Jersey is a little island just off the north coast of France. It's British but has its own quirkiness related to its French heritage. Not least among the quirks is its Primary Care. The majority of the practices have been computerised for a decade or so; about half the time of those in the UK. Most of these have used EMIS PCS but three have loyally remained with Synergy and two haven't computerised at all! Data capture is variable but improving!
The health system was originally modelled on a hybrid of the French and New Zealand ones. Secondary Care has always been funded via taxation and is free at the point of entry. Primary Care, on the other hand, is paid for by patients and the States (our local parliament) combined. Originally the subsidy for a surgery consultation was set at approximately 50% of the cost in the 1960s but this figure has gradually been eroded to around 30% and we are in the process of a projected overhaul of funding mechanisms...sound familiar?!
Jersey IT aims
Since 2007 I have been proposing a unified IT model to facilitate better exchange of data which will follow the patient. Needless to say acceptance of the advantages has been slow but funding has now been made available and we are working closely with EMIS to introduce EMIS Web for all practices. From our perspective this will consist of 16 practices' systems sharing infrastructure with appropriate sharing mechanisms inbuilt into the product. This obviates the need for third-party software and provides an integrated IT environment for all healthcare workers in Primary Care. We envisage links to district nursing, our local hospice and nursing homes based on sharing agreements and patient consent.
There will be a central repository of data with documents and other practice data uploaded to 'the cloud'. There will also be access to anonymised data for preparation of island-wide statistics, analysis of quality indicators and limited access to data for recalls.
We do not have patient registration and patients can very easily change practice. In order to allocate patients to practices of their choice we have interrogated the States' IT system to determine consultation habits and, where multiple GPs have been seen by an individual patient, are in the process of writing to those patients to determine their choice of primary practice. Other links to government-produced population address register are being explored (with updates from general practice and other agencies involved) in order to maximise accuracy of demographic data and produce a consistent format for addresses.
Agree opt-out consent
Consent for the process is opt-out and has been agreed by our local data protection department, with whom we have worked very closely since inception. Access to medical notes will be assumed to be full, unless otherwise agreed, and patients will, of course, be able to grant limited access to their data (traditionally excluding psychiatric or sexual history) or close notes to all except their own practice - the default position.
We are in the process of rolling out a communications package which will include media coverage and access to a website with more details including a data protection guarantee and forms for patients to advise if they do not want full access to records. Our experience, so far, is that most patients are surprised that clinicians do not have full access to their notes when working away from the surgery or out-of-hours.
The website, from the perspective of health workers, also includes details of local referral processes - not only to other clinicians but also to charities and support groups and has a wealth of evidence- based information to support these. With the nature of the work of general practice in mind we also hope to put in place a mobile solution based on web access using tablets/iPads via a 3G/4G network.
Naturally we will have patient access for appointments and repeat prescriptions (eventually electronic) and will aim for full patient access to their notes as per the UK in 2015. We would like links to Secondary Care for a truly integrated record but we have not identified a precedent in the UK and it seems, to us, to be beset with problems of confidentiality. Perhaps this can be avoided if notes are accessed in the presence of patients but we're not sure how that can be policed. An alternative approach would be intelligent analysis of potential breaches of data protection, which we understand is being trialled in Cumbria and we await feedback with interest. To us the advantages of an electronic patient record (EPR), if the difficulties outlined could be overcome, would be immense. Effectively, consultants would simply enter their data like another partner in a practice with clear, temporal, coded data available to all parties involved in clinical care.
Lastly, for out-of-hours, we intend to link EMIS Web to the Odyssey triage system (trialled extensively in London) with call handling and voice recording. There has been talk of co-siting with our emergency department to provide a single point of access for patients but our disparate funding streams have put paid to that for the time being.
Putting patients in the centre of healthcare
In essence, Jersey wants to create a model that puts the patient in the centre and wraps care around them. The aspirations for our IT infrastructure will not only facilitate that, they are, in fact, the key to the process. As the primary interface between patient and healthcare services, Jersey GPs have a pivotal role, the principles of which the majority now support. A White Paper for health reforms is being discussed in detail and we hope it will build on a system of health which fortunately still already enshrines individualised care.
When our GP Central Services (GPCS) goes live, local GPs, their political representatives and a host of people working for States' departments (not least our project manager and his IT guru) will have worked together to create something special for the benefit of all Jersey residents. I've felt like John the Baptist for the best part of five years but will hopefully see the project through without losing my head...if not some degree of sanity!