Record hazards

Dr Glyn Hayes

The vision of the NHS Patient Care Record is seen by many as a means to improve patient care; all of the relevant information about a patient being available wherever they have care is described as a major advance.

In order to maintain the confidence of patients a great deal of emphasis is laid on patients having the right to control who sees what parts of their record. The NHS Care Records Guarantee states “you can choose not to have information in electronic records about you shared” What are the implications of this for normal patient care?

Once these records are implemented we have to understand that human beings have a habit of believing, in a non-judgemental way, what the computer screen presents.

Potential mistakes

Many years ago there were problems with some patients being prescribed the wrong drugs by doctors using computers. The classic example is the prescribing of penicillamine, a dangerous drug used only in severe cases of arthritis, instead of penicillin, a fairly safe antibiotic used for all sorts of infections. The reason was ludicrously simple. When the doctor typed in “pen 250” as the shorthand for “Penicillin V 250mg” the picking list presented to the doctor showed “Penicillamine 250mg” at the top and Penicillin 250 mg” lower down the list.

Doctors, working under tight time constraints, just pressed return several times without checking exactly what was happening and the patient got the wrong drug. It may sound incredibly stupid but it is what human beings do.

Another example was one GP system which performed very accurate checking of drug interactions and allergies but did not check for contraindications, ie. whether a drug should not be used if the patient had a certain disease. This was because the designers of the system knew that determining what disease the patient had suffered from is extremely difficult to do precisely since doctors record things in varying ways. They decided it was better not to do this particular checking if it could not be done accurately.

However most of the users of this system believed that it did do such checking and thus felt they did not need to do such checks manually.

So, if human beings believe what is on the screen and assume the computer is always right, what implications does this have for a record which is likely to be incomplete because patients have opted to exclude some of their information?

Missing information

Suppose a woman sees her GP with a chest infection, and the doctor prescribes Amoxicillin, a widely used antibiotic. Subsequently the woman finds she is pregnant; the reason being the GP was not aware she had been prescribed the contraceptive pill by a family planning clinic because she had decided to withhold this data. Amoxicillin can stop the Pill working.

Who is at fault? The doctor for not asking her if she was on the pill? Of course, it is good medical practice to ask such things but he had many patients waiting and had become used to the computer warning him about such things. The patient for excluding such important information? Only if she was completely aware of the implications of her withholding such information.

There is no doubt in my mind that the effective implementation of electronic records will produce huge advances in patient care. However we must do all we can to educate doctors that they should not have unquestioning faith in these patient controlled records and we must educate patients that their right to withhold data is potentially very dangerous and should only be used in exceptional circumstances.