Background
Research questions
Method
Patient involvement in the design and conduct of the study
Design
Setting and sample
Participant job titles | Duration (minutes) | |
---|---|---|
Focus group 1 | GP Partner, FY2, Healthcare Assistant and Receptionist, Practice Manager | 41:08 |
Focus group 2 | Patient Service Manager, GP, Medical Secretary, Lead Practice Nurse | 28:51 |
Focus group 3 | GP Partner, GP, Healthcare Assistant, Advanced Nurse Practitioner | 37.11 |
Focus group 4 | GP Principal, Patient Service Manager, Practice Nurse, Patient Service Assistant | 28:10 |
Dyadic interview | Administrator, Practice Manager | 29:45 |
Single interview | Office Manager | 16:06 |
Procedure
Ethics and governance
Data analysis
Findings
Theme: information – what, why and when?
Level of information
Nonetheless, it was acknowledged that at present, even certain coded information might not be in an accessible format, and this could result in misinterpretation:‘Um, it’s a good thing, so that they know exactly what’s happening. I think they should be able to see most of the stuff but not the, the free text information because, quite often that can be doctor’s thought process down on there…’ GP Partner (Focus group 1)
‘I think as well some of our coding is a bit out of date, so I find when I am going through like my post-natal checks, that I am tidying up if you like the major coding and…where I am just kind of like “oh that doesn’t need to be there” and I think there might….I think our notes aren’t necessarily tidy enough in some respects just because of the way things have been coded in the past..’ GP (Focus group 3)
The use of information
‘I think when you mention the allergy thing, that’s quite a good one cos in both ways, so sometimes you have things on their, coded, like, where it says they’ve got an allergy but actually it was, they didn’t, it was they were it was vomiting or it wasn’t really an allergy or for some reason it’s not, and it might prevent them having an antibiotic that otherwise could’ve been really useful if they get a chest infection or something else, and equally there might be something missing on there and it might be a severe allergy. So that sort of thing would be really useful if patients could see that and could notify us of any problems there.’ F2 (Focus group 1)
‘… I think to know whether something’s safe you need to know what is expected. So that you should have you blood pressure done every year, so you’d need a list of, I should have my cholesterol done and my… these bloods done and my blood pressure done every twelve months, or if you were diabetic your foot check and all those kind of things. And if they then checked whether they’d had them or not...’ GP (Focus group 2)
‘I can see some benefits for certain patients, you know, having their medical records if they’ve got a complex medical story, urm, and having access to information from the past and then, you know, a lot of the time, you know there’s a thing in there, you know, I’ve had this condition for twenty years and you’ve been to a one hour lecture on it, who knows my condition more, the patient will say that...’ GP Principal (Focus group 4)
Historical information
‘...I think I worry about them being able to see what has been written in the past when we didn’t know when they would be able to access there, erm because it is easier to be a little bit more mindful about how you might write something, you might still write the same information but you might write it just in case they saw it in a way that was more tactful or something like that because you didn’t have that opportunity in the past, erm so that is of concern...’ GP (Focus group 3)
‘...I’m personally fearful, I think it’s a really good idea giving patient’s access to their information, you know, it’s not our information it’s theirs and it relates to them.... I’m very fearful about the consequences on workload with people going through records and coming in complaining about some entry that we made years ago or recent entries that there’s a misinterpretation.....So the actual factual information of a medical record, this is somebody’s story, these are the events that have taken place in their lifetime, this is their bloodgroup, this is their allergies, all that sort of stuff I can see the benefit of. The actual bit about, the, the sort of handwritten notes in effect, just not so sure necessarily how that, urr, can only cause problems really, personally....’ GP Principal (Focus group 4)
Theme: changing behaviours and protecting relationships
Prompts, reflection and monitoring symptoms
‘It would more, it would cause more problem, if patient can see the, the everything, like the consultations, because I see it as consultations are quite often our thought processes, like this person has a cough for two weeks, if, but has also this as well, they come back I’ll refer the person for, if I put that on then that, and they read it …that automatically that pushes the anxiety of, cos like it’s my thought process but I need to put it on there so that if it’s not me who is seeing the patient next week or the week after they can pick it up and then they do something about it and so it’s just a thought process, but that can lead to significant distress'.’ GP Partner (Focus group 1)
‘I guess it is a bit frightening really, I feel, them reading everything that you document and whether they are going to question what you are writing, you have to be really careful what you write’. Advanced Nurse practitioner (Focus group 3)
Professional reputation
‘… Yes difficult consultation, long consultation you know and we need to be able to write things that might protect us if things went wrong and there was a complaint or a negligence complaint or something like that and you know so it is important that we write down that we weren’t able to engage with the patient because of this reason very well and you know we tried our best and things like that, which we don’t write in those terms but we will write things like it was a difficult consultation because they had lots of agendas that they wanted to discuss and we wanted to discuss these and things, and then if they read that sort of thing they would probably have a very different perspective on it and would not like to see that we have written those kind of things but they are important for us to write down for our own protection really erm'. GP (Focus group 3)
Unintended consequences – changing patient behaviour
‘.....then you don’t really know, do you? No one’s ever going to feel safe of coming to the GP practice and saying actually what is the problem or what’s wrong if they’re going away from family members to come here to, like, disclose something, it’s not going to really stay between, within the room is it?’ Administrator (Dyadic interview)
‘.....people can ask you why you’ve put something. In fact, somebody today I was just saying to her no one is going to read these records except you and me because she didn’t want me to put that she was stressed....... but people have this paranoia that the big world out there is going to…’ GP (Focus group 2)
Rapport, relationships and sensitivities
‘.....Be less specific, but I don’t think that is helpful because it acts as a really good aide memoire to me that builds my relationship with the patient because I can start the conversation by going “how is your daughter”? “how are they getting on with such and such”?’ GP (Focus group 3)
‘Yes in terms of the way you have interpreted something that we have written or as you say some things that they perceive as not being recorded accurately or not, but equally erm it may allow them to be on the same page as us and more trusting so I think there pros and cons of that as well.’ GP Partner (Focus group 3)
-
‘Participant 4: Or the coding that we use for alcohol. So we have all sorts of codes for that, problem drinker, alcohol dependent you know
-
Participant 3: Alcohol abuse
-
Participant 4: Alcohol misuse, all sorts of things and I can imagine that that could be a whole can of worms and could become quite awkward so…’
‘Yeah and I guess some people, people want to sometimes be anonymous in their feedback and that way it would be, it’s clear who’s given that feedback so it might mean that they don’t openly give feedback through those things.’ F2 (Focus group 1)
Theme: secure access and safeguarding
Secure access and verification
‘Yeah, but it’s like if we’ve done the online thing here, you’ve given them the records but we don’t know who’s actually going to access those records. There’s no, you know, who have they given that password to and who they’ve given that online access to, because it could be anybody couldn’t it?’ Practice Nurse (Focus group 2)
‘.... So if they’ve changed address or, urm, changed their contact number or something. With address we do prefer to have some form of proof, so we, ideally we like them to bring in some kind of proof, but sometimes like if it’s a young mum or something they might have seen the health visitor which they might have seen the proof of update in which case then we’d accept it, cos you know health professional has, has seen the proof, so we’d accept it...’ Office Manager (Single interview)
Safeguarding
‘.... but I think there’s an element of… not… coercion’s the wrong word isn’t it? But there’s sort of an element of control and stuff within families and stuff that that’s what you do and… you know, and older people as well. So, you know and that’s fine if that’s, that’s what they want to do and often a lot of us look after our older relatives and older stuff and do stuff, but that step, next step is that you want to go delving around in their notes… urm… I think that you just have to be careful about people who are vulnerable, yeah, and people who can’t read and write…' GP (Focus group 2)
Equitable access
‘...they’re not literate with the computers, so they’re dependent on other household members, which means that, you know, they’re going to wait for their son, their grandson, granddaughter, it could be anybody, any member of the family, but it depends on whether they’re going to give them that time to be able to access…’ Practice Nurse (Focus group 2)
‘.... And also, it’s sharing your records then with somebody else, I mean, often they come in with somebody else here, but we have interpreters here all the time. So actually, anybody could come in by themselves and not have to bring a family member. Whereas, I suppose if they don’t read and write…’ GP (Focus group 2)
‘...of what they’ve found and it could be, I think it could be quite dangerous in that way, because there might have been something that’s mentioned within, within her notes, um, and it could have a detrimental effect on the patient whose notes they are that’s the access is actually… well, because she doesn’t know what’s been, cos if, if she can’t read and write, um, and then it’s husband, it could be a father in law, son, it could be anybody, that’s actually, and so it’s a third member of the family that’s actually looking into the notes.’ Lead Practice Nurse (Focus group 2)