Healthcare, like any other industry, must evolve and adapt to technological advancements, but the AJGP commented recently on the implications for general practice of using AI software to write medical notes. The World Health Organisation (WHO) expressed similar concern over the use of AI, when it published a call for the ‘safe and ethical’ use of AI in healthcare.

General practice summariser training is a crucial aspect of modern healthcare that focuses on efficiently summarising patient records to enhance the quality and timeliness of care. Summarising patient information is essential because it condenses extensive medical histories into concise, easily accessible formats. By providing healthcare professionals with a comprehensive overview of a patient’s medical background, good summarising techniques streamline the decision-making process, enabling prompt and appropriate care delivery.

Effective summarising reduces the reliance on accessing patients’ paper records, which can be time-consuming and cumbersome. In traditional healthcare settings, healthcare providers often had to manually sift through voluminous paper records, searching for relevant information. This process was not only time-consuming but also prone to errors and delays. However, with the advent of digital summarising tools, healthcare professionals can swiftly retrieve pertinent patient details, saving valuable time and resources.

By reducing the need to access paper records, good summarising techniques enhance efficiency and enable healthcare providers to allocate their time more effectively. Instead of spending excessive time searching for information, practitioners can focus on providing personalised care to patients. This accelerated decision-making process ensures that patients receive the most appropriate level of care promptly, leading to improved patient outcomes.

Furthermore, efficient summarising enhances communication and collaboration among healthcare professionals. By presenting a concise summary of a patient’s medical history, these tools facilitate effective handovers, enabling seamless transitions in care. Whether it is a transfer from primary care to a specialist or a hospital admission, accurate and comprehensive summaries provide healthcare professionals with the necessary information to make informed decisions promptly.

Clear and concise summaries help identify potential drug interactions, allergies, or underlying medical conditions that may impact treatment decisions. This information ensures that healthcare professionals have a holistic understanding of the patient’s health, reducing the likelihood of adverse events and improving patient safety. While Chat GPT might be able to produce output, it is easy to confuse confidence with competence, and the output of these programmes certainly appears extremely confident. Tools like ChatGPT have not been designed or tested in this area. We would expect doctors not to prescribe untested medications; we should expect the same with using these tools for clinical work without appropriate safeguards.

Routine blood tests are a common part of medical care and are used for a variety of purposes, including monitoring chronic conditions such as diabetes and high cholesterol. However, they may also have a role in detecting cancer early. New blood tests could help general practice clinicians diagnose ovarian cancer faster and more accurately, according to research from the Universities of Manchester and Exeter.

In fact, the NHS offers a cancer blood test called the CA125 test, which measures the levels of a protein called CA125 in the blood. This test is primarily used to monitor ovarian cancer in women who have already been diagnosed, but it may also be used as a screening tool for women who are at high risk of developing the disease, such as those with a family history of ovarian cancer.

The CA125 test is just one example of how routine blood tests can be used for both diagnostic and screening purposes. Other blood tests, such as those that measure levels of prostate-specific antigen (PSA) for prostate cancer or carcinoembryonic antigen (CEA) for colon cancer, are also commonly used for screening and monitoring purposes.

The potential for routine blood tests to predict the risk of developing cancer is a particularly exciting development, as it could allow for earlier detection and treatment of the disease. This could ultimately lead to better outcomes for patients and a reduced burden on healthcare systems.

However, it is important to note that there are limitations to the use of blood tests for cancer screening. Not all cancers produce biomarkers that can be detected in the blood, and some biomarkers may be elevated for reasons other than cancer.

Furthermore, there is a risk of false positives and false negatives with any screening test, which can lead to unnecessary anxiety and further testing, or a false sense of security that could delay diagnosis.

Despite these limitations, the potential for routine blood tests to be used for cancer screening and early detection is a promising development. It highlights the importance of understanding the different types of medical investigations and their uses, as well as the need for ongoing research to improve their accuracy and effectiveness.

As medical technology continues to advance, it is likely that we will see more and more overlap between different types of medical investigations, and a growing need for healthcare professionals to be able to interpret and integrate information from multiple sources. The ability to do so will be critical in improving patient outcomes and reducing the burden of disease.

Never has it been more important to learn the requirements for summarising medical records, following the recent announcement from the Health and Social Care Secretary who has set out his priorities for health care by harnessing the power of technology at the Health Service Journal Digital Transformation Summit.

He announced ambitions including for 90% of NHS trusts to have electronic patient records in place or be processing them by December 2023. This move underpins the Government’s drive that the NHS should be using technology to improve productivity, reduce costs and ultimately enhance patient care.

In announcing the launch of a new data in health strategy at London Tech Week’s HealthTech Summit, the NHS app is set to become a central point of access for GP appointments, prescriptions and hospital records. The app will also make it easier for patients to get hold of their GP records. Improvements to the mobile app to make it easier to request historic information including diagnoses, blood test results and vaccinations are set to be rolled out by the end of next year.

Good training in summarising medical records not only ensure that electric data is accurate but can help to achieve QOF targets. All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one. The information held in the Summary Care Record gives health and care professionals, access to information to provide safer care, reduce the risk of prescribing errors and improved patient experience. The Summary Care Record contains basic information about allergies and medications and any reactions patients may have had to medication in the past. Some patients, including many with long term health conditions, have previously agreed to have additional information shared as part of their Summary Care Record. This additional information includes information about significant medical history (past and present), reasons for medications, care plan information and immunisations.

Currently, the app has 28 million users, around half of England’s population. The rollout plan has a target of 75 per cent of the adult population to be registered to use the NHS App by March 2024, with the overall aim for the app to be a “one-stop shop for health needs”.

The Health Secretary also promised in February to speed up the digitisation of the NHS, with 90 per cent of patient records to be held electronically by next year.

Summarising medical records is not without its issues and good training provides an understanding of how confidentiality can become compromised during summarising

More information can be found at:

https://www.gov.uk/government/news/health-secretary-sets-out-ambitious-tech-agenda

https://digital.nhs.uk/services/summary-care-records-scr/summary-care-records-scr-information-for-patients

https://www.telegraph.co.uk/news/2022/06/13/nhs-app-will-one-stop-shop-appointments-prescriptions-medical/

The importance of a basic understanding of medical terminology and medicines is as important as it ever was, and has been highlighted recently by this example of two medications with similar spellings – but for completely different complaints

A patient, had to be treated in hospital after she was given the wrong medication due to a mix-up.On attending the emergency department of a Glasgow hospital, the patient was found to have conjunctivitis and a defect on her cornea. However, the erectile dysfunction cream that was dispensed to her had a similar name, Vitaros, to the eye lubricant she was actually prescribed – VitA-POS. The patient suffered with blurred vision, a swollen eyelid and redness and discomfort immediately after putting the erectile dysfunction cream into her eye.

Experts have said GPs must use block capitals when writing prescriptions after a woman was mistakenly given erectile dysfunction cream for a dry eye

Eye doctors from Glasgow’s Tennent Institute of Ophthalmology, who treated the woman, have now written an article on the case in BMJ Case Reports, the medical journal

“It is unusual in this case that no individual, including the patient, general practitioner or dispensing pharmacist, questioned erectile dysfunction cream being dispensed to a female patient with ocular application instructions.

“We would like to raise awareness that medications with similar spellings exist,” the report said.

Importantly, doctors noted that one in 20 prescriptions were estimated to be affected by a prescribing error.

The original report can be read here

Over the last 16 years I have delivered face to face training to non-clinical staff in primary care. In light of easy access to technology and information on the internet, what are the training needs today for non-medically trained professionals working in close contact with the medical profession?

What’s required of the role?

The class of 2016 are involved extracting and imputing key medical data from medical notes. Often referred to as note summarising, they scan medical reports onto IT systems and link them to a problem title. Then once this has been done read codes are attached to each medical diagnosis, operation or problem. This process requires clarity and key medical knowledge; it is not enough to record a patient as having had a hysterectomy (uterus removed). There are at least 10 different codes or ways of having a hysterectomy, and it must be correctly coded.

The non-clinical team also update medical summaries as letters arrive from hospital departments. Staff are expected to work with other agencies and need background information to deal with patients, doctors and other multidisciplinary staff.

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Medical terminology transcription errors could be putting patients lives at risk, because of a growing number of cash-strapped hospitals sending medical notes abroad to save money, Unison warned today.

The union has compiled a dossier showing that 21 NHS trusts are piloting the outsourcing of confidential patient information to India and South Africa, which are then sent back to the UK and added to patients’ individual records.

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