Introduction In most UK hospitals, clinical episodes are recorded with a letter sent to the referring general practitioners (GPs). This requires dictation, typing, proof-reading, correction, printing, sign-off and posting. We have used a mind map template to record the patient journey. We evaluated the GP responses to these Easy View Care Maps (EVCMs) and the cost comparison with the traditional GP letter.
Methods An EVCM was prepared by a secretary using information available from the GP referral. The draft EVCM was available for the clinician to complete during the consultation with the patient. Three completed EVCMs were printed: one to be incorporated into the patient's notes; the second to be given to the patient; and a third copy posted to the GP. At follow-up, the EVCM was modified to reflect results. GP responses to EVCMs were sought by a postal questionnaire sent to 266 GPs. A comparative cost analysis was performed.
Results Over 10 months, 568 EVCMs were used as the sole source of information recorded for the hospital file, patient and GP. The mean turnaround time for a dictated letter is 5.2 days while EVCM generation is immediate. Ninety per cent of GPs reported that they received the necessary information with 71% indicating acceptance as an alternative to the traditional letter. Net annual departmental saving was £31 344.
Conclusions EVCMs offer a new visual representation of the patient's journey. They are easy to follow and expose the clinician's thought processes. They provide an intuitive record at low cost.
- Assistive Technology
- Global Health
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Unlike general practitioners (GPs), most UK hospital doctors and nurses use pen and paper to record each clinical episode. These documents summarise the facts and thought processes that determine the patient's journey, and build the patient's healthcare record. Thumbing through a patient's hospital file often reveals a mix of legible and illegible handwritten entries, test results, prescriptions, administrative documents and copies of letters to GPs. The typed GP letter brings some order to the medical notes but each completed encounter requires dictation, typing, proof-reading, correction, printing, sign-off and posting. In 2012–2013, there were 75.5 million outpatient attendances in England and 17.7 million inpatient consultant episodes. With a letter being created at each event, this volume of outpatient activity would generate 93.2 million dictated letters.1
The electronic patient record (EPR) offers advantages of the shift from analogue to digital. The EPR allows a patient's record to be viewed when and where needed, and allows entries to be shared online. The EPR can be implemented in a number of formats and the data, aggregated in electronic form, are readily retrievable, potentially searchable, and can serve as a useful resource for audit and data mining. As presently conceived, however, most hospital EPR systems represent incremental innovation, swapping a printed paper record for a similar digital health record, achieved by scanning the typed text in order to create a digitised archive copy.
The switch to digital offers far more opportunity to fundamentally change the structure and function of the clinical entry, in order to improve communication between hospital and primary care.2–12 The Easy View Care Map (EVCM) is one example of this approach. Rather than authoring each clinical encounter as traditional handwritten prose, the EVCM is developed from mind mapping software that embeds the narrative in a root and branch flow diagram, graphically illustrating the evolution of the patient's journey. At the end of each consultation, an updated EVCM is immediately available, allowing a printed, rather than written, copy, to be included in the patient's notes as the clinical entry. A copy can be handed directly to the patient and a further copy printed and posted to the GP. If the hospital IT infrastructure allows it, the EVCM can function as an inexpensive EPR with a printed copy forwarded electronically to the GP as a PDF or directly integrated into the GPs electronic record system. At each subsequent encounter, test results, audio and video, can be appended to the appropriate node and, as the pathway evolves, the EVCM can be readily modified by amending, adding or deleting nodes. The EVCM challenges the traditional method of documenting clinical episodes and the role of the medical typist.
A root and branch template (figure 1) was developed using ‘off the shelf’ mind mapping software.13 In advance of the outpatient appointment, the gastroenterology departmental secretary prepared each patient's EVCM from a mind map template. Using the information available from the GP referral letter, the secretary pre-populated the appropriate nodes with information on the consulting specialist, the patient's presenting complaint, previous medical history, family history, operations, previous investigations, allergies, current drug therapy and smoking and alcohol history. The EVCM draft was then saved to the hospital's network drive making it instantly available for the clinician to complete in the outpatient department.
During the consultation, the clinician added further information including clinical findings, differential diagnosis, planned investigations, treatment plan and follow-up strategy. At the end of each consultation, the updated EVCM was saved, as a flow diagram, to the hospital's network drive, and three EVCMs were printed on the local clinic printer and signed. A paper copy was included in the patient's notes as the clinic entry, a copy handed to the patient and a copy immediately posted to the referring GP.
GP responses to this new representation of the specialist consultation were sought by a postal questionnaire sent to 266 GPs who had previously received an EVCM as the sole source of outpatient communication. As a reminder of the transaction, a copy of the EVCM was appended to each questionnaire.
In this hospital, outpatient clinic typing is outsourced with hospital secretaries finalising, addressing and posting the letter. The direct and indirect costs associated with implementing EVCMs were compared to costs associated with the traditional typed letter.
Over a 10 month period, 568 EVCMs were drafted for gastroenterology outpatient visits and used as the sole source of information recorded for the hospital file, patient and GP. The mean turnaround time for each dictated letter is 5.2 days while the delivery of the EVCMs to patients is immediate.
Of the GP questionnaires, 110 of 266 (41%) were returned, 106 complete and 4 incomplete. The responses to the completed questionnaires are summarised in table 1.
The direct cost of converting dictation to text is 7 pence per line. The average line length of dictated appointment letters is 22 (range 16–44)14 with an average cost of £1.54 for each dictated letter. Assuming each patient attends one new and one follow-up appointment requiring a letter on each occasion, and 4200 new outpatients are referred each year, annual transcription costs for the line count alone amounts to £12 936. With EVCMs carrying no cost other than an annual 10-user site license of £1500, there is potential annual saving of £11 436 in transcription costs per year. When the costs of dictating the letter in clinic are added along with the secretarial costs of managing the letter authoring process, annual savings of £31 344 for the gastroenterology department can be found (see online supplementary file).
EVCMs represent a new model for recording clinical encounters, substituting repeated written text entries with a single flow diagram. Based on ‘over-the counter’ mind mapping software, the EVCM template provides a low cost, intuitive and easily customisable EPR that can be readily implemented for single or multiple users.
Unlike the traditional written or typed text entry, the mind map builds on a single flow diagram that can be modified and updated with each clinical encounter. Although each node entry demands brevity, additional information can be added and attached to an appropriate node as a ‘sticky note’, a text box or an audio file recorded using the programme's inbuilt recording software. Investigation results including pictures and videos can be appended to the appropriate node as a ‘paper clip’ link, and large or complex pathways can be accommodated by extending the map to a large virtual screen or embedding maps within maps. The EVCM has high levels of inbuilt security and users can be designated as authors or viewers. All modifications can be tracked by author, date and time.
The mind mapping format is likely to have clinical benefits. The flow diagram provides a visual representation of the patient's journey that is easy to follow and, by using the same decision tree structure used to display local, national and international guidelines, the EVCM encourages the clinician to generate personalised guidelines for each patient. The customisable template encourages a uniform standard for free form data entry and the mind mapping decision tree structure exposes the clinician's thought processes. The format is also readily amenable to both clinical audit and coding. While the EVCM can operate as a low cost paperless EPR system, currently, most hospital records require hard copy. The software allows easy conversion of flow diagrams to a PDF format that can be printed, with copies immediately available for the clinical file, the patient and for posting to the referring GP.
In this phase of the project, the option for GP authoring and online viewing has not been implemented, and GPs only received the hard copy EVCM as an alternative to the traditional ‘Dear Dr’ letter. The questionnaire, returned completed by 106 of 266 GPs who had previously received an EVCM, indicates a high level of acceptance of the printed version, with 72% indicating acceptance as an alternative to the traditional dictated letter.
The efficiency of EVCM is reflected in the reduction of departmental transcription costs amounting to £11 436 per annum. Further savings on indirect costs increases potential savings to £31 344 per year. Switching to the EVCM model also changes the medical secretary's role from transcription coordinator to mind map developer responsible for extraction of information from the GP referral letter and integration into the draft available online to the specialist in the outpatient clinic.
The EVCM removes the need for dictation and transcription, and can be securely shared cross-platform and across the primary-secondary interface. Costs of documenting outpatient episodes are reduced. Turnaround times for reporting are reduced radically, with patients and GPs receiving documents more quickly.
Robust and inexpensive mind mapping software is easily configured as a template to provide an inexpensive EPR. The node and branch structure provides an integrated framework to annotate and illustrate the evolution of the clinical journey in a manner not possible with text-based entry. It helps structure thought processes and encourages clinicians to commit to ‘what if’ clinical pathways. The information in the documents can populate a database, which can be analysed by computer for clinical activity, outcomes and coding purposes.
As the National Health Service (NHS) embarks on another multimillion pound EPR initiative, we suggest that the EVCM mind map EPR model, currently known to be used in a single department, is made available to any clinician at minimum cost and risk.
Review history and Supplementary material
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Data supplement 1 - Online supplement
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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