Clinical Timeline Details

Case study – providing a facility for effective viewing of correspondence in mental health electronic records

The setting – health records in mental healthcare Health records contain essential information about a patient’s care. For many mental disorders, these contain extensive documentation over long periods, as many of the conditions being treated are longstanding and/or prone to relapse. A particularly important function of the health record is to provide a clinician (e.g. a doctor or a nurse) with previous information on a patient’s condition (e.g. symptoms), what interventions (e.g. medication, talking treatments) were received, and what the response was to these. Typically this is achieved through visually scanning (speed-reading) previous correspondence between the mental health service and the GP, or between different professionals in the mental health service. These letters are particularly useful because they are often structured with sub-headings (albeit using varying systems) and contain summaries of current/previous treatment and of a patient’s current situation. They are much easier to read than directly entered case notes because of this structuring and formatting, and because of their summarising function.

The problem – viewing deficiencies of electronic health records Nearly all mental health services in the UK now use electronic rather than paper-based health records. Most such electronic records systems have been in place for 5-10 years. On most systems, clinical correspondence is incorporated as attachments which can be opened and viewed within the record. Electronic health records have many advantages over their paper-based predecessors. However, visualisation of the full record is relatively poor, compared to the paper-based system. In old paper-based records, a clinician used to be able to flick rapidly through previous correspondence in order to gain the historic view of the patient’s symptoms and treatment. As mentioned, this rapid visualisation is facilitated by the structured way in which information is recorded and by the different types of correspondence (e.g. ranging from a lengthy case summary, useful for some purposes, to a brief account of an outpatient assessment, useful for others) – these can be distinguished by clinicians at a glance and it is relatively easy to ‘zone in’ on the parts of the document of most interest. Electronic records currently fail to provide this facility. For example, in the Patient Journey System – the electronic mental health record under consideration here – browsing through correspondence requires the clinician to move in and out of documents, opening and closing these attachments in other programs (e.g. Word, Acrobat). This is very cumbersome and time-consuming, particularly for lengthy and more complicated records. Although files are often accompanied by labels indicating the type of document (e.g. ‘letter to GP’), the content can’t be previewed (e.g. whether the letter is providing a full case summary or just a few lines on an appointment non-attendance) and there is no browsing option.

The importance of the problem This issue is not just a matter of inconvenience for clinicians. The more cumbersome it is to retrieve clinical information, the more likely important information will be missed, resulting in less adequate health care – e.g. inappropriate interventions being given, failure to identify or avoid adverse drug events (side-effects). An additional potential benefit arising from solving this problem would be in establishing a domain outside the electronic record where derived data can be displayed and decision-support applications developed and housed. A facility to display correspondence fields would be highly valuable to clinicians and would improve the likelihood of an extra-record domain being opened and used in routine clinical practice.

The solution – functionality required The following requirements need to be met in any solution: A viewing platform is generated that allows a clinician to browse all patient correspondence on an electronic mental health record in the same way that they would a paper-based record. The solution will assume that there is an appropriate domain to house it outside the record, but readily viewable from the record itself. The solution will ideally avoid significantly modifying the source record and will be a parallel resource to the current ability to view attachments. The viewing platform will be able to display all correspondence regardless of its original format (e.g. some letters will be attached to the record as Word documents, others may be scanned in pdf or other images). The solution will therefore ideally be neutral to the original format.
The primary purpose of the viewing platform is to allow the clinician to see the original record in its original format (e.g. headings, paragraphs etc.). Additional processed data (e.g. on type of letter, date sent etc.) might be helpful supplementary information but should be seen as peripheral compared to the original unprocessed text. We are also not looking for a solution which attempts to re-organise original material or which requires any change in clinician behaviour (i.e. it accepts the heterogeneity of the source material and does not try to change it). The viewing platform should ideally provide a full view of letters – a previewing function which only displays part of a letter is unlikely to be clinically useful. The viewing platform should ideally avoid the necessity to open and close individual correspondence fields (this is the problem with current records). The viewing platform should ideally display all correspondence in a single view with a scrolling/page-turning facility. However, some records will have a very large number of lengthy documents attached, so an acceptable solution might possibly split views (e.g. collating correspondence by calendar year, by treatment episode) if the large size of source documents might impede performance.