I arrive at work, and quickly check my emails on my phone before I enter the signal black hole that is the hospital where I spend my working life. The SHO is not in yet, so I persuade the ward clerk to briefly give up one of only 3 functional computers on the ward and update the patient list with the details of the 2 new patients, whose names are scrawled onto the whiteboard. I skim through their notes, and cast my eyes over them to make sure nothing urgent is required. I leave a note for the SHO requesting her to arrange some tests, before I go to the secretaries’ office to hunt for a working dictaphone and a spare tape.
I arrive in outpatient clinic 15minutes before the first patient’s appointment and turn on the PC. I find the printed lists of the expected patients and pick up the first set of notes, searching through the years of mis-filing to find the referral letter. I finally find it in between a yellowing letter from Ophthalmology in 1994 and one from General Surgery in 1990 that I’m sure was typed on a typewriter.
This closely resembles my NHS clinic computer
By the time I have read the referral letter the computer has loaded up as far as the login screen. I enter my details, listen to it whir, and watch the egg timer turn over and over. I call in the patient and start the consultation as I wait for the screenprompts to enter separate passwords for the Radiology and Pathology applications. I take a history and perform a physical examination. I finally get access to laboratory tests, but have to filter the results in several different ways to get all the results I need. I can then finally look at some recent imaging, although I can’t compare this to old xrays as they have been archived and I don’t have time to ask the computer system to retrieve them from the data store as this has all taken quite a while and there are many patients waiting in the corridor. I fill in the patients details on multiple separate forms for additional blood tests, a CT Chest, and a further clinic appointment, and fill in a form that I keep to one side to fax to the GP later to advise on new medications. I want to check whether the new medication will interact with one of the patients’ other regular medications but the BNF that should be in the clinic room is missing. I can’t check on my phone as there is no wifi and no 3G signal and I don’t even try the desktop. I run out to the corridor and thankfully the nurse finds me a paper copy and I confirm the new drug is safe.. The patient leaves the room and I dictate a letter. As I rewind to correct a phrase I realise the tape is not working. Thankfully I have learned this lesson the hard way before so have a spare. I feel under pressure as I am already starting to fall behind schedule, grab the next set of notes and call the next patient in.
The morning continues like this, with the Radiology system completely crashing at one point, leaving me unable to review one patients’ latest scan. I therefore have to apologise to them and promise to call them later with the result.
After clinic I return the dictaphone and tape to the secretary and ask her to fax the necessary forms. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them try to look up the recently published guidelines for pleural disease to confirm the latest management advice . The intranet is being difficult and is blocking Google, so I find a patch of signal between the store room and the toilets and resort to reading the guidelines in tiny text on my phone before going to see the patient.
We start the Consultant ward round, pushing the notes trolley around the bays, trying to find the drug charts and observations charts for each patient. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about, but we’re unable to show her the scan as she is bedbound and the “Computer On Wheels” on the ward has not been charged so can’t move from the wall where it’s plugged in.
We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a few months ago, and was investigated at our sister site. She can’t remember what they told her about the results, and we do not have the old notes as they have not arrived from the off site store. We see from the pathology system that some abnormal cells were seen, but without any old letters or notes it’s difficult to know what the clinicians who have been managing her since then have planned. We make a plan that will at least relieve her symptoms in the short term, and hope the notes will arrive before the weekend so we can integrate previous management into our plan.
Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view but social services claim they never received the assessments we faxed and therefore have not put in place the package of care he needs to go home. We apologise to Mr Low for the delay and promise to do our best to get him home before the weekend. The sun is shining and he’d prefer a view of his garden to our car park.
After all the patients have been seen and everything documented, the SHO writes a request form for an urgent xray and walks two floors to drop off the form in the Radiology department. After searching 2 control rooms she finds a Radiographer who accepts the form and promises to make sure the xray is done that evening on call. She then returns to the ward, checks the blood tests and chest xrays that were pending, writes discharge summaries for the patients due to go home the next day, and updates the patient list. Since all these systems are separate it takes a while, but finally it’s done. The medical students she had promised to teach got bored waiting for her to complete all her paperwork and went home. She feels guilty for letting them down.
I have misplaced my patient list, but retrieve it from between 2 sets of notes in the trolley and take it with me to the office. I check the x-rays from the morning clinic and call the patient who’s scan I was unable to see. Thankfully it’s reassuring, so I do not have to break any bad news over the phone (what I was fearing all day). I check and sign the letters typed by the secretaries from a clinic earlier in the week and they are posted out. I write myself a to-do list for the next day, take off my stethoscope and head home, late again.
I arrive at work. The SHO is not in yet so I grab my personal work iPad from its charging station and login. It opens immediately and I click the app for our patient list to see that the integrated system has automatically updated to feature our 2 new patients, whose names are highlighted in bold. I click on each of them in term and rapidly review their electronic admission notes, imaging and lab results. I have some time before clinic so introduce myself and chat to each of them, checking that each test required has been requested. The system shows an allocated slot for the echocardiogram, which I feedback to the patient. A CT has not yet been requested so I click on this, the system automatically inputting the patient’s details and latest blood results, and input my password to sign off the request. It appears as “pending” in the patient folder so the SHO will not waste time also requesting it if I don’t catch her before I head to clinic.
I arrive in outpatient clinic 15minutes before the first patient’s appointment and login. I pull up the clinic list, and due to the integrated system am able to directly link to all results and previous clinic letters. I read the first patients’ referral letter, check any recent results and review recent chest xrays. I compare to old xrays which is invaluable in this case, revealing a new shadow. I am thankful that old imaging is easily accessible since the hospital solved its data storage problems.
I have a lot of information before I call the patient is, allowing me to take extra time taking a history and performing a physical examination. There is time to explore the patients’ worries and answer questions. With a few clicks I request the additional blood tests, a CT Chest, and a further clinic appointment, and complete a template “urgent GP letter to advise on new medications”. This is automatically saved in my email outbox, with the relevant GP practices email address completed, for me to review and send later. I click on the BNF app and quickly confirm that the new medication will not interact with one of the patients’ other regular medications. The patient leaves the room and I dictate a letter onto the voice recognition system. I notice a few typos but I elect to save the letter and review at the end of clinic before it is sent.
An example app, developed In London by North East London, North Central London and Essex Health Innovation and Education Cluster (NECLES HIEC) in partnership with Asthma UK, Queen Mary University London, Solar Software.
I am on time, and review the next patients’ recent letters and results before calling them in. I see that they have asthma and have started a new inhaler. I notice that they have been using an app to record their peak flow, which allows the patient, respiratory nurse and me to access the recorded data. I click to view the graph and feel well prepared to have some important discussions on treatment plans with the patient. The morning runs smoothly and I finish clinic with time to grab a coffee on my way up to the ward. I check my twitter feed in the lift and see a link to an article on new evidence on pulmonary fibrosis treatment that I save as a favourite to read later.
I review and approve the letters from clinic and them and dock the iPad to charge. The letters automatically download and email themselves to the relevant GP practices. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. While I eat I read the article I saved from my Twitter feed and think about a recent patient I saw that I must discuss with my Consultant. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them I look up the recently published guidelines for pleural disease to confirm the latest management advice. I have these guidelines saved as a link in my browser bookmarks so they’re easy to access.
We start the Consultant ward round, entering our comments onto the electronic notes system using our iPads. The drug charts are also electronic, allowing us to make changes at the same time that the nurses are logged in, dispensing drugs from the cupboard. The intelligent prescribing system prompts us to reduce the dose of a patients medication whilst they are on a particular antibiotic. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about but since we’re able to show her the scan on the iPad she is better informed and is able to understand what will happen at the proposed lung biopsy.
We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a year ago, and was investigated at our sister site. She can’t remember what they told her about the results, but we are able to pull up the old notes on the electronic system and can see what decisions were made before, and what the clinicians’ opinions were. We see from the pathology system that some abnormal cells were previously seen, but that after discussion with the patient and her family it was felt inappropriate to further investigate due to her frailty. We therefore make a plan that will relieve her symptoms and are able to start planning a supported discharge with community support.
Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view, and since the relevant forms were sent to social services electronically they logged them on the day they were sent and immediately put in place the package of care he needs to go home. The hospital transport arrives as we are saying goodbye to him and he thanks us for getting him home to enjoy the sunshine in his garden, rather than forcing him to spend any longer staring out at our car park.
After all the patients have been seen and everything documented, the SHO clicks to request an urgent xray and calls the “hot room” where the on call Radiographer is keeping an eye on the urgent referral work stream. He looks at the request on his screen and promises to make sure the xray is done that evening on call. The SHO then checks the outstanding blood tests and chest xrays that were pending, completes the discharge summaries for the patients due to go home the next day (which have results of blood tests and scans auto-populated into them), and updates the patient list. She is then free to do the teaching she promised the medical students, and still finishes on time.
I check the x-rays from the morning clinic and pop in to see my consultant to discuss a patient I saw earlier in the week. I bring up the new evidence I read at lunchtime and we discuss how this relates to this patient. We complete an assessment on my e-portfolio, and I add an entry to TILT, which I also post on Twitter.
I write myself a to-do list for the next day, take off my stethoscope and head home, on time.