JRSM > Volume 96, Number 8 > Pp. 395-397

This Article Abstract Full Text (PDF) Send a Quick Comment Alert me when this article is cited Alert me when Quick Comments are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, J. J Articles by Beattie, D. K Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?

Use of information technology in general practice

Jason J Smith DMI FRCS   Rebecca J Mallard-Smith MB DFFP1  ¹ Victoria Beattie MB BS1  ¹   David K Beattie MD FRCS2  ²

¹ The John Hampden Practice, 97 High Street, Prestwood HP16 9EU
Department of Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF
² Department of Surgery, St Richard's Hospital, Spitalfield Lane, Chichester PO19 4SE, UK

Correspondence to: Mr Jason Smith, The John Hampden Practice, 97 High Street, Prestwood HP16 9EU, UK E-mail: jj.smith{at}imperial.ac.uk

	SUMMARY

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
The internet and NHS Net are used increasingly in UK general practice. A questionnaire survey conducted in southern England examined these applications. 77 (55%) of 141 practices responded. Of these, 71 were connected to one or other service and 27 offered a practice website. Only a small minority used a website for direct patient booking or access to pathology results. Moreover, among those with a practice website, none paid the necessary attention to data security. The survey revealed some fundamental misunderstandings that may partly account for the slow uptake of these technologies in British general practice.

	INTRODUCTION

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
The use of information technology (IT) by an increasingly computer-literate public, both at home and in the workplace, is growing. 40% of households have at least one computer at home and the number is increasing. The UK Government is committed to population-wide internet access, preferably by a broadband connection, affording patients quick and easy access to health information and advice. One reputable source, available online, is NHS Direct [http://www.nhsdirect.nhs.uk]. The internet has become an important source of information for patients and with this have come increasing expectations as to the type and quality of information available.

However, the information even on credible websites is not always accurate or current.¹ When patients consult a general practitioner (GP), they not infrequently bring a printout from a website. Most practices in the UK now have internet access via an NHS Net connection. Yet, despite the obvious potential for improvements in practice—for instance, direct and rapid consultation with hospital specialists,² ordering of investigations and receipt of results, access to evidence-based databases,³ communication with patients and continuing medical education—take-up of the service was initially slow. Some GPs have set up their own practice websites, but others will have asked, ‘Why invest time and money when so many information sites exist already?’

In view of the vast potential of the internet for use in general practice, a questionnaire survey to assess the ways it and the NHS Net are used, and the information and services offered to patients, with particular emphasis on practice-based websites, was performed in southern England.

	METHODS

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
A questionnaire was sent by mail to 141 general practices—50 in the London area, 49 in Buckinghamshire and 42 in Hertfordshire—randomly drawn from the lists on local government websites. Practice managers were asked to address 15 questions about use of the internet/NHS Net and provide details of any practice-based website: who designed them, who maintains them, their information content, their use for booking appointments etc., and plans for the future (full questionnaire available from the authors). Anonymity was offered, so we were unable to pursue non-responders. If the practice had a website, the practice manager was invited to supply the address so that we could examine the site in more detail.

	RESULTS

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Of the 141 questionnaires sent out, 77 (55%) were returned. 60 practices reported a connection to the internet and 71 to the NHS Net. Table 1 summarizes responses to an open-ended question about use of the NHS Net: only 2 were using the direct booking system with their provider trusts and 4 were accessing pathology results; a further 2 had the system installed but were not using it. When asked how often they used the NHS Net, 30 practices said ‘daily’, 18 said ‘several times a week’, the others ‘once a week or less’.

View this table: [in this window] [in a new window]   Table 1. Services of the NHS Net used by general practices

 

21 practices had a website, in 3 cases only just made available; the mean time for which websites had been accessible was 12 months. Practice staff had designed 2 of the sites; the others had been commercially designed. 1 in 4 of these practices were unhappy with the site itself—for example, because of expectations unfulfilled or perceived high maintenance costs.

Of the 50 practices connected to the internet but without a website, 35 were planning to develop one in the future. When asked the likely cost, most respondents thought it would be £250-500 and less than £100 a year for maintenance.

For those practices with websites, the information and services available are shown in Table 2. In most cases, the information mirrored that in their practice leaflet. Some offered electronic self-help leaflets and advice on what to do in an emergency. A few sites offered dynamic content based on user input or an ‘end product’ after completion of an online form, repeat prescriptions being the most common such application. On examination of the practice websites engaging in data transfer, we found that in no case was the data transfer being made over a secure server/connection.

View this table: [in this window] [in a new window]   Table 2. Information and services on practice websites

 

	DISCUSSION

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Conclusions from this survey must be qualified by the low response rate: the practices that replied may have been atypical in their experience and plans. However, it does seem that a substantial proportion of practices (here 45%) either have a practice website or will soon be offering one. Disappointing findings in this survey are that connections to the internet/NHS Net are little used, and that some practices with websites are ignoring the NHS requirements for data security.

One curious feature of the data is that more practices declared themselves connected to the NHS Net than to the internet: this reflects a misunderstanding since the NHS Net allows full access to the internet as well. The reverse does not apply as commercial internet service providers (used by 5 practices) cannot offer access to the NHS Net. The survey also revealed some unrealistic notions of cost. Of those practices contemplating establishing a website, most thought that the initial expenditure, including design, should be less than £500. In the commercial sector, this sort of financial commitment would provide a basic site of just 3-5 pages, with two or three images and no dynamic content (i.e. no capability for interactive service provision). The £50 a year that most thought an acceptable price for maintenance was similarly unrealistic: once a website is online, the files have to be held on a server. In effect, this means renting space on a web-host's hard drive (which the host has to purchase and maintain), renting bandwidth (which relates to site activity) and the continued upkeep of the domain name. Some of the dissatisfaction expressed with websites in this survey may be traceable to lack of expenditure on design and maintenance.

Clearly, the establishment of a general practice website demands much thought. Disadvantages are the expense of the site and associated experience, the need for special training, and the hazard that third parties may gain access to confidential information via electronic transfers. So, why make the effort? The main reason is to provide local information that is not available on the larger sites. Links to the general sites can be provided if the content is judged accurate; in this way, the GP extends his or her role as trusted adviser. The website can provide local information about the practice and other health facilities, and can offer services to patients. From our survey, it seems that the specific facilities of the NHS Net, such as access to patient results and direct hospital outpatient bookings, are at present little used. The questionnaire did not ask why these facilities are not used and one can only speculate about the reasons, such as unfamiliarity with the system and lack of facilities in the provider units. Time constraints appear to be an important factor in failure to use information technology: in one of the practices questioned, this was the reason why e-mail was the only NHS Net service used.

According to one recent study, just 26% of practices have a computer in the consulting room,⁴ but other experience indicates that practitioners, once committed, quickly learn how to navigate to the best sites.

The single most concerning aspect of this study was that of security of data. None of the practices using online forms for the transmission of patient information did so over a secure connection. Protection of such information is a fundamental reason for the inception of the NHS Net. The NHS Net is the largest ‘virtual private network’ in the world; it offers security that no standard website or internet connection can provide, access being controlled by routing traffic through specific servers with strict controls on the IP (internet protocol) addresses of the computers attached to it. Security of patient data is a serious matter: in UK law the penalties for disclosure of confidential data are severe. Special security measures are required since, according to a UK Government report, 60% of organizations experienced a security breach in the past two years

[http://www.dti.gov.uk/cii/datasecurity/infosecuritybreachessurvey2000/index.shtml].

Computer ‘hackers’ (correctly termed crackers) attack websites by intercepting data transmission or exploiting loopholes in security of networks or programs. The potential to do this to patient information is obvious. The following link from the NHS Information Authority summarizes the important aspects of security for anyone considering establishing a medically related website:

[http://web.archive.org/web/20001218045900/www.standards.nhsia.nhs.uk/sdp/resource/index.htm]

For online forms such as repeat prescriptions, the server should be equipped with a minimum of 128-bit secure socket layer (SSL) encryption, recognizable by https rather than http at the start of the address. Information from these forms is to be sent via NHS Executive approved encryption. In addition, a firewall must be established between the practice network, the NHS Net, and any other external network, to prevent unauthorized access to confidential data. All incoming files and e-mails, especially from the internet, should be scanned by an antivirus package. For repeat prescriptions, special measures are needed to check that drug information entered by the patient is correct and that non-patients are not misusing the system. Official advice on what should and should not be included, for patient purposes, on a medically related website is obtainable from the following:

[http://www.doh.gov.uk/nhsidentity/websites.htm]

[http://www.e-envoy.gov.uk/publications/webqualitybrief/design-framework/].

The internet is here to stay in one form or another and all general practitioners should embrace the technology and make it work efficiently and securely for themselves and their patients.

	REFERENCES

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 

1. Kunst H, Groot D, Latthe P, Latthe M, Khan K. Accuracy of information on apparently credible websites: survey of five common health topics. BMJ 2002; 324: 581-2[Free Full Text]

2. Bergus GR, Sinift SD, Randall CS, Rosenthal DM. Use of an E-mail curbside consultation service by family physicians. J Fam Pract 1998; 47:357 -60[Medline]

3. Young JM, Ward JE. General practitioners' use of evidence databases. [see comments.] Med J Aust1999; 170:56 -8[Medline]

4. Ely JW, Levy BT, Hartz A. What clinical information resources are available in family physicians' offices? J Fam Pract1999; 48:135 -9[Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This article has been cited by other articles:

				Minerva BMJ, August 16, 2003; 327(7411): 402 - 402. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Send a Quick Comment Alert me when this article is cited Alert me when Quick Comments are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, J. J Articles by Beattie, D. K Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?