Almost all British general practitioners use computer based patient records, but most hospital doctors do not. This review (the first of two) focuses on how, over 30 years, incentives led to enthusiastic adoption of computing by general practitioners but widespread alienation of hospital doctors.

#### Summary points

Almost all British general practitioners use computers in their consulting rooms, but most hospital doctors do not

Over 30 years, leaders of the general practitioner profession have worked with government to provide incentives for computerising practices and to remove barriers

In hospitals computing was treated as a management overhead, and doctors had no incentives to become involved

The success of the government's plans for “joined up,” computer based health services depends on providing appropriate incentives to hospital doctors

This article has had a long gestation. Much of the evidence comes from my experience over nearly 30 years, first as leader of the computer evaluation unit at the Charing Cross Hospital, London (1974-80), then as a general practice system supplier (1980-90), and as a supplier of clinical information systems for hospital doctors (1990-9). An initial version of the article was written in 1993 and extended for the NHS Executive's integrated clinical workstation project 1995. A later version was presented at the AMIA Symposium, Washington DC, November 2001 (proceedings, pp 42-6).

Wanless pointed out Britain's particularly poor record on the use of information technologies in the health service and called for an immediate doubling of expenditure on computing.1 The Department of Health has responded with a new national strategy to deliver the benefits of working practices supported by information technology and computer based records across the NHS.2 Concern is not limited to Britain: in 2001 the US Institute of Medicine stated that “IT must play a central role … if a substantial improvement in quality is …

https://www.bmj.com/content/bmj/325/7372/1086.full.pdf

Why general practitioners use computers and hospital doctors do not--Part 1: incentives.

General practitioner (GP) computing has its origins in the 1970s when the benefits of clinical coding and prescribing were demonstrated. During the early 1980s Dr James Read, working with Abies Informatics Ltd, developed the eponymous Read Codes, which were broader and more comprehensive than other schemes, yet intuitive and easy to use. In 1988 a joint working party of the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) recommended that the Read Codes be adopted nationally.
The Read Codes have been used by almost all GPs in the UK since the mid-1990s. Many developments in general practice, including GP fundholding (where GPs held the budgets to commission elective care for their patients), the Quality and Outcomes Framework (QOF - pay for performance for improving chronic disease management) and GP commissioning (the current NHS reform in which primary care leads commissioning of services for their patients) would have been impossible without all GPs using a common clinical coding scheme.
Systematized Nomenclature For Medicine - Clinical Terms (SNOMED CT) is a merger of the Read Codes with SNOMED RT - the original SNOMED reference terminology developed by the American College of Pathologists.

https://hijournal.bcs.org/index.php/jhi/article/download/811/823

The history of the Read codes: the inaugural James Read Memorial Lecture 2011

Over many years, general practice computing has prospered, whereas hospital clinical computing has not. Differences in leadership and economic incentives partially explain this. In general practice the government and the profession worked together to remove barriers and provide incentives to computerisation. In hospitals the opposite happened. Changes are needed to provide professional leadership and economic incentives in both primary and secondary sectors. An early step would be to establish united stakeholder organisations for clinical users and information technology professionals in health care, covering all aspects of healthcare computing The NHS is now planning to deploy integrated patient record systems across both primary and secondary care. The examples of Kaiser Permanente and the Veterans Administration suggest that such systems may play a critical part in improving effectiveness and efficiency. However, such a project faces several technical obstacles, mainly associated with scalability. It is much easier to computerise small general practices than large complex hospitals, let alone provide integrated services across an organisation as large as the NHS. These technical issues—which include patient record architecture, terminology, interoperability standards, security, and developments in computer technology—are the subject of my second article.

History of the TDS medical information system

> ‘… Medical schools should recognise they have a responsibility to patients to educate and prepare half of all graduates for careers in general practice … Teaching and promotion of general practice as a career which is as professionally and intellectually rewarding as any other specialism. Those medical schools which do not teach primary care as a subject should be held to account by the General Medical Council.’1 
> 
> ‘… It [ general practice ] is a really hard job. They GPs, have to be clinically, intellectually , and emotionally strong … to identify major clinical problems masquerading as minor ailments and it is utterly relentless. It requires a lot of intellectual flexibility and people have to be very tolerant individuals. It is one of the hardest jobs in medicine.’2 
> 
> ‘… Health Education England is currently working with the Medical Schools Council, higher education institutions, the RCGP and the GPC to increase the profile of general practice in medical schools and in their curricula . A working group, chaired by Professor Valerie Wass OBE, will publish recommendations in Summer 2016 about recruitment and selection, finance and curriculum and the promotion of general practice as a specialty . ’3 (author’s italics)

These statements underline why medical students should study general practice as a specialty or specialism, that is as a distinct subject, and that this needs to be done intellectually, a word appearing three times in these extracts. ‘Intellectual’ is defined by the Oxford Dictionary as ‘possessing a high level of understanding …’ implying understanding of general practice research.

An intellectual approach is needed as current medical students have been highly selected on intellectual criteria. They want know the ‘hows and whys’ of medicine. If they hear theory and principles only from hospital specialists, they will be drawn only to hospital practice and 81% …

https://bjgpopen.org/content/bjgpoa/1/1/bjgpopen17X100569.full.pdf

Towards research-based learning outcomes for general practice in medical schools: Inaugural Barbara Starfield Memorial Lecture

To assist clinical assessment and decision making, a computer-based system has been developed to organize key data of individual medical records and display these data in a standard graphic format for each disease. A program for multiple myeloma has been completed and 150 case records entered. The data accessed by computer-based case tracing on all cases of a particular disease are available for cumulative and comparative analyses of different therapeutic regimens. (JAMA239:1772-1776, 1978)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=359583&pdfFileName=jama_239_17_016.pdf

Computer-based case tracing (COMTRAC).

During a five-week period, which began in January 1970, an on-line computer record maintenance and retrieval system was in operation in an Exeter general practice for use in patient management. The doctor and his secretary used visual display units, and had immediate access for 3 hours each evening through a Post Office telecommunication line to a computer disc file 180 miles away. The on-line record system was compared with an alternative system, in which print-outs of the computer-based record were amended in handwriting by the doctor, and input to computer file by his secretary. The orderly structure and revised emphasis given to the data by this method of record construction, as well as the speed of retrieval and ease of maintenance, provided valuable assistance to the general practitioner during consultations.

N.G. Pearson

Papers

An on-line record maintenance and retrieval system in general practice.