COMPUTERS started to be used in general practice in the 1970s and really took off in 1987 with the introduction of ‘no-cost’ computer schemes. It has been estimated that by 1997, 92% of GP practices will be ‘computerised’. The major suppliers in 1993 were VAMP (now Reuters), AAH Meditel, EMIS and Genisyst (now LK Global).

For non-principals, practice computers can be a nightmare. Many practices still use their systems for the minimal three ‘R’s - Registration, Repeat Prescribing and Recall. Increasing numbers of practices are becoming virtually paperless, meaning that non-principals need to know the systems in order to know what is going on. The NHS Executive recently hinted that the electronic record would soon be legitimised and this may mean more practices move towards becoming paperless. When the NHS wide network is achieved, practices will have more reason to use their systems to their full extent. With this in mind, non-principals should try to get to know as many systems as they can. Computer-friendly locums are more desirable than computer phobics.

Practices should train non-principals on their system or accept the potentially dangerous consequences of employing a doctor whose access to full clinical records is severely compromised. It is difficult doing a surgery without access to up-to-date records, especially drug histories. It is just a matter of time before such a problem contributes to a serious error. Sadly few practices give enough thought to such basics. Even fewer will pay the non-principal for her time whilst learning the system despite expecting non-principals to ‘do’ as other partners on the computer. Non-principals should consider seriously the amount of personal responsibility they and the principal for whom they are deputising has when inadequate computer training is provided. In practices that have a computer on the desk and still pull the notes, you need to know where they prefer you to record the consultation. Recording in the notes and on the computer is a terrible duplication of effort.

To do a surgery, you need to know the following:

• how to switch on and off;
• how to log in and out;
• how to personalise your password and ensure it is unique to you;
• how to use a computerised appointments system;
• how to view previous medical records including a summary and recent consultations;
• how to view previous drug histories including sensitivities;
• how to prescribe acute and repeat medications, alter doses, quantities, number of authorised repeats, review dates and to switch to generics;
• how to reprint and reset a jammed printer;
• how to find patients’ phone numbers on the system;
• how to record Item of Service payments.

It is also beneficial (for non-principals and practices) to know how to use other functions, where they exist. Useful functions include how to:

• use practice templates;
• use other networked software;
• email other partners.

Actual ‘hands-on’ experience is the key to using systems. They all tend to do the same thing - record information. Experience with one helps with another. Remember computers don’t bite and just trying things out for half an hour will get you a long way. Find out the name of ‘dummy patient’ on whose record you can practise. Becoming familiar with systems will help non-principals who intend to become principals in the future. Not having to learn a computer system (because you already know it) will make the first few weeks easier and if your partnership decides on a change of system, experience with several is invaluable.

Some of the computer suppliers will have new user guides. If your practice doesn’t have one, phone the supplier. If they don’t have one, ask them why not. For contact numbers see chapter Useful Contacts.

Effects of the Computer on the Consultation
Different doctors find that introducing a computer has different effects on the consultation ^{Note 1}. Doctors whose partners’ handwritten notes are almost unreadable find that moving to a computerised medical record (CMR) speeds up their consultations. Their partners may be slowed down, but the notes have improved.

Non-principals in a practice are likely to gain more from this increase in legibility than others who have had years to learn how to interpret various squiggles in the notes.

A well known effect of moving from typewriters to word processors in any organisation is the tendency to revise more often. Control this. School yourself to ignore the odd spelling mistake in the notes, and do something constructive rather than go back and correct it. The corollary is that you should not be snappy about typos in other people’s notes. There is no need to write more than you would in a handwritten record ^{Note 2}.

Patients also find that computers affect the consultation. How much this is so depends on the patient and the computer, but mainly on the doctor. A GP who likes his computer, finds it a helpful tool and projects this, will usually report that his patients like it. Conversely GPs, who struggle with a system they do not like or which is not easy to use, will find their patients resent its presence in the consultation.

Probably patients are more likely to be upset when the computer is used (during the consultation) just to record codes for statistical analysis, with the ‘real notes’ still being made on paper, than if the whole of the consultation goes onto the computer. We are becoming a sophisticated society and few patients will be surprised that their doctor chooses to change from paper to electrons but any suggestion that their time is being used to collect statistics will rile them, and probably the doctor too. And rightly so.

The same rules apply to the CMR in the consultation as to the paper record. Patients are quite happy to see you look up a letter or result or a previous note but prefer to be told what you are doing.

Adopting a routine with the computerised medical record as with the paper records ^{Note 3} helps lead to satisfaction all round. Check the patient’s name and age to ensure you are talking to someone of the right sex and era before you continue with the consultation. Check their summary page and then head for a consultation or medication record. Flashing or otherwise highlighted areas may remind you of the need to get health promotion data, encourage uptake of screening activities or just to review medication.

Some GPs feel that using the computer during the consultation increases the length of their consultations from 5 minutes to 7.5 minutes or so, others feel that it allows them to accomplish more in 10 minutes than they could without it.

The factor most influencing the effect of the computer on the time you need is whether you duplicate the notes on paper and electronically. Putting data in two places takes longer than recording it once, but many practices feel that for safety or in order to limit the pace of change, they must keep a paper record. Even if the computer is used only to keep a coded summary, this approach adds to the time required and does nothing for the satisfaction of the user who has no commitment to statistics.

You must avoid having a previous patient’s notes visible on the screen when the next one comes in. Switching to the next patient’s notes as a way of concluding the consultation is also best avoided. Both of these are likely to provoke complaints and you could fall foul of the Data Protection Act. If someone tries to look at another patients details on the screen you must prevent them. This applies to mothers looking at their daughter's contraception records and such like.

Dealing with interruptions in a computerised surgery
The options are:

• Don't allow telephone interruptions; ring them back;
• Exit from one patient's record, load the other and then eventually go back to the first;
• Do without the computer notes for the telephoning patient;
• Have software which allows switching between two or more patients' records.

When the Computer Goes Down
More consultations are done without past notes available because of missing paper records than computer faults. Nevertheless it is inconvenient when a computer, a terminal or the network goes down; there should be a routine for it. Generally you will make notes on male and female record cards (FP7 or FP8), or on the sticky labels used for visits. A secretary can then type the notes in when the beast recovers. If the practice only uses the computer to log attendances, then it is someone else’s problem anyway. A practice with networked PCs should be able to let you type into a text file on the PC if the network is down, and later print it out so that at least the notes are legible. Moving to another room or getting a spare terminal to replace a failed one are options that may save time and effort in the long run.

Visits and Computers
Once a practice commits itself to keeping data on the computer, it must solve the problem of access to that data on visits. The obvious solution of carrying a computer is expensive, and it is technically difficult to link the notes made during a visit back into the main database. Systems for doing this do exist, and will become more common. Most practices make a printout of a patient's notes before each visit and leave this filed in the paper record. Additions are typed into the computerised record by admin. staff later, or by the doctor on returning to the surgery. It is best to make some form of contemporaneous note either written on the printout or dictated in the car afterwards to avoid loss of information4. This should then be added to the computerised record. The most likely information ^{Note 4}to be lost is what the hand-written prescription was, and according to Sod's Law, it is the item most likely to be useful in the next consultation ("The tablets were really helpful, can I have some more"; "Is this rash due to those white tablets?").

The notes given below may be of some help.

Adrian Midgley & Shaun O’Connell

Note 1
If this seems strange imagine an earlier generation debating whether it is acceptable or beneficial to introduce paper notes! Most of the arguments are the same. At least the computer is a head up display. "All I ever saw of my doctor was the top of his head, until he got a computer. Now I see his left ear".

Note 2
Defence organisations regularly advise GPs that they should write more on the FP7, which they no doubt should, but that is another issue.

Note 3
Find it, weigh it, note the changes of address and doctor, look for red warnings on the front, then at the last note and last prescription.

Note 4
Also because notes on the computer are accepted as the best evidence available if they are made contemporaneously but not necessarily if they are made much later.

Note 5
The clicks of a mouse can be altered to suit your dominant side through the Control Panel in Windows 3.1 and 95. Select the mouse icon and Button Configuration to change it. Better change it back when you finish!