The Scottish Emergency Care Summary – an evaluation of a national shared record system aiming to improve patient care : technology report

Background In Scotland, out-of-hours calls are all triaged by the National Health Service emergency service (NHS24) but the clinicians receiving calls have no direct access to patient records. Objective To improve the safety of patient care in unscheduled consultations when the usual primary care record is not available. Technology The Emergency Care Summary (ECS) is a record system offering controlled access to medication and adverse reactions details for nearly every person registered with a general practice in Scotland. It holds a secure central copy of these parts of the general practitioner (GP) practice record and is updated automatically twice daily. It is accessible under specified unplanned clinical circumstances by clinicians working in out-of-hours organisations, NHS24 and accident and emergency departments if they have consent from the patient and a current legitimate relationship for that patient’s care. Application We describe the design of the security model, management of data quality, deployment, costs and clinical benefits of the ECS over four years nationwide in Scotland, to inform the debate on the safe and effective sharing of health data in other nations. Evaluation Forms were emailed to 300 NHS24 clinicians and 81% of the 113 respondents said that the ECS was helpful or very helpful and felt that it changed their clinical management in 20% of cases. Conclusion The ECS is acceptable to patients and helpful for clinicians and is used routinely for unscheduled care when normal medical records are unavailable. Benefits include more efficient assessment and reduced drug interaction, adverse reaction and duplicate prescribing.


Introduction and context
Since the 1990s, Out of Hours care had been moving from general practices towards Out of Hours Service Providers and in Scotland responsibility moved explicitly to them with the new GP Contract in 2004. By 2004, with prescribing records being routinely updated on the practice system. In Scotland, out of hours calls were all filtered through NHS24 but the clinicians receiving triage calls had no direct access to patient records.

Aims of the Emergency Care Summary
The aim of the ECS is to improve the safety of patient care in unscheduled consultations when the GP practice is closed. Many patients have difficulty remembering all their medications or pronouncing drug names, especially when ill or confused. An accurate record of the GP's prescribing intentions when these patients call NHS24 or are seen in hospital as an emergency, should help save clinician time and reveal some of their medical history. Potential benefits of ECS therefore include more efficient assessment and reduced drug interaction, adverse reaction and duplicate prescribing rates.
The ECS was first piloted in 2004 and launched nationally across Scotland in 2006. Since then, it has grown to be a national system across all 14 Health Boards in Scotland covering over 5.4 million patients. The information for ECS is provided from GP practice information systems. Details of prescribed medications and adverse reactions for patients who have not opted out are copied twice daily from the GP practice systems to a central store. With patient consent, these data can be accessed by clinicians treating patients outside the GP practice in out of hours (OOH) services, accident and emergency (A&E) and the national call centre for Scotland (NHS24). The ECS contains records of 99.9% patients in Scotland and 50,000 records are accessed every week. 1,740 (0.03%) patients or 1 in 3000 have opted out of the system and all patients are asked for their consent for each access to their record. Warnings on the limitations of the data held in ECS are given to users, and advice given to General Practitioners to ensure that prescribing data is as accurate as possible, by promptly recording medications prescribed by others and those which have been discontinued.
We have found that clinicians feel that use of the ECS can improve unscheduled care of patients and it is now relied on by many clinicians as an integral part of such consultations.
This contrasts with the evaluation published in June 2010 reporting on the English Summary Care Record, (SCR) a direct equivalent of the Emergency care Summary consisting of medication and adverse reaction information for patients extracted from GP records in England. Coiera reported that "the only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify [ii]" Greenhalgh carried out a mixture of qualitative and quantitative studies to look at the SCR and found that "When the SCR is accessed, the main benefit seems to be that the doctor or nurse finds the consultation "easier" and less stressful. The evaluation did not directly demonstrate an improvement in patient safety but the findings were consistent with a rare but important impact of the SCR on reducing medication errors

Aims of the study
The Scottish Emergency Care Summary is one of the first shared record systems to achieve universal coverage nationally. It is believed that sharing information on medicines prescribed will improve patient care but it is difficult to prove specific clinical benefits of ECS. A randomised trial was proposed but rejected by clinicians working out-of-hours as they felt it would be unethical to manage some patients without ECS support. Following establishment of the ECS system, clinicians now depend on its availability, and many others working in scheduled situations are keen to have access too. Instead, a modified critical incident Modifications were made in order to ensure that the questions were understandable to users and that the answers would be unambiguous. Forms were emailed to each clinician working on a shift during the study week and they were invited to give feedback on their experience of the ECS, whether good or bad. No reminders were sent out as different staff were on duty each night.
The questions asked whether users considered the ECS helpful, whether it changed management, and to give examples of any critical incidents. The results were entered into an excel spreadsheet so that scores for usefulness and change in management could be presented in graph format. The comments were all individually recorded and quotes illustrating particular points have been extracted to illustrate common themes.

Results
A total of 118 replies were received from a potential 300 users.
Overall, 81% of respondents rated the ECS as helpful or very helpful (Table 1) and they said that ECS had changed their management in 20% of reported incidents ( Figure 2). Many NHS24 clinicians said that even an empty record was useful to confirm a patient's claim to be in good health. ECS was particularly helpful if patients were confused or receiving multiple medications.
However, 43 replies (36%) pointed out that the medicines listed on ECS, drawn from the GP practice system, did not match those reported by the patient. This concords with the evaluation of the SCR by Greenhalgh (11) which states "The evaluation showed that SCRs sometimes contain inaccuracies (e.g. incomplete medication lists or missing allergies), but that clinicians use their judgement when interpreting such data and take account of other sources of information including the patient.

Discussion
We believe that the response rate of 37% still gives representative results as many users did not feel strongly positive or negative about ECS and the people who did feel strongly were motivated to fill in the form.
From these responses we have identified the following data quality issues in GP systems: • Discontinuation of drugs is not always promptly updated • Delay or failure to transcribe into the GP record system prescriptions written by others, e.g. nurse prescriptions, drug trials, hospital-only drugs, private prescriptions, methadone from Drug Services • Non-concordance with prescribed treatment and use of over the counter drugs is rarely recorded NHS24 staff comments on ECS are summarised under three categories in Appendix 2.

ECS System design and implementation
Initially, patients and clinical groups were consulted to verify our understanding of the problem and opportunity. Clinical leadership came from the Royal College of General Practitioners, Colleges of Nursing and the Scottish General Practitioners' Committee, as well as clinicians in Out of Hours services. It was clear that working without patient data in unscheduled care when GP practices are closed posed a significant clinical risk. A focus group study was carried out to explore patient views[ iv ].
Many requests were received to allow unrestricted access to GP records, but this was unacceptable to patients and to GPs, as custodians of patient-identifiable data. A two stage opt out then opt in consent model was therefore developed. Upload of data from GP systems to ECS uses implied consent with opt-out for patients who request it, while the second stage requires explicit consent with patients being asked to give permission for their data to be read by any clinician involved in that episode of care. This minimises privacy risks and operational delays, and was approved by the Information Commissioner.
Information is held on ECS in a secure database, the "ECS Store,"

Other evaluation studies and results
Evaluations of the pilots were carried out in 2006,[ vi ] and by pharmacists using ECS for medicines' reconciliation in acute receiving units in 2008. Key measures of success were whether transfer of medication and adverse reaction data from GP records to ECS is acceptable to patients and helpful for clinicians.
Views about ECS varied widely and are best described by role.
For example, many pharmacists cited valuable time saved in medicines reconciliation by not having to phone GP practices or ask relatives to bring in medications. More experienced clinicians working in A+E found that they look at ECS records infrequently, but when they did it was for the more complex cases, where the information was considered vital. One consultant A&E clinician said "I only access ECS once a day but when I do it is absolutely critical". GPs working out-of-hours are experienced in making clinical decisions when there is uncertainty due to partial information. For other clinicians in NHS24 and OOH, ECS is used to confirm details and reduce uncertainty about the medication history, thus increasing confidence for the clinician and safety for the patient. While the ECS medication record is updated twice daily from GP systems and is much better than nothing, the data quality issues discussed above limit its reliability, so it could be further improved by adding medication information from other sources. This is consistent with the conclusions of an Audit Scotland report[ x ].

Lessons learnt and conclusions
Our study shows that many clinicians report that ECS can improve patient safety and care, save significant time for clinicians and reduce risks to patients by alerting clinicians to potential adverse reactions and risk of overdose of prescribed medication.
ECS can benefit patient care by increasing the accuracy of medicines management. This is particularly beneficial where patients cannot give details of their medication over the phone.
The medication summary as taken from the GP prescribing record may lack details of medication prescribed by other agencies or acquired by the patients themselves.
In conclusion, deployment of effective clinical information technology on a national scale takes time. Clarity of objectives and an incremental approach based on using IT to address real clinical problems are critical to success. This report on the clinical benefits of ECS should help to inform the debate on the safe and effective sharing of health data in other nations.