Imran Rafi

Patients' online access to their electronic health records and linked online services: a systematic interpretative review

Objectives To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues. Setting Primary care. Participants A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol. Primary and secondary outcome measures Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services. Results No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt. Conclusions Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1. Systematic review registration number PROSPERO CRD42012003091.

Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59–4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05–1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

The CPRD and the RCGP: building on research success by enhancing benefits for patients and practices.

Anonymised primary care electronic health records (EHR) have been available for research in the UK for at least two decades. The time has come for a rethink in how we coordinate the sharing of data for research, in a way that provides clear benefits for patients and practices as well as researchers. Up until now, sharing data for research provides long-term benefits for the public, patients, and practitioners as a result of the implementation of these research findings. While these benefits are clearly in the public interest, our current approach provides few immediate benefits.

Identifying current training provision and future training needs in allergy available for UK general practice trainees: national cross-sectional survey of General Practitioner Specialist Training programme directors

BACKGROUND There are ongoing concerns about the quality of care provision for allergy in primary care. AIMS To identify current training provision in allergy to GP trainees and to understand how this could be enhanced. METHODS A cross-sectional survey of GP Speciality Training (GPST) programme directors was undertaken. Programme directors of the 174 GPST schemes were sent an online questionnaire which was informed by the content of the Royal College of General Practitioners curriculum. Quantitative data were descriptively analysed and a thematic analysis was undertaken of free text responses. RESULTS We obtained responses from 146 directors representing 106 training programmes. Responses indicated that two-thirds (62%, 95% CI 53.1 to 71.5) of programmes were providing at least some allergy training, with the remaining third stating that they either provided no training or were unsure. Overall, one-third (33%, 95% CI 22.7 to 42.2) of programme directors believed that all the relevant allergy-related curriculum requirements were being met. Where provided, this training was believed to be best for organ-specific allergic disorders but was thought to be poorer for systemic allergic disorders, particularly food allergy where 67% (95% CI 57.5 to 76.5) of respondents indicated that training was poor. There was considerable interest in increasing the allergy training provided, preferably through eLearning modules and problem-based learning materials supported by those with relevant specialist knowledge. CONCLUSIONS This UK-wide survey has identified important gaps in the training of GP trainees in relation to allergy care. Addressing these gaps, particularly in the management of systemic allergic disorders, should help to improve delivery of primary care-based allergy care.

Giving patients online access to their records: opportunities, challenges, and scope for service transformation

Many people use online applications to communicate with friends, book travel and hotels, order goods, organise diaries and conduct their affairs. It is therefore reasonable that patients may expect to interact with their general practice online. Internationally online access is provided by some general medical services providers1 and in certain specialist areas.2 While many UK practices already have websites for their patients that point them towards online repeat prescription ordering, appointment booking, and other services,3 few offer online access to records, the NHS Operating Framework states less than 1%. This is despite many primary care computerised medical record systems having the required functionality. The NHS Commissioning Board (NHS CB) expects all general practices in England to offer Patient Online services by 2015.4 In this context Patient Online describes patients accessing services online; booking and cancelling appointments, ordering repeat prescriptions, communicating online with the practice, and accessing their electronic health record [EHR]. In 2012 The Royal College of General Practitioners (RCGP) was commissioned by the Department of Health to produce guidance for patients and practices about what Patient Online …

Motor neurone disease

This is one of a series of occasional articles highlighting conditions that may be more common than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, university lecturer in general practice, Department of Primary Health Care, University of Oxford, and Richard Lehman, general practitioner, Banbury. To suggest a topic, please email us at practice@bmj.com

RCGP Research and Surveillance Centre Annual Report 2014–2015: disparities in presentations to primary care

BACKGROUND The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises over 100 general practices in England, with a population of around 1 million, providing a public health surveillance system for England and data for research. AIM To demonstrate the scope of data with the RCGP Annual Report 2014-2015 (May 2014 to April 2015) by describing disparities in the presentation of six common conditions included in the report. DESIGN AND SETTING This is a report of respiratory and communicable disease incidence from a primary care sentinel network in England. METHOD Incidence rates and demographic profiles are described for common cold, acute otitis media, pneumonia, influenza-like illness, herpes zoster, and scarlet fever. The impact of age, sex, ethnicity, and deprivation on the diagnosis of each condition is explored using a multivariate logistic regression. RESULTS With the exception of herpes zoster, all conditions followed a seasonal pattern. Apart from pneumonia and scarlet fever, the odds of presenting with any of the selected conditions were greater for females (P<0.001). Older people had a greater probability of a pneumonia diagnosis (≥75 years, odds ratio [OR] 6.37; P<0.001). Common cold and influenza-like illness were more likely in people from ethnic minorities than white people, while the converse was true for acute otitis media and herpes zoster. There were higher odds of acute otitis media and herpes zoster diagnosis among the less deprived (least deprived quintile, OR 1.32 and 1.48, respectively; P<0.001). CONCLUSION The RCGP RSC database provides insight into the content and range of GP workload and provides insight into current public health concerns. Further research is needed to explore these disparities in presentation to primary care.

Child maltreatment: time to rethink the role of general practice

Many children and young people do not receive the care, nurture, and protection that they need and deserve from adults in their household or wider community. They may suffer abuse or neglect, collectively termed maltreatment, or they are vulnerable due to their difficult circumstances at home. Based on self- and parent-reports, between 4–10% of children and young people 80% of which is attributable to parents or parent-figures.1,2 Far greater numbers of children can be considered ‘vulnerable’, living in very difficult household circumstances or with compromised parenting. Household surveys in England suggest more than one in five children live with an adult who misuses drugs or alcohol or who has a mental health problem.3 We recently published a report that challenged policy makers’ perceptions about the role that general practice can play in the safeguarding of these children, young people, and their families.4 The findings from this overview of policy, practice, and research were positive: GPs in the UK already know about many maltreated and vulnerable children and young people, and we found examples of a range of GP responses to these children and their families. A better model of child safeguarding across general practice needs two things: While we do not have accurate estimates of the numbers of maltreated and vulnerable children identified by general practice each year in the UK, we do have evidence about how often these concerns are recorded. In a sample of almost 77 000 children, 0.8% had …

Genomics in routine clinical care: what does this mean for primary care?

> ‘ The NHS will need to be ready to use genomics as part of its routine care 1 But how will genomics impact on primary care and what is needed for primary care to be genomics-ready? While genetics focuses on DNA coding for single functional genes, genomics is the study of the entirety of our DNA, recognising the crucial regulatory role of non-coding DNA and the complex interactions between multiple genes and the environment. Genomics and variation is fundamental to precision medicine which, through its four components of predictive, preventive, personalised, and participatory medicine, aims to promote wellness as well as to more precisely treat disease. The transformational 100 000 Genomes Project funded by the Department of Health aspires to kick-start a UK genomics industry and set up a genomics medicine service within the NHS.1 GPs will play an important role within a genomics medicine service both in supporting patients through diagnostic and treatment processes and in using knowledge of genomics for disease prevention. There are 356 000 new cancer cases diagnosed in the UK each year.2 Testing of both the patient’s own genetic makeup (‘germline’ DNA) and the tumour DNA (‘somatic’ testing) are important here. A tumour’s genomic signature may be used to make a precise diagnosis, enabling more accurate prognosis and better tailored treatment. Examples include Herceptin® (trastuzumab) in breast cancer treatment and BRAF inhibitors in malignant melanoma. Treatment can also be based on germline genomic information; PARP inhibitors are more efficacious in the treatment of ovarian cancer in individuals who carry a BRCA gene mutation. Cancer follows …

A simple clinical coding strategy to improve recording of child maltreatment concerns: an audit study

Background Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE) but there is evidence of substantial under-recording. Aim To determine whether a simple coding strategy improved recording of maltreatment-related concerns in electronic primary care records. Design and Setting Clinical audit of rates of maltreatment-related coding before January 2010–December 2011 and after January–December 2012 implementation of a simple coding strategy in 11 English family practices. The strategy included encouraging general practitioners to use, always and as a minimum, the Read code ‘Child is cause for concern’. A total of 25,106 children aged 0–18 years were registered with these practices. We also undertook a qualitative service evaluation to investigate barriers to recording. Method Outcomes were recording of 1) any maltreatment-related codes, 2) child protection proceedings and 3) child was a cause for concern. Results We found increased recording of any maltreatment-related code (rate ratio 1.4; 95% CI 1.1–1.6), child protection procedures (RR 1.4; 95% CI 1.1–1.6) and cause for concern (RR 2.5; 95% CI 1.8–3.4) after implementation of the coding strategy. Clinicians cited the simplicity of the coding strategy as the most important factor assisting implementation. Conclusion This simple coding strategy improved clinician’s recording of maltreatment-related concerns in a small sample of practices with some ‘buy-in’. Further research should investigate how recording can best support the doctor–patient relationship. How this fits in Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE), but there is evidence of substantial underrecording. We describe a simple clinical coding strategy that helped general practitioners to improve recording of maltreatment-related concerns. These improvements could improve case finding of children at risk and information sharing.