As a result of this we would like you to attend a health check… further appointment details. There is no need to be concerned about this appointment we are just striving to maintain the standards of care we provide for you. For example, the justification for the check is presented only in terms of maintaining the standards or a regular procedure.
The requirement for data was—occasionally—the primary reason for the consultation. She had been reviewed in the hospital's cardiology clinic the same week. These examples illustrate that while on one hand the electronic patient record facilitates the regular recall and review which are critical to a high-quality chronic disease programme, 47 there are potential pitfalls to a highly automated recall system, especially if it is disconnected from the wider set of relationships within which care is delivered, or if the rationale behind it does not make sense to individual patients.
The electronic record also shapes and constrains how the consultation unfolds moment-by-moment. Chronic disease consultations often though not always took a linear and standardised format. Consultations tended to start and finish with the same questions, and focus on information gathering and documentation. Table 2 shows a detailed transcript revealing this institutional ordering in an asthma clinic. This metaphorical separation of disease from patient was common.
The use of the word assessment sets an evaluative tone and anticipates an enquiry which incorporates smoking status, inhaler technique, concordance with medication and peak flow measurement. It might be interpreted as reassurance, but this is a reassurance about what he may expect of the structure of the clinic, not that his specific concerns will be addressed.
There is a considerable scope for unhelpful, potentially incorrect labelling of patients. An example is shown in the ethnographic field notes in box 2. Box 2 Constructing patienthood in the asthma clinic ethnographic fieldnotes Sam, a lively 2-year-old came with his mum. He ran excitedly around the clinic room investigating every corner. The boy's dad and grandparents were asthmatic, but Sam only saw his dad occasionally at weekends these days. The nurse explained that the diagnosis of asthma cannot be certain in a 2-year-old.
Things might be clearer by the time he was about 4. His mum was obviously relieved to know that it was not a definite thing. She was very anxious that her ex-partner would not know how to look after her son when he visited him. She explained what the different inhalers do…. The nurse pointed towards the computer, saying that she was going to make some notes.
She completed the template line-by-line and there was no talking for several minutes. The electronic patient record EPR consisted of a collection of Read coded entries with some limited free text alongside:. The contrast between the mother's relief at the uncertainty of the diagnosis, and the certainty which was constructed in the record is striking. In this study, nurses were often defined by chronic disease specialty. For example, in one practice, photographs of the nurses in the waiting room had their disease-specific expertise listed alongside eg, Christine—Asthma.
In one practice, healthcare assistants conducted cardiovascular and hypertension reviews. Although able to gather information needed to inform chronic disease management eg, blood pressure and details of smoking healthcare assistants are not clinically qualified. The extensive use of templates as a way of delivering chronic disease managements was rarely questioned.
Several nurses suggested they relied on templates and might easily forget things without them. This incident highlighted the extent to which her work had become interwoven with technology use.
It seems unlikely that this senior, experienced nurse could not do a cardiovascular check without the prompts before her eyes. Rather it was because her embodied practices had become so finely tuned to incorporate the technology that to conduct a consultation without it had become almost impossible.
In one practice, an information technology manager was responsible for developing and maintaining computer templates, and he identified templates as a fundamental characteristic of quality care. The template shaped not only what was relevant to record, but also how this was recorded.
Some nurses displayed exceptional creativity in how they used the template. We illustrate this by reference to tables 3 and 4 which shows two extracts from a single consultation in the asthma clinic. Until then, she faces him across the corner of the desk, occasionally jotting notes on a paper placed between them.
The patient hesitates and there are some relatively long pauses in his telling, but she refrains from filling these with anything other than tokens of attentiveness. She goes on to encourage the patient to describe his inhaler use, and learns that he had recently woken up short of breath. His inhaler had not worked well and he could not get back to sleep.
She makes occasional notes, describes aloud what she is noting, then summarises the story which the patient confirms. The nurse says that it was not very good and that he could do better—which makes him laugh—then she demonstrates how to do it. Well done. What we got? There we go. LOOK five hundred and thirty that time. The nurse and the patient are fully involved in this activity, in Goffman's sense of being both cognitively and affectively engaged. Again the nurse uses inclusive language as she orients towards the screen, inviting the patient to look.
She enters his height, points at the screen, makes a joke. By making the template deliberately visible and socialising around it she retains control over the progress of the consultation and legitimises her need to attend to some institutional work.
But by involving the patient in the recording activity not literally, but through making it a shared endeavour and using much inclusive language she effectively maintains a patient-centred approach while briefly attending to institutional requirements. The patient does not initially respond although he continues watching the screen. When the patient hesitates and suggests it may have been higher, the nurse suggests a recheck.
This confirms the measurement, but the act of repeating it displays a collaborative approach. In summary, this nurse is successful in eliciting a narrative, while also making the bureaucratic requirements deliberately visible.
A different nurse described herself as a paper person and yet also used the words template-driven to describe her work. She said she had found it impossible to combine getting through it all with what she regarded as a patient-centred approach.
This nurse went to great lengths to minimise her need to look at the computer during her consultations, seizing brief opportunities as they arose eg, as patients removed socks. She often placed her left hand on the patient's arm as she rotated her chair to look at the screen, keeping it there as she typed with her right hand—an awkward posture, but one which allowed her to maintain a physical connection to the patient as she attended to the template.
She meticulously studied the record of each patient she was anticipating, and copied blood results and other information she thought she may need to refer to. In sociological terms, this particular nurse had internalised the template—working with it in a symbolic sense, but marginalising it from her embodied activity in the interaction. It had become part of a new professional habitus, 51 52 which helped to define her normative behaviours and expectations.
In this paper, we have focused on the detailed practices of using computer templates in chronic disease management in UK general practice. In particular, we have highlighted the tension between different ways of framing the patient, and the requirement on clinicians nurses especially to sustain a dual orientation to both individual patient and institutional imperatives.
We have argued that electronic templates make a significant contribution to four interrelated phenomena: how disease is defined; how care is delivered; what it means to be a patient; what it means to be a clinician. The template can be seen to do definitional work.
The template is not just a simple faithful record of what goes on. The template does not simply identify things which must be done but comes to define what chronic diseases are. On the other hand, the template is integral to the consultation, and actively shapes what goes on, sustaining normative standards which are realised through consensus and performed daily through social practices. The work of transforming stories into data—and erasing ambiguity—is in itself complex interactional work for both the clinician and patient.
At no point in our field work did we encounter any suggestion from participants that the care of patients with chronic diseases might be done otherwise. Nurses vary in their approaches, and individual nurses used different strategies within and across consultations according to emergent local contingencies.
This is unsurprising. We have described one nurse's collaboration with a patient around the template and another who succeeded in simultaneously internalising and excluding the template.
It is also important to acknowledge that templates are still a relatively recent introduction to clinical practice and that although they appear to be embedded as part of normative practice, it is possible that some clinicians are still on a learning trajectory with regard to modifying their practices to incorporate these new technologies. Does this matter? One argument goes that as long as the interaction between the clinician and patient facilitates the narrative, the particular, the complex and the ambiguous and this occurs within a therapeutic relationship which supports relational continuity, then it may not matter much.
But a close observation of actual practice suggests that, more often than not, nurses are constrained by the linear, instrumental logic of the template with its tendency to privilege biomedical, measurable concerns. The consultation can become a relatively bureaucratic transaction in which patients are shaped into an institutional framework 55 and meaningful involvement is difficult to sustain.
Our approach has enabled us to study the subtle complexities of interaction between humans and technologies, while retaining a broad appreciation of the institutions within which these interactions take place.
It has enabled us to explore working practices at a level of detail that more conventional qualitative methods such as interviews or semistructured questionnaires cannot reach. Our approach is time-consuming and resource intensive, and our prioritisation of depth of analysis over breadth has meant that we have included only two general practices in this study and these may not be typical of all practices in how they approach either chronic disease management or the use of technologies.
Furthermore, both practices used the same clinical system EMIS LV and there may be important technical differences between systems. Templates are not unique to the EMIS LV system, and we suspect that our findings may resonate with the experience of many clinicians who are using electronic checklists in the clinic. Although our methodological approach does not allow us to quantify the extent to which clinicians are able to combine a patient-centred approach while meeting the needs of the institution, we have been able to observe a range of practices which highlight the need to think more critically about what is being accomplished through the implementation and use of electronic templates in this context.
Ostensibly the data recording necessary for institutional processes such as the QOF emerges effortlessly from regular clinical care, and serves to improve the quality of care. While incentivising clinicians may well result in better data quality it should not be assumed that the quality of care in its most holistic sense improves, although the care of the patient may be profoundly changed.
We suggest that in educating for chronic disease management, it is essential to incorporate a greater recognition of the way in which clinicians integrate the electronic patient record and to regard this as an integral aspect of the consultation. The rational institutional logic inherent in the template does not align easily with the complexity of emergent dialogue between the clinician and patient and it seems unlikely that minor adjustments to the design of template fields would address the communication challenges that we have identified in our research.
The challenge for clinicians and educators is to appreciate that the incorporation of templates and other technologies renders the consultation more complex rather than less complex… and hence this is worthy of explicit educational attention. We would also urge a shift towards models of care delivery which embrace multimorbidity as the norm and which seek to embrace the complexity of this reality in primary care, while still allowing appropriate data capture to inform the evidence-based management of specific diseases.
We thank the staff and patients in two UK general practices for their participation in this work. We also thank our peer reviewers for their helpful comments on our first manuscript. Transcribing conventions, adapted from Atkinson and Heritage DS completed all the data collection.
All authors contributed to the interpretation of the data. All authors approved the final version. DS is the guarantor for the paper. Our funders were not involved in the selection or analysis of the data, or in contributing to the content of the final manuscript.
Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement No additional data are available. You will be able to get a quick price and instant permission to reuse the content in many different ways. Skip to main content. Log In More Log in via Institution. Log in via OpenAthens. Log in using your username and password For personal accounts OR managers of institutional accounts.
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B est Practice. Link to PDFs. Gastroenterology Outpatient Clinic Referral Form. Contact irad swsphn. Chronic disease often has a significant, negative impact on the lives of individuals and their families.
Chronic disease management is the responsive, person-centred planning and coordinating of health care for a patient that has one or multiple chronic diseases.
The disease management for chronic conditions is undertaken by health professionals working in partnership with the patient. This can include monitoring, coaching motivation and educational support. This education aims to encourage the patient to take greater responsibility for their health through enhanced self-management behaviours.
To achieve improvements in health-related quality of life, coordination, consistency and continuity of care is the aim of all chronic disease management. Practice Coaching is an online training tool developed by SEMPHN which empowers general practice to enhance frontline chronic disease care by building capacity in the following areas:.
Practices can gather ideas to streamline chronic disease processes, optimise workload distribution throughout the practice team and encourage a focus on patient-centred care, as per best practice principles.
Sign on here to Practice Coaching. For more information email This email address is being protected from spambots. You need JavaScript enabled to view it. A Patient-Centred Medical Home combines the traditional core values of family medicine — providing comprehensive, coordinated, integrated, quality care — that is easily accessible and based on an ongoing relationship between a person and their health care team.
A medical home is a general practice that commits to being accountable for ongoing high-quality care for its patients. It provides care that is patient-centred, accessible, comprehensive, and coordinated and has a focus on quality and safety. Implementing the medical home model provides practices with the opportunity to implement refined ways of working within their practice and in their interactions with the broader health system.
The model results in better chronic care management for patients.
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