Another view: returns to IT for GP federations

By the time you read this, my co-director in Howbeck Healthcare and I will have presented to a major IT company at one of its away days.

We’ve been asked to outline where we think general practice is going, and how IT needs to develop to meet the needs that it will have along the way.

Predicting the future is a difficult game. I’ve just watched the trailer for the Steve Jobs movie, and many say his genius was in leading us to a new world – pushing the boundaries.

Yet, you could also argue that what he did well was to see which product had potential and make a superior one that people wanted.

Pick a product, any product…

Is that what we need to do for primary care IT – pick a product? Well, no. There isn’t really a product to identify. Plus, it’s really difficult to foresee the emergence of new technologies.

Could cave men predict the internet? Can we see the next revolution? Perhaps it will be nano-robots circulating in our systems, spotting problems and fixing them. However, I don’t think it’s that kind of speculation that our hosts will have been looking for.

The other risk of the pick a product approach is getting sucked into identifying problems instead of thinking about developments. It’s really easy to say: “This doesn’t work, that user interface could be improved.” But that’s feedback, not horizon scanning.

Or start to think about what we need

So why were we asked? Well we have helped set-up three, not-for- profit GP alliances so far, covering 700,000 patients and almost 100 practices.

We get a lot of feedback on their problems, but what I think is more interesting is the learning we have made from putting separate practices together and trying to think of things that could save them money, make them more productive, or deliver services in new ways.

In almost all cases, we have hit the boundaries of current technology fairly quickly. So here are a few of the things that we will be telling the IT company.

Workforce brings up several issues. First, an increasingly part time workforce, working in bigger teams, means we need very robust ways of coping when people aren’t in.

There are lots of advanced collaborative and project management tools out there, most of which could help primary care if they were tweaked a bit.

Locally, we have developed GPask; a collaborative website for a health economy to share information and expertise. But it’s only a partial answer.

Never mind patients Skyping the doctor…

Getting everyone at a meeting to discuss things can be difficult. So never mind the adoption of Skype for doctor-patient interactions, let’s have video-conferencing for doctor-doctor interactions (and other staff interactions, for that matter).

Let’s have video conference rooms or video calling from the desktop or even video calling from home. That way, all the doctors working across the multiple sites covered by a single federation could attend training/updates without wasting time on commuting.

Why isn’t a video camera, two monitors, and a decent headset mic part of the standard build?

Staff need to be able to work from home. They shouldn’t have to stay at work until midnight to finish something because they can’t do their results away from their desk.

Space is short and needs to be maximised to save cost, so relying on remote desktop isn’t a solution, because other people will need to use the room – and even the computer – on which the desktop is running. Either desktop virtualisation or web-based tools are needed.

The flip side is that while staff may work across multiple sites, in multiple roles, and need better access to information, they need access to what they need – and no more. I’m not convinced that current access controls are good enough.

Doctors need to be able to supervise others

Skill mix is probably going to increase. Pharmacists/ physios/others? However, a lot of people working in these new roles will need to work under supervision; and our current tools for undertaking that supervision are poor.

Two examples. A GP registrar does a surgery. There is no way of me watching what they are doing in real time. There is no way for them to record notes for me that aren’t part of the consultation. There is no way of going through the list without going into each patient’s records, one by one.

Our practice pharmacist wants to ask about a patient. There is no better way for them to do this than to send me a practice note or to knock on my door.

Care plans also need a real overhaul. The current consultation model of recording what we are doing is getting old fashioned.

We need better tools to manage groups of patients to Starfield principals. Actually, we need better tools just to manage care, instead of reacting to requests for appointments. Drop in pathways/Gant chart-like flow diagrams/other ideas? They all need to be experimented with.

What about practices that don’t want to merge?

Merging practices makes some of these things easier. It means there’s one database and all the staff can be on one system.

But, for the moment, our federations don’t want to merge. If they don’t, how does a receptionist in a practice that is quiet help to answer the phones for another that is busy? How do you pool or out-source this?

When I ring my insurance company, the phone is answered in the name of that company. I know full well it’s being answered by someone sitting in a big room full of people dealing with calls for a whole group of companies, using the same script. How do we get there?

Managing all this is going to be a nightmare – knowing who is doing what, when, and how much it is costing the different bits.

This is partly why we are helping develop Apex. It’s a BI tool for primary care. If you are managing 100 GPs across ten to twenty sites then performance metrics make a real difference; as long as they are used properly and not just as a stick.

Supporting good ideas

Perhaps the biggest problem that we come across is that people do have bright ideas, but find they are unable to develop those ideas.

One person wants to change the way that diabetes care is done. One wants to explore online group sessions. One likes the idea of more computerised triage on the phones and online. Another thinks the way we do results and follow up appointments could be radically improved.

Big suppliers tend to have their own road map for developing their products. They think in terms of something they can sell to 1,000 or more surgeries; not just to ten, and certainly not to the one with a hunch.

Becoming an accredited partner is difficult and very expensive. The barrier to entering the market is huge. This needs to be broken down, so more of those ideas can make their way through.

Ok, before the IG people go bananas, I know that we can’t have every 15 year old writing a piece of software that sends all our medical info to North Korea just so it can be plugged into some wonderful new app.

But creating a tool to do your diabetic clinic the way you like, or being able to change the user interface of your main clinical system to better suit what you want to do, should be easier than it is.

You shouldn’t have to convince the system supplier to add it to their roadmap, for release at some unspecified date. You should be able to hire a developer and get it done; in the way that I can for most web-tools.

Should the software be open source? Should we be able to download the prescribing module, get it working the way we want, and release that idea back to others to amend further?

Time to take charge of the roadmap

If you have been lucky enough to visit organisations like Kaiser Permanente in the states, you will know that they own their own IT.

Their roadmap is theirs, not some regulator’s, and it’s joined up – from the front door to the ITU. Their management systems are as important as their clinical systems, not just from a billing point of view but from a being able to monitor and evaluate change point of view. We have a way to go in a short time.

Dr Neil Paul Dr Neil Paul is a full time partner at Sandbach GPs; a large (22,000 patient) practice in semi-rural Cheshire. He is also one of the directors of Howbeck Healthcare Ltd. Dr Paul has been involved in primary care IT and health service management for more than ten years in various roles, including PEC member and urgent care lead. In his spare time, he writes medical iPhone software and is a keen photographer.