Portable medical record for the homeless mentally ill

Access to records and client held records for people with mental illness

Increasing involvement of users in health service planning has led to a movement towards patients having more information about their care. Some have advocated patients having access to their medical records and this is now a statutory right. There has been concern as to whether this is suitable in mental health. An addition or alternative to access to medical notes is a client held record which might increase the patient's feeling of autonomy while also improving communication and compliance. In studies on access most patients and staff have found this beneficial. Client held records have also been positively received in the few studies reported but more evaluation in routine practice Is needed.

Medical records: Patient-held records in mental health

‘But don't they get lost?’ This is usually the first comment made when the authors mention the use of patient-held records (PHRs) to colleagues. Nevertheless, PHRs have been used in mental health care as well as several other settings, including services for diabetes, cancer, maternity and child health. In some of these services, including mental health, PHRs have been an addition to clinician held standard notes, whereas in others the patient holds the only record for their care. The main purposes of introducing PHRs have been to empower patients with a sense of ownership of their care and to improve communication, between both patients and clinicians, as well as between different clinicians involved in that person's care (Laugharne & Stafford, 1996).

A follow-up study of the use of a patient-held record in mental health

Aims and Method

Patient-held records have been introduced in mental health over the past 2 decades. This follow-up study aimed to evaluate one pilot project 5 years after the records were introduced. All patients initially interviewed 4 years previously were approached and asked about their use and opinion of the record.

Results

Of the 19 people interviewed, 12 were still using the record and had a positive opinion of its usefulness. Of all community mental health team contacts, 72% were recorded in the patient-held notes.

Clinical Implications

Patient-held records are sustainable in a naturalistic clinical setting over the period of 5 years.

User-held personalised information for routine care of people with severe mental illness

BACKGROUND

It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. User-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with severe mental illnesses is unknown.

OBJECTIVES

To evaluate the effects of personalised, accessible, user-held clinical information for people with a severe mental illness (defined as psychotic illnesses).

SEARCH METHODS

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register in August 2011. This register is compiled by systematic searches of major databases, and handsearches of journals and conference proceedings.

SELECTION CRITERIA

We included all relevant randomised controlled trials (RCTs) that:i. have recruited adult participants with a diagnosis of a severe mental illness (specifically psychotic illnesses and severe mood disorders such as bipolar and depression with psychotic features); andii. compared any personalised and accessible clinical information held by the user beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available.

DATA COLLECTION AND ANALYSIS

Study selection and data extraction were undertaken independently by two authors and confirmed and checked by a third. We contacted authors of trials for additional and missing data. Where possible, we calculated risk ratios (RR) and 95% confidence intervals (CI). We used a random-effects model. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

Four RCTs (n = 607) of user-held records versus treatment as usual met the inclusion criteria. When the effect of user-held records on psychiatric hospital admissions was compared with treatment as usual in four studies, the pooled treatment effect showed no significant impact of the intervention and was of very low magnitude (n = 597, 4 RCTs, RR 0.99 CI 0.71 to 1.38, moderate quality evidence). Similarly, there was no significant effect of the intervention in three studies which investigated compulsory psychiatric hospital admissions (n = 507, 4 RCTs, RR 0.64 CI 0.37 to 1.10, moderate quality evidence). Other outcomes including satisfaction and mental state were investigated but pooled estimates were not obtainable due to skewed or poorly reported data, or only being investigated by one study. Two outcomes (violence and death) were not investigated by the included studies. Two important randomised studies are ongoing.

AUTHORS' CONCLUSIONS

The evidence gap remains regarding user-held, personalised, accessible clinical information for people with psychotic illnesses for many of the outcomes of interest. However, based on moderate quality evidence, this review suggests that there is no effect of the intervention on hospital or outpatient appointment use for individuals with psychotic disorders. The number of studies is low, however, and further evidence is required to ascertain whether these results are mediated by the type of intervention, such as involvement of a clinical team or the type of information included.

A cluster randomised controlled trial of patient-held medical records for people with schizophrenia receiving shared care

BACKGROUND

Patient-held records can improve communication across the primary-secondary interface. There has been no previous rigorous assessment of the utility of patient-held records for people with schizophrenia from a primary care perspective and their value for this population is unclear.

AIM

To evaluate the effectiveness of a patient-held record for patients with schizophrenia receiving shared care.

DESIGN OF STUDY

Cluster randomised controlled trial.

SETTING

Seventy-four general practices and six community mental health localities in Birmingham, England between June 1998 and June 1999.

METHOD

A sample of 201 patients with schizophrenia (ICD-10 classification F20) was recruited; of these, 100 were intervention and 101 were control. Patient-held records were given to the intervention patients. At 12-month follow-up, all patients were accounted for and 191 (95%) were revisited. Primary outcomes were the Verona Service Satisfaction Scale-54 (VSSS-54) and the Krawiecka and Goldberg (K & G) rating scale of psychopathology at 12-month follow-up. Secondary outcomes were use of primary and secondary care services.

RESULTS

A total of 63/92 (68.5%) patients still had the patient-held record, 64/92 (69.6%) had used it, and 39 (60.9%) of the 64 who had used it said the patient-held record was regularly used by their keyworker. However the patient-held record had no significant effect on primary outcomes (VSSS-54: F1,116 = 0.06, P = 0.801, K & G: F1,116 = 0.6, P = 0.439) or on use of services. A higher symptom score was associated with not using the patient-held record.

CONCLUSIONS

The trial provides no good evidence to suggest that patient-held records should be introduced as part of routine shared care for all patients with schizophrenia. However, the patient-held record was acceptable to patients with schizophrenia and acted as a communication tool, particularly between patients and keyworkers.

The development and piloting of a patient held record with adult mental health users

This article reports on the development and piloting of a patient held record for adult mental health users. Development of the format and content of the record was determined in consultation with a user group. Piloting and subsequent evaluation of the record with users revealed a number of issues which need to be addressed in the promotion of a patient held record.

Patient held clinical information for people with psychotic illnesses

BACKGROUND

It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. Patient-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with serious mental illnesses is unknown.

OBJECTIVES

To evaluate the effects of personalised and accessible patient-held clinical information for people with a diagnosis of psychotic illness.

SEARCH STRATEGY

Electronic searches of AMED (1980-1998), Biological Abstracts (1985-1998), British Nursing Index (1994-1998), CAB (1973-1999), CINAHL (1982-1999), The Cochrane Controlled Trials Register (Issue 1, 1999), EMBASE (1980-1999), HEALTHSTAR (1990-1999), HMIC (King's Fund Database 1979-1998 & HELMIS 1984-1998), MEDLINE (1966-1999), PsycLIT (1887-1999), Royal College of Nursing Database (1985-1996), SIGLE (1990-1998), Sociological Abstracts (1963-1998) and the Internet (http://www. controlled-trials.com/) were undertaken. This was supplemented by personal contact with the Executive Board of the European Network for Mental Health Service Evaluation.

SELECTION CRITERIA

The inclusion criteria were that studies should: i. be randomised or quasi-randomised trials; ii. have involved adults with a diagnosis of a psychotic illness; and iii. compare any personalised and accessible clinical information held by the patient beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available.

DATA COLLECTION AND ANALYSIS

Study selection and data extraction was reliability undertaken. Analysis was not possible.

MAIN RESULTS

Not one study met the inclusion criteria for the review. One study (Stafford 1997) was found on the use of client held records for people with long term mental illness but the participants had not been randomised. Two important randomised studies (Lester 1999, Papageorgiou 1999) are ongoing.

REVIEWER'S CONCLUSIONS

There is a gap in the evidence regarding patient-held, personalised, accessible clinical information for people with psychotic illnesses. It cannot be assumed that patient-held information is beneficial or cost-effective without evidence from well planned, conducted and reported randomised trials.

Attitudes towards, and utility of, an integrated medical-dental patient-held record in primary care

BACKGROUND

The need for closer coordination between primary care medical and dental services has been recognized.

AIM

To assess the attitudes of general medical practitioners (GMPs), general dental practitioners (GDPs), and patients to an integrated medical-dental patient-held record (integrated medical-dental PHR); to examine patients' use of these records, and the utility of the records for doctors and dentists.

METHOD

A three-phase study was carried out: (1) postal survey of GMPs and GDPs; (2) randomized trial of patients, using postal questionnaires before and one year after the issue of integrated medical-dental PHRs to cases; (3) assessment by doctors and dentists of anonymized integrated medical-dental PHRs from this trial. The study was carried out in medical and dental practices in affluent and deprived areas in Greater Glasgow Health Board. Two hundred and thirteen GMPs, 183 GDPs, and 369 patients registered with GMPs and GDPs were surveyed. Eighteen GDPs and GMPs assessed the integrated medical-dental PHRs.

RESULTS

Eighty per cent of dentists had contacted a doctor and 16% of doctors had contacted a dentist in the previous three months; 87% of dentists and 68% of doctors thought an integrated medical-dental PHR would be of some use. Twenty-one per cent of dentists and 85% of doctors had practice computers. Most patients wanted to be able to see and read their own records. Twenty-four per cent of patients said there were mistakes and 30% noticed omissions in the integrated medical-dental PHR issued. Experience of having an integrated medical-dental PHR made patients more positive towards the idea of having a patient-held record and being able to check the accuracy of records. Integrated medical-dental PHRs contained important information for half the GDPs and one-third of the GMPs.

CONCLUSION

Both professionals and patients have reasonably positive attitudes towards the use of patient-held records. Among patients, the experience of having the integrated medical-dental PHR led to greater enthusiasm towards the idea. Dentists in particular would benefit from the transfer of information from doctors, but better methods are needed to ensure that patients take the integrated medical-dental PHR with them. Given the current lack of ability to easily produce an integrated medical-dental PHR, further examination of the routine issue of a copy of their medical summary, by GMPs, to all patients would be worthwhile.

The Hampstead Schizophrenia Survey 1991. II: Incidence and migration in inner London

BACKGROUND

The previous paper reports a high prevalence of schizophrenia (broad definition) in an inner London area. In this paper we test hypotheses for this finding and examine the characteristics of people with schizophrenia who move frequently.

METHOD

People with schizophrenia in the Hampstead area were identified by key informant methodology, at two censuses five years apart. This allowed identification of incident cases during these five years and identification of people who had moved into and out of the area.

RESULTS

The incidence of DSM-III-R schizophrenia in Hampstead between 1986 and 1991 was at least 0.21 per 1000 of the population aged 15 to 54. There was a significant movement of people with schizophrenia to this inner London area from outer London between 1986 and 1991. People with schizophrenia who were relatively mobile were significantly more likely to be male, to suffer with prominent hallucinations, and to have no contact with a GP.

CONCLUSIONS

The high prevalence of broad schizophrenia in this inner London area is, in part, due to geographical drift. A significant excess of the people with schizophrenia who move frequently are men with positive symptoms.

The homeless in the emergency department: a patient profile

OBJECTIVE

To explore the possibility that homeless people use the accident and emergency (A&E) department as a substitute for primary care and to quantify the role of alcohol abuse in their attendances.

METHODS

The study period lasted six months. Attendances of all patients registering with "No fixed abode" as their address were analysed from the A&E notes. Information gathered included details of the presenting complaint, general practitioner (GP) registration, and alcohol involvement in the presentation.

RESULTS

135 homeless patients attended the department 233 times; 91% of patients were male with an average age of 40 years; 46% of attendances were during office hours; 81.5% of presentations were for minor problems; 65.2% of patients had co-existing medical problems, with 14.8% having a chronic alcohol problem; 23.7% of patients gave details of their GP and the remainder were either not registered or did not know their GP registration status; 29.6% of attendances directly involved alcohol and another 10.3% were requests for inpatient or outpatient alcohol detoxification; 42.1% of patients questioned said they were aware of the medical facilities available to homeless people in the community; 52.6% of those questioned said they preferred being seen in the A&E department when ill, with 23.7% preferring GP treatment and 10.5% attending community homeless clinics.

CONCLUSIONS

The local homeless population may be using the A&E department as a substitute for primary care even in the presence of homeless healthcare facilities in the community. Heightened awareness of these facilities may improve their uptake. Alcohol plays a large role in homeless people seeking medical help in the A&E department. More accessible community facilities for dealing with this problem in this patient group are needed.