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Practice comment

''Information systems are now a fundamental part of care''


Jeremy Hunt, secretary of state for health, gave a speech in January in which he challenged the NHS to go paperless by 2018 to save billions, improve services and help meet the challenges of an ageing population

This ambition means that, whether a patient is being seen in primary care, hospital or a care home, the professionals involved can see the patient’s history at the touch of a button and share crucial information easily.

This will be a challenge for many nurses and other practitioners. In some settings, little has changed in the way we document care and access information in the decades I have been nursing.

However, in some areas, we are starting to see the emergence of new technologies that have the potential to make a major difference for staff. See, for example, the mobile health worker project featured on page 16.

If, as a profession, we are serious about using electronic records and information to help us deliver better, more efficient care, we need a wider professional debate about how to achieve that goal. This debate could cover: what standards need to be in place so we can share information? How can we record information that matters to improve care and reduce harm in a way that patients understand? How do we record information once - at the point of care - then use it many times for outcome assessment, audit, service improvement and research?

Nurses need to take professional responsibility for the information we record and where and how we record it. We need to understand the balance between sharing information and protecting information about patients. We need to acknowledge that records rightly belong to patients and that we are contributing to their records.

On top of all of this, it’s no longer about nursing records. They are the patients’ records and we need to understand the shift in professional attitudes required. Information is not a by-product of care but a fundamental part of it.

All these issues will require leadership at all levels. Using information and information systems is no longer optional in nursing and midwifery work; in a modern world, it is fundamental to how we do things.

Embracing the brave new world will take courage. Yet we should take solace from the fact we have already started this journey. In many areas of practice, we have coped with an evolution of technological innovation already.

So what do we need to do? We need to think carefully about the care we deliver and have the commitment and courage to adapt and change.

We need to consider record keeping and how we share information in records with our patients. We need to understand the importance of transparency and good-quality information. It is not going to be an easy journey but it is one worth travelling.

Anne Cooper is National Clinical lead for Nursing, Department of Health informatics directorate.

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Readers' comments (5)

  • How much money has been wasted by the NHS across the UK with IT systems that don't do what they say on the tin and cannot speak to other systems in the same hospital!

    Agree with making better use of IT and the vision of a paperless system; but make sure the NHS is not lumbered with a system that is about as useful as a chocolate ashtray on a motorbike

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  • Are there any community nurses using a paperless system who have remote access to patient records?

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  • Millions have been spent on varying IT systems but all of their pros but all have massive cons!! The biggest being they don't talk to one another!! In this day and age it should be one system for all!! I mean I have to use one system for practice patients, another to view test results from hospitals, a third to order things like x-rays etc!!! Is it any wonder that care can be fragmented, at best, and at worst dangerous because things are missed????

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  • We are moving towards it. but the system they have is nearly 20 years old now. hopelessly slow and outdated and really unweildy to use. Takes 5 times longer to order tests etc than it used to and many people find it difficult to use because its so unintuitive.
    The computers we have are old and running old versions of software. the money required to bring it up to date is not there.
    Our patient assessment on pc is now 12 pages long for each patient, having to be done twice a day and takes over an hour to complete if you were doing it thoroughly. Audit departments keep adding more data collection to it, to fulfill their targets, but none of it actually effects the patients care that day.They just look at is as an easy way to get someone else to collect their data.
    I feel more like a data entry clerk than a nurse

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  • It is all bent. More fraud in these deals for substandard IT systems, that require more and more bods on the end of the phone, than anywhere else in the NHS.

    More profits for the private sector though. Surely, with all the IT whizz kids in the NHS they should be able to come up with a workable system for bloods, patient records etc.

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