email: akmidgley@swis.zynet.co.uk
Why wait for the NHS wide network to link hospitals and practices? Modern software makes local links possible.
Our local hospital sent printouts of hospital events (appointments made, appointments cancelled, appointments attended, admissions and discharges) which arrived as half-inch thick piles of A4. All the information was there but it was almost unusable. I arranged to receive the file on a floppy disk, just as it would otherwise be sent to the printer.
Initially I used the copy of Q+E which came with Microsoft Excel version 4 to analyse the files, and while this was easy, it did depend on knowing what one was doing. Q+E can store searches as small text files, and will also accept instructions through DDE but neither of these was sufficiently robust and transparent to let staff loose on, or perhaps I mean "to inflict on staff". Having worked out what information to extract and report, I turned to Visual Basic, the easiest Windows™ programming language around, and wrote a program containing a spreadsheet-like browser, and a couple of forms for importing files and administering the database. The interface has the usual collection of menus, including print and copy to clipboard, and a short-cut buttonbar.
On arrival in the practice, each disk is read into the database, and the information is then available at any PC on the network.
Table 1
Shortcut reports Purpose
All events last month Analysis
Out-patient appointments due last Awareness; check for letters,
week and this week possibly update referrals or
notify cancellations
Admissions last week/month Awareness
Discharges last week/month Check for letters, review
Day case episodes last week/month Check for letters, review
All events for one, named, "When is my appointment?"
patient
The most useful reports for me are "Who is booked for out-patients next week?" and "Who was booked for out-patients last week?". The lists of admissions and discharges on disk usually (although not always) lag behind the discharge summaries, but are available for later analysis of referrals. Reports for one doctor generally occupy about one screen and printing them out is therefore unnecessary.
Windows™ database programs should offer "drill-down". In this context drilling down means that right-clicking on the entry for a particular patient offers a menu to bring up their referral letters, clicking on a type of event or a patient's name displays all of that type of event, or all the appointments for that patient from the set already selected, for example, all the general surgical appointments, or all the antenatal clinic attendances.
The hospital files contain patients' hospital numbers, and the program steals these and saves them in a database table I added for the purpose and which our word-processor accesses and then automatically inserts in subsequent referral letters, saving the secretary a few moments and avoiding errors.
The practice's fax service is integrated into the PC network so it is easy to generate a fax automatically from any patient's appointment entry. I implemented a pop-up form to offer a list of suggestions about why they will not be attending this appointment (better, emigrated, died, in hospital already, and so on) for the user to select and amplify and send it directly to the appointments office.
We save referral letters on disk with a predictable filename based on the patient's surgery identification number, followed by a type character of either ~ or # (tilde or hash) and a sequence number. They can be opened into a word-processor from the appointment listing, to be updated with recent events, current medication and lab results and printed as an updated version, or even faxed directly to the hospital. Eventually I may set this up to run automatically, but at the moment it poses the usual GP problem. If we do this, it improves the service by avoiding wasted appointments, and by ensuring our colleagues have the information which makes their work easier, but it is done at our expense. Fundholders might use such a process to negotiate a cheaper contract for services, and indeed, might take a closer interest in the follow-up appointments and cross-consultant referrals than I do.
The program links particularly well to the Micro Solutions Surgery Manager clinical records system, that being what we run, but will run alone, and at least in principle could be linked to Meditel System 6000, Encounter, or Vamp Vision all of which share Surgery Manager's open systems approach to allowing the user access to their own data through using industry standard databases. I used the Microsoft Access database engine ("Jet") which comes with Visual Basic, using two Access .mdb files, one containing the queries and the other the data tables. The event data is held in Access native format tables, and I attached DBase format files in the different directories where they are kept by their parent applications. Jet can attach DBase and Paradox files directly, import FoxPro files, and read InterBase files through ODBC. The same functionality could be provided on other clinical systems by using the clinical system's inbuilt reporting capabilities to generate text files with the required fields of information, and automatically importing these into database tables in a format Visual Basic can relate to.
The Patient Administration System used by the Royal Devon & Exeter Hospitals is used in much of the South West Region. It originated in Trent Region, and has migrated from a Vax to a PC network with the Micronetics MUMPS in which it was written now renamed 'M' language. Any hospital IT department could route the information to a disk instead of a printer.
The next developments to look forward to are for the files to be sent by email rather than disk, saving a little work once it is set up, and for the waiting lists and planned admissions to be added. When I get that information, I shall automate a task I hate, and print the form the hospital still requests before each admission, with details of current treatment and allergies, so that it is waiting for the patient to collect instead of being brought in for me to handwrite during surgery.
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