Qualitative Research Pathways
The NHS Five Year Forward View sets the target that “by 2020, all care records will be digital, real-time and interoperable,” predicated on the belief that by combining and sharing key patient and service use data, health services can provide more timely, rational and integrated care. However, the anticipated benefits of health information technology (HIT) remain largely unproven, with the mechanisms by which health systems can realise the gains yet to be fully described. To allow the potential benefits of HIT to be better visualised, we conducted a qualitative study exploring views of NHS clinical staff on the impact of current HIT in the context of unscheduled hospital care and follow-up for three different chronic ambulatory care sensitive conditions; chronic obstructive pulmonary disease (COPD), epilepsy, and alcohol dependency.
The study was conducted primarily within four NHS acute trusts in the North West Coast region of England; two of which used mainly hand-written case notes supported by various HIT packages, while the other two used mainly digital health records within an integrated HIT package. Semi-structured interviews were conducted with 33 clinicians within the ambulance service, A&E units, medical assessment wards, outpatient clinics, specialist nursing services, Regional Neuroscience Centres and GP practices.
Participants at sites with primarily hand-written case notes and poorly integrated HIT packages expressed frustration at what they saw as unnecessary time spent searching for internal information, logging in and out of different HIT packages, and recording the same information on multiple systems. Occasionally, information could not be found when needed, or was illegible, potentially impacting on patient care. In contrast, participants at sites with integrated digital health records were happier with the way the systems functioned internally. Participants at all sites described problems in obtaining timely access to parts of the patient health record held by other organisations. This included unnecessary time spent requesting and providing information, duplication of diagnostic tests, negative impacts on patient care, and missed opportunities to intervene to improve health. Examples of impacts on patients included:
People with exacerbations of COPD being inappropriately treated with high-flow oxygen, worsening their condition
People with alcohol-related liver diseased being admitted to hospital on the basis of a single blood test when access to previous results would have shown that the condition was stable
Discussions about end of life or ceilings of care being had more than once, or inappropriate treatment given because this information is not available
People with multiple alcohol-related A&E attendances across different hospitals not identified and therefore not targeted for intervention
Participants at two sites had limited direct access to GP summaries, which they described as very useful, especially in A&E. Referral processes between providers varied widely and were often described as time-consuming, potentially unreliable, and ineffective in optimising the information transferred. The processes viewed as most efficient and effective used a structured form sent via a digital link directly from the patient record system and were available only to specific services within sites that used mainly digitised health records.
Our findings confirm that within a hospital, introducing fully digitised health records and wellintegrated HIT can have positive impacts on health service quality and staff satisfaction. These capabilities also appear to be the foundation on which a more connected, integrated health system can be created. However, effective communication and data-sharing across organisations remains a major challenge even in the presence of the necessary digital technology, and it will take time to identify priorities, forge agreements between providers, design systems and processes, and overcome continuing problems with interoperability.