data and aggregation of data with online access
* reducing redundant form filling by providing link to a centralised data store thereby
* data access and retrieval is relatively easy compared to paper notes, and those generated by different hospitals
* Allow consultants remote access to information
* Paper record is more flexible, portable and available i.e. PRA forms
* Computer based systems are more structured with constrained interfaces
* Data inputting via keyboards
* Problems such of screen size, viewing angles and the ability to share multiple documents simultaneously by people in the similar room
However, due to poor system design and poor investment means that hospital doctors do not use computers.
4.3 Electronic patient records
“An EPR is generally a computerized lawful health record created in hospital and doctor's surgery that delivers care”.
Electronic Patient Records (EPRs) are the recommended format promoted by the NHS information strategy, the National Service Frameworks, and the NHS plan. EPRs aim to improve patient care, improve the communication and coordination of care between primary and secondary health care services, monitor the health of populations, and undertake primary care research .
An Electronic patient record consists of following:
* Present and past problems
* Test results
* Immunisation record
* Allergies record
* Attachments (scanned letters from hospital or other secondary care)
* Current and past drugs list
* Family history
* Due diary entries
4.4 Clinical codes
Clinical codes play an important in General Practices today. All the data of patient is read coded which helps in doing patient searches and audit trails. Whilst adequate for primary care, the clinical code system does have its limitations in the wider environment of the integrated care record, and SNOMED CT (Systemised Nomenclature of Medicine) has been selected as the standard terminology scheme for the National Programme for IT (NPfIT, see below) .
4.4.1 The National programme for Information Technology
The UK Government's vision is to establish, an NHS information technology system which will be able to communicate within itself through its agency connecting for Health (transfer of information between GPs, the hospital sector and community services), with external agencies such as social services, and with health services globally .
To deliver the objectives, several components need to be in place, the most significant of which are explained below :
* N3 the National Network allows secure connection
* GP to GP transfer allow transfer electronic transfer of patient records
* NHS Care Records facility securely accessible by the patient
* Choose and Book Referrals- patients select their choice of hospital and can make their appointment
* Electronic Prescription Service- enables GPs to electronic transfer of prescriptions dispensers
· The National Health Service Spine - It is the National database which stores each patient's complete medical record. Detailed information from NHS number to past problems The NHS Spine has been shown below in the . The represents how NHS spine is connected to secondary and primary care system.
4.5 Electronic Patient Record stands Lawful Alone
From October 2000 it became lawful that GPs can keep only electronic patient records, i.e. the whole idea is to become paperless. As patient data is very sensitive, GPs and hospitals follow rules and regulation according to Data Protection act. More steps are taken to safeguard patient information which otherwise can be misuse.
As Electronic Patient Records is easily accessible there are many advantages and disadvantages associated with it. Few are discussed below in Table 4.1 .
Table 4.1: pros and cons of the EPR
All the data can be easily found.
Typing skills required which makes doctors as computer centric and many are using ever more abbreviations and acronyms.
Patient data can be easily reached and confidential, of staff and level of use carefully controlled.
People can misuse passwords, which can be troublesome or swapped which will make system can be completely inoperable.
No filing required which save staff time from filing.
It is time consumable as its take more time for scanning letters and data entry.
Identifiable staff or clinician enter encounter date and time.
Necessary patient information print-outs often of deprived quality and unclear.
Drugs prescribed can be accurately recorded which will includes date, amounts of repeats and staff initial issuing medication.
The patient may get confused due to current and repeat medication
Results can be displayed easily and BP readings that can be in tabulated or graph form.
To view different results can sometimes only be found by many screen changes and mouse activity.
Data is back up every day this made records more secure.
Paper records are also need to be kept
Patient data is more easily transferable by email, patient card or disc so risk of loss or misuse of data
Many GPs sill do not transfer records using GP2GP links
Data Quality of record can be high if data is entered accurately.
Data Quality depends on the skills of the user and the software
Due to patient summaries and drugs warnings can be easily displayed safer prescribing is possible
Read codes can be used for clinical purpose which make Doctor or clinician life easy.
Sometime many codes are meaningless.
4.6 The main Clinical Risk areas of EPR
There are numerous areas of risk of patient records. The two main risks are
* Inability to transmit patient data between GPs
* restriction of the PC screen for viewing patient data
The other few clinical risks are discussed below :
4.6.1 GP to GP Transfer
The risks associated in transferring the information using GP2GP links are as follows:
* Different surgeries use different computer systems which are not inter compatible, due to which transfer patient records does not takes place accordingly.
* As many patient moves from place to place and get register each time. Sending their medical summary to each practice practically not possible due to due to cost. When the record is reached to the practise it goes on computer manually which need trained staff.
* From the above problems it may leads to some of the data loss and time consuming
4.6.2 Viewing Notes quickly
Viewing notes quickly leads to Information Fatigue. Just as traditional notes are impossible, enormous patient data is more difficult manage can't view in one go and going back to previous screen is also difficult. It quicker to scan all hospitals letter, when doctors try to locate for the particular letter it takes time, he might miss important information.
4.6.3 Problems in Clinical Negligence
Using computer in GPs is giving many problems for those who are working in clinical negligence. It is important for the staff to know what information may be obtainable, recognising and understanding that the standard of practice has been changed and finding new solutions to old issues, makes knowledge of the EPR vital for clinical negligence lawyers .
4.6.4 The patient's complete Record
Solicitors now request the whole record of patient and also they need to be told which software is being used at the practice and to what extent the system is being used by the practice. Already cases have arisen when a paper record was not entered on a computer system and was negligently overlooked.
4.7 New solutions to old issues
There are few well known issues in medical negligence and those are presented differently below .
4.7.1 Which notes practitioner is responsible to see for
When doctor is doing or writing series of consultations it has frequently been necessary to give opinion as to which of the previous consultations a practitioner would have read or considered.
With the paper record, a doctor is more likely to have read the penultimate consultation if it was on the same page and less likely if a crucial consultation occurred some entries back in the record. In general, when an entry is made immediately below another, the preceding entry cannot be overlooked.
4.7.2 Notes has been modified or not
There are many risks associated with paper based records such as suspicious handwriting and changes ink for fraud entries. The computer record can more easily be altered or misuse can easily send via email or copied to pen drive but it leaves an audit trail.
4.7.3 Different Computer have Different Style
To some extent using a computer in the practices may look easy but there are chances of errors. Doctors and other healthcare professionals may get confused due to these problems.
The LV5 version of EMIS for example encourages a separate entry for History, Examination, Comment and Problem, whereas some systems allow the doctor to enter the entire consultation under one free text area which, although quicker, is less likely to produce a safe structured entry. The former will be more likely to provide a sound defence.
I have no doubt that within ten years some systems will be identified as much more liable to medical accident as others .
4.7.4 Automated Warnings
* Computers not only keep records of discussion with patient, but they also provide automated warnings about medicine, annual alerts such as diabetes review, asthma review and in some situation a GP has to ignore a warning in order to print the patient prescription.
* Some programmes such NHS sponsored SCRIPT or PRODIGY will prompt medicine choices in certain
* Systems like British National Formulary and Electronic MIMS advice such as Mentor can all be installed .
4.7.5 Length and Accountability of Doctor's Consultations
Presently with many systems such as EMIS it is possible to find out patient arrival time, waited for doctor to see and how long doctor has spent time with patient. Most clinical negligence lawyers are aware with this information and this is useful for deciding whether a systematic opinion has been made .
4.7.6 The Doctor as Typist
* It is now essential for doctors to have typing skills otherwise they will spend more time in data entry and patient have to wait
* It is not possible that Medical school train doctors each system in use and some doctors will be working with systems with which they are unknown.
* Additional training required to train doctors and health care professional. Without full training the possible for locum doctors to error is greatly enhanced .
4.7.7 Out of Hours Services
Patients these days prefers to be see nurse practitioners at a Walk in clinic or centre, or duty doctors at a Primary Care's OOH centre and before doing so they have to go through a triaged by a message handler, doctor or nurse at triage or attended to by a paramedic .
In this chapter we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter.
Read Codes and Its Challenges
In the early 1980s hierarchically-arranged Read Codes are controlled clinical vocabulary and it mainly consists of three maintained description of various complexities. The read codes are updated quarterly as they are dynamic in response to user requests which includes clinicians in both General Practices and PCT's, System suppliers and advice from a group of expert healthcare professionals. The progress of codes content within versions creates tensions between different users and uses of coded medical data. In-house processes, outside interactions and new structural characteristics are implemented by the NHS Centre for Coding and Classification (NHSCCC) for user interactive continuation of the Read Codes is described .
The Codes are dynamic medical terminology; they are updated in order to release on a quarterly basis for medical terms and monthly basis for drugs and appliances. The release gap supports stability for the need of quick response to feedback and also reduces problem to the users. The revise process is difficult by the need to concurrently maintain three separate versions that remain in active use: the early four byte set, Version 2, and Version 3. Even though they support migration to Version 3, the essential upgrades to hardware and software are expensive, and there is responsibility to ensure that older versions are supported .
Even though the formal classifications need stability over a period of time to allow continuity in data aggregation, a maintained vocabulary for the compilation of clinical data needs to be dynamic. The updates of frequency and mechanisms will differ in response to a number of factors: in particular, size, design purpose, ownership, and available resources. For ex: the revision of annual ICD-9-CM are in printed and electronic formats, but the UML Meta thesaurus is issued annually on CD-ROM, and SNOMED International has enlarged its frequency of electronic updates .
The three versions are as follows 
* The Four Byte set
* Five Byte Set
* Version 3
5.1 The Four Byte Set
In the early 1980's the read codes were first introduced to keep a summary record of clinical and clerical data for the Surgeries. These were introduced to record patient's clinical summary and administrative data for General Practice. “The Four-character alpha-numeric code decides position of term in a hierarchy is called as the The Four Byte Set. It is divided in to two delimited text files, file 1 one contain fields for the read codes and the thirty character preferred term (For Ex: F682.| Sensorineural deafness) and the second contains four character keywords and synonyms, for ex: F682.| Sensorineural deafness| SENS and F682.| Nerve deafness| NERV). Even though the easy code-dependant structure is attractive to both users and developers there are quite resulting problems persist”.
* It has simple code-dependant structure
* This version attractive to users and developers
* Simple structures but resulting in numerous problems
* Compare to 4 Byte set, Version 2 has shorter terms and keys
* Multiple parentages are not supported, leading to either partial classification or to replication .
5.2 Version 2
Both Four Byte Set and Five Byte Set have cross-mappings to other classifications, including OPCS4, ICD9, ICD10, the British National Formulary (BNF), and the Anatomic and Therapeutic Chemical Classification Index (ATC).Version 2 is the most widely used format because of the Five Byte Set .
The Five Byte Set consists of two files, they are one file contains the five-character code for the notion and the preferred term of up to 198-characters and additional fields for mappings to formal classifications (Table 4.1). “Another file contains all the terms that can describe a concept, such as the preferred term and synonyms. Another field holds a two-digit term code that flags a term as preferred (00) or synonymous (11, 12, 13, etc.)”. Each record has a field that may hold a term key of up to 10 characters to facilitate searching.
Advantages and Disadvantages of Version 2
* Most widely used because of Five Byte Set
* Simple and meaningful
* Version 2 is not flexible
5.3 Version 3
In 1994 Version 3 structure, “a link-based directed acyclic graph hierarchy was introduced which has complex structure includes meaningless identifiers (see 5.1), a prototype table to maintain semantic definition and attachment of qualifying detail, and a more sophisticated cross-mapping scheme”. Furthermore, Version 3 concept also is flagged with a status, enabling extraction of different sets of codes for specific purposes and additional functions as discussed below.
Current codes form the core of usable clinical concepts within Version 3, whereas codes flagged as optional are not deemed clinically useful by the SWGs and can be filtered out if desired. Two additional status flags allow preliminary new development of the Thesaurus to be tested without affecting existing users. Finally, there are experimental concepts, accessible only to in-house authors at the NHSCCC, and allowing preliminary exploration of different options. The features of the three versions are compared in Table 5.1.
In order to facilitate inter-version compatibility, current work aims to incorporate all Four Byte and Version 2 codes into Version 3, thus making Version 3 a “superset” of all versions (see 5.2). Any concept or term added to an earlier version must, therefore, now be added Version 3, and a record must be entered in appropriate inter-version mapping tables.
5.3.1 Read/SNOMED Codes
Read/SNOMED codes are used to classify medical activity and offer to be the means by which patient's clinical records will in future be transferred from one GP to another GP.
In 19th Century, James Read produced an international classification called Linnaean classification of species of medical activity to include illness names, operations and procedures. The aim was to allow easy transfer of information between GPs, hospital and tertiary care and be easy to use by healthcare profession, clinical staff and planners .
* Coding is good only if the user has good knowledge of it and knows the best way to use it. Most of the doctors use the Read/SNOMED Code as computer system in use allows and insists on coding each consultation.
* Coding has made obligatory in all practices, as locum does not have much knowledge of each system in use in this sense the code can prejudice and doctor may enter wrong code.
* Coding is easy for some conditions but the more complex for the other. It is reliable and useful once users have good knowledge of how to use it.
5.4 Read Codes Maintenance
Although Read Version 3 has become standard clinical coding system within the NHS, earlier versions remain in widespread use and need ongoing maintenance. Their fixed code-dependent hierarchies, however, limit maintenance to a relatively small number of additions and corrections. Read codes are maintained by two processes, internal process and external interaction .
5.6 Advantages of Read code
* An electronic medical (clinical) record for individual patients
* Read Codes are used for recording clinical and administrativeinformation such as codes dealing with registration, certification claims and other patient related information
* Allow Quick search and Audit trails for quarterly and yearly reports, auditing major and chronic disease for most practices (patient medical summaries)
* Rapid data entry using clinical read codes can be performed. Read codes make data entry as accurate, complete, timely and accessible
* The 2 types of description for Read codes one is ‘Preferred' term only one per Read code (like enter P in the Read code browser and user will get list of options)
* The other is ‘Synonymous' term - there may be numerous for one code (say if you enter G30 Read code browser it will give user with number of options such as Heart attack, Coronary thrombosis,Cardiac rupture - MI)
5.7 Disadvantages of Read codes
* All the medical staff and doctors need training to avoid errors
* Cost and time for training
Every quarterly most of the codes are change
This chapter focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions.
Evaluation: Though version 3 comes with its flexible directed acyclic graph hierarchy, greater synonym purity, and more flexible cross-mapping scheme, incorporating default and alternative maps, avoids these limitations. This flexibility, however, allows other potential problems
Database and Its Structure
Providing patients the top quality service is the main aim of UK government's healthcare programme, and in 2005 connecting for Health programme strategies came into operation, which support this goal of healthcare programme. Electronic patient records offer a rapid, consistent, and protected method of sharing patient data .
The National Health System employs the country's good solutions to sustain this programme of healthcare reform. EMIS is based in Leeds, one of the leading companies in UK. “An IT supplier in primary healthcare, the company already hosting more than 39 million patient records within and around 60 percent of the country's doctors use it as well” .
Example: Data transfer within PCT (Primary Care Trust)
The below 6.1 explains how data transfer takes place within the PCT. Patient records is accessed by hospitals, pharmacy, Out of ours service and the surgery. Its also shows that where patient records are kept in order to access them whenever required.
Its also represent data transfer between surgery and Spine.
According to Sheavills “Gp's can utilise their time (even a 30 second) to view patient records as they don't have wait for screens to get refresh as that is not acceptable in this environment.” Sheavills says that has always been a challenge to achieving that performance over a network the scale of the NHS. “It hasn't easy to attain sub-second systems. People have always been a negotiation between usability and speed. But due to Microsoft latest release products this changed.” 
EMIS Web suite has been redeveloped to take the advantage of latest-released of Microsoft technologies including the Windows Server 2008 Enterprise operating system and the Microsoft Visual Studio 2008 development system. EMIS firmly believes that these Microsoft technologies provide the high levels of performance and scalability that meet and exceed industry all needs.
EMIS have design database in such a way to accept upgrades in future. Patient database is designed as shown in 6.2 (The database model of EMIS is shown below in the 6.2). Where patient variable are defined in order meet the NHS requirements. The shows patient class relationship with hospitals, staff at GPs or hospital and Insurance companies. In other way it shows that hospital and insurance company have limited access to patient data .
6.2 Scalable and Secure Database
Microsoft SQL Server 2005 database environment support EMIS Web now with a view to improve to SQL Server 2008 (see 6.3). It offers EMIS the different levels of performance clinicians need regardless of the total number of patient numbers and NHS by means of the technology. Using SQL Server tools such EMIS Web is providing scalable, secure database applications. EMIS is using it to distribute patient records in real time between all surgeries .
SQL Server Service Broker offers excellent security, by using secure Service Broker services and routes millions of patient medical records are transferred between distributed databases each day .
6.3 Better Patient Support using Sub-Second Transactions
Today with added usability that suits clinicians' needs across all fields EMIS Web match the speed of text-based systems. The new EMIS Web solution now offers “very good speed of service that exceeds NHS requirements but the using previous ASP.NET version doctors and patients need to wait as it used to take longer time for screens refreshed” .
The new version offers speed which is very best from the previous version and it ensure all the transactions are now at least sub-second—a full second faster than the previous version. As a result, doctors can make use of their time with patients not as computer centric. Using the latest technologies EMIS has created an excellent user experience across its big database network and data centres which hold around 39 million patient records and medical records information about more than 100 terabytes” .
6.4 Secure Solutions Protect Patient Interests
EMIS Web has the tools to protect processes and stop security breaches or loss of patient information. According to Sheavills , “features from Microsoft technologies such as Windows Communication Foundation in Visual Studio 2008 deliver both system scalability and data security which has become possible. Few organisations have already taken this on or they have succeeded,” he says. “EMIS Web is successful because of the use of the right technologies for the job, which contain Windows Communication Foundation and SQL Server Service Broker. He says that there are no other technologies that allow distributing the amount of data EMIS distributing between dat
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