New approaches - full abstract

The Positive Impact of Medic Bleep, An Asynchronous Communication Platform Versus Existing Communication Methods: An Observational Study

Meenakshi Jhala(1), Rahul Menon(2)
(1)St. George's University of London, (2)Guys’ & St. Thomas’ NHS Trust

Background: Healthcare systems revolve around intricate relations between humans and technology. System efficiency depends on information exchange which occur on synchronous and asynchronous platforms. Traditional synchronous methods of communication may pose risks to workflow integrity and contribute to inefficient service delivery and medical care.

Aim: To compare synchronous methods of communication to Medic Bleep, an instant messaging (IM) asynchronous platform and observe Medic Bleep’s impact on clinical workflow and quality of work life alongside associations with patient safety outcomes and hospital core operations.

Methods: Cohorts of healthcare professionals were followed using the Time Motion Study methodology over a two-week period, using both the asynchronous platform and synchronous methods like the non-cardiac pager. An 11-item questionnaire was sent out pre and post implementation of Medic Bleep and 24 interviews were conducted, both to identify staff attitudes towards both platforms.

Results: A statistically significant figure (P<0.01) of 20.1 minutes’ reduction in average task completion was seen with asynchronous communication, saving 58.8% of time when compared with traditional synchronous methods. In sub-category analysis for staff: doctors, nurses & midwifery categories, a P value of <0.0495 and <0.01 were observed; a mean time reduction with statistical significance was also seen in specific task efficiencies of “To-Take-Out (TTO), patient review, “discharge & patient transfer” and escalation of care & procedure”. 67% of staff found easy implementation and a Likert scale value of 8.7 favoured asynchronous communication more.

Conclusion: The asynchronous platform improved clinical communication compared to synchronous methods, contributing to efficiencies in workflow and may positively affect patient care.

Video clinics versus standard face-to-face appointments for liver transplant patients in routine hospital outpatient care: a feasibility study of myVideoClinic

Janet Jones(1), Sarah Damery(1), James Ferguson(2), Elaine O'Connell Francischetto(1), Gill Combes(1)
(1)University of Birmingham, (2)University Hospitals Birmingham NHS Foundation Trust

Background: Video clinics, in which patients can have a hospital appointment with their clinician from home, are emerging in practice, but their effectiveness is unclear. This study evaluated the feasibility of implementing video clinics at University Hospitals Birmingham (UHB) NHS Foundation Trust and assessed whether the intervention improved patient satisfaction compared to standard face-to-face appointments for liver transplant patients.

Methods: Clinically stable liver patients at 1 to 5 years post-transplant were randomised to video clinic appointments (intervention) or standard face-to-face appointments (control). The intervention group had their routine follow-up appointments from home via a secure video link accessed through the UHB online patient portal. All participants completed baseline questionnaires prior to randomisation and follow-up questionnaires after each appointment during the subsequent 12 months. The primary outcome was the difference in scores between baseline and study end by patient group for three domains of patient satisfaction on the modified Visit-specific Satisfaction Questionnaire (VSQ9): convenience of location, getting through to the office by phone and length of time waiting. Secondary outcomes included: quality of life (EQ-5D-5 L), costs, clinical contacts and user experience. Descriptive statistical analysis was performed on an intention-to-treat basis, and patients and health care professionals were interviewed about their experiences of video clinics. The interviews were transcribed verbatim and analysed thematically.

Results: Fifty four patients were randomised; 29 to the video clinic arm and 25 to usual care. Only 26% of eligible patients were recruited, yet all participants remained in the study for its full duration. There was substantial crossover between arms with 13 video clinic patients swapping to usual care leaving only 16 in the intervention arm. Reasons for swapping included patient request (n=9), patient did not attend their video clinic appointment (n=2) and health reasons (n=2). Across both study arms, 129 appointments were completed with 64% of surveys returned. Survey responses showed a significant increase in patient satisfaction in both arms for the three primary outcome domains assessed. Video clinic appointments saved patients time and money by removing the need to travel to the hospital, and some reported that video clinics were more relaxing and took less of a toll on their health. All were satisfied with the care they received from their clinician. Nevertheless, many patients and clinicians encountered technical problems with the video clinic software and appointments were frequently carried out over the telephone. Patients were required to obtain blood test results locally before their video clinic appointment which proved challenging for some, but as the study progressed this became less problematic as workarounds were developed. All usual care patients saw the benefits of video clinic appointments in relation to saving time and money even if they believed this to be an unsuitable option for them. Overall, clinicians and patients saw video clinic appointments as the way forward but any future rollout would need to be carefully planned and executed.  

Implications: The NHS is facing huge challenges with regards to staffing, budgets and space due to increasing patient numbers. Being innovative by using available technology to offer routine follow-up appointments via secure video link may help ease some of the burdens and free up clinic space for those patients who need to be seen face-to-face. This study has shown that despite positive views and eagerness from both patients and clinicians for video clinic appointments, if there is to be a wider rollout to other specialties, several issues need to be resolved and most importantly, patients should always be offered a choice of face-to-face or video clinic appointment. 

Implementing remote measurement technology in clinical pathways for depression, epilepsy and MS: Results from a large-scale survey of clinicians in primary and secondary care

Jacob Andrews(1), Michael Craven(2), Alexandra Lang(3), Jenny Jamnadas-Khoda(4), Richard Morriss(2), Chris Hollis(2)
(1)University of Nottingham, NIHR Mindtech MedTech Cooperative, NIHR Nottingham Biomedical Research Centre, (2)University of Nottingham, NIHR Mindtech Medtech Co-operative, NIHR Nottingham Biomedical Research Centre, (3)University of Nottingham, Human Factors Research Group, (4)University of Nottingham, NIHR Mindtech Medtech Co-operative

Background: Remote Measurement Technology (RMT) uses the sensors and software found in wearable and mobile devices to record data on movement, behaviour, heart rate and other biological indicators, while additionally enabling collection of self-report data (Majumder et al., 2017). Together, these data can be used to gain insight into a person’s physical and psychological health, for example to estimate time and quality of a user’s sleep, exercise and social interaction. RMT also offers the potential to transform interactions between patient and clinic (Liao et al., 2019). However, little guidance is available to direct the use of RMT in healthcare settings and not much is known about how, or whether, data from these devices are currently being used in such settings. We also know little about clinicians’ views on the value of these technologies and the data they produce, or how these could be put to use in healthcare pathways in future. (Vegesna et al., 2017).

The RADAR-CNS project (Remote Assessment of Disease and Relapse: Central Nervous System) is a large 5-year programme involving university and private sector partners across Europe, funded by Horizon2020 and the Innovative Medicines Initiative ( The project seeks to explore the potential of RMT in epilepsy, depression and MS – conditions where less work has been conducted around the use of RMT, compared to cardiac conditions and diabetes, for example. The present study seeks to explore the potential value of RMT for the management of these conditions, according to clinicians working in these specialisms.



Primary objective: To understand if RMT interventions currently have a role in clinical practices and decision points.

Secondary objectives: To understand where healthcare professionals believe there to be potential for RMT to impact pathways of care, decision making processes and interactions with patients, whilst also exploring the potential challenges to the implementation of these technologies.


We are conducting an online survey of clinicians working in the care of people with epilepsy, MS or depression. The survey asks about: clinicians’ use of digital services and devices in their role; thoughts on using digital devices for long term monitoring; job roles most likely to make use of RMT data; areas where RMT data is most likely to provide benefits; likelihood of accessing/using the data; potential challenges to implementation; and technical support requirements. Participants complete an online process of informed consent before completing the online survey.

Recruitment to the survey has been via social media and with assistance from the Clinical Research Network, also via contacts of the research team. To date we have received over 500 responses to the survey and recruitment will remain open until the end of March 2020.


All questionnaires will be fully anonymised and analysed within the Bristol Online Questionnaires Tool, with further analysis to be conducted in Microsoft Excel.

Ethics and research governance:

Ethical approval for the study was granted by the University of Nottingham research ethics committee, and approval was granted by the Health Research Authority for involvement of the Clinical Research Network.

Results: The study will close at the end of March 2020 and results will then be analysed and included in our final presentation.

Implications: RMT may have the potential to improve care by allowing clinicians to make better informed decisions and improving detection of relapse in a variety of conditions. There is a need to understand whether and how RMTs are currently utilised in care, as well as how they could be used in future. Our survey will help to provide an informed vision of the potential use of RMT in clinical pathways for epilepsy, MS and depression.


Liao, Y., Thompson, C., Peterson, S., Mandrola, J., Beg, M.S. 2019. The Future of Wearable Technologies and Remote Monitoring in Health Care. American Society of Clinical Oncology Educational Book 39, 115-121. DOI: 10.1200/EDBK_238919

Majumder, S., Monda, T., Deen, M.J. 2017. Wearable Sensors for Remote Health Monitoring. Sensors 17(1), 130. DOI: 

Vegesna, A., Tran, M., Angelaccio, M., Arcona, S. 2017 Remote Patient Monitoring via Non-invasive Digital Technologies: A Systematic Review. Telemedicine and e-Health 23(1). DOI:


The Remote Assessment of Disease and Relapse – Central Nervous System (RADAR-CNS) project ( has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 115902. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and European Federation of Pharmaceutical Industries and Associations (EFPIA) ( This communication reflects the views of the RADAR-CNS consortium and neither IMI nor the European Union and EFPIA are liable for any use that may be made of the information contained herein. The funding body have not been involved in the design of the study, the collection or analysis of data, or the interpretation of data.

This research was supported by the National Institute for Health Research: NIHR MindTech MedTech Co-operative; NIHR Nottingham Biomedical Research Centre; and NIHR Applied Research Collaboration East Midlands. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Download RADAR-CNS poster.  

Feasibility, usability and acceptability of a gamified strength and balance training and healthy ageing platform (Keep-On-Keep-Up) for older adults living in the community

Emma Stanmore(1), Emma Stanmore(2), Katharine Fisher(1)
(1)University of Manchester, (2)The University of Manchester

Background: Falls in older adults are common and costly. Multifactorial falls prevention programmes that include progressive strength and balance exercises can reduce falls but such interventions are often expensive and may be inaccessible to older adults. Digital technologies can offer new, inexpensive approaches to increase access and engagement with falls prevention programmes. Keep-On-Keep-Up (KOKU) is a gamified, self-manageable, tailored falls prevention platform with exercises and health literacy games to educate users about home safety and bone health. The aim of the study was to determine usability and acceptability of the KOKU platform for older adults in assisted living facilities and to assess feasibility of study procedures. 

Methods: A mixed methods, multi-centre, pre-post feasibility trial was conducted.  Older adults aged 55 years and older residing in assisted-living (sheltered housing) facilities in the UK were invited to use the KOKU tablet-based platform, unsupervised, three times a week for six weeks. Data collection included 15 hours of observations; baseline and 6 week questionnaires and assessments; semi-structured interviews with 14 older adults to explore views about study procedures, platform usability/acceptability and training and support needs and one focus group with falls prevention therapists to explore usability of the platform.  Data were analysed using thematic content analysis to identify themes arising from older users’ and therapists’ perspectives of KOKU. 

Results: Thirty older adults (mean age = 75 + 9) were recruited and twenty-two completed post intervention testing. Mean SUS score was 71 + 14. Although the study was not powered, a trend towards an improvement in SPPB total score was apparent. Key qualitative themes included: ease of use (app usability; iPad physical properties; method of exercise presentation), usefulness (physical/psychological benefits; falls education), attitude towards the app and intention to use (technological barriers; flexibility of use; exercise class versus app). The therapists (n=6) viewed the KOKU platform positively and suggested extensions to the exercises and health literacy games for further progression and patient inclusion. No adverse events were reported during the study.

Implications: This research demonstrates that KOKU is a safe, acceptable and easy to use falls prevention intervention that facilitates community dwelling older adults’ ability to access strength and balance activities and health literacy games at a time, and in a location, that suits them. Further development of the platform would help ensure that a range of physical abilities are catered for, and sustain long-term interest in the exercise programme.  

The Online Booking Experience study: Early findings from a qualitative interview study.

Abi Eccles(1), Gary Abel(2), John Campbell(2), Jeremy Dale(1), Leon Poltawski(2), Graham Roberts(3), Helen Atherton(1)
(1)University of Warwick, (2)University of Exeter, (3)Lay representative

Background: Online appointment booking is offered in most general practices as an alternative to booking via the telephone. It is intended as a way to improve access and alleviate pressure on existing booking systems. The UK government have been keen to promote and invest in online services and have recently developed an NHS smartphone app with an online booking feature. However, despite such promotion, evidence shows that most patients continue to book appointments via phone, with very few using online booking services. Many factors may influence patients’ booking methods, which are likely to differ according to background, circumstances or functionality of the booking systems available to them. But currently, evidence examining these mediators is lacking and little is known about how patients use online booking and their perspectives about them.

Methods: The Online Booking Experience (OBoE) study uses mixed methods to examine patients’ experiences of using, and not using, online booking. The study comprises of two stages. Initially data from the General Practice Patient Survey was analysed to examine patterns between online booking behaviours and patients’ demographic backgrounds. Findings from this stage not only demonstrated differing levels of awareness and use across England, but also provided a detailed picture of the types of people who are more and less likely to be aware of, and use, online booking.

This abstract focuses in the second stage of the OBoE study. In this part of the study we carried out approximately 40 semi-structured qualitative interviews with individuals who had recently booked GP appointments. During the interviews we explored in depth patients’ experiences of and views about booking appointments online. Interview participants were recruited from 12 practices selected according to demographic features, aiding maximum variation within the sample. Initially a scoping survey was distributed to all eligible patients who had booked an appointment for a selected day, within participating practices. The survey collated information about participants’ backgrounds and their booking behaviours and awareness. This data enabled us to purposively sample interview participants according to their booking behaviour and awareness, as well as demographic background. The sampling strategy was iterative and thus guided by the findings from the first stage of the study, the ongoing interview analysis and maximum variation sampling. Interviews were carried out via the telephone, audio-recorded and transcribed. Once anonymised, interview data was analysed by two researchers using framework analysis, enabling comparison of cases in key areas.

Results: We will present the early findings from analysis of the qualitative interviews, which will be ongoing from March 2020. Developing from the first stage of the study, these qualitative findings will provide further exploration of the patterns identified within the General Practice Patient Survey data; explaining some of the reasons behind contexts when online booking is, and is not, appealing or feasible for different individuals. 

Implications: Examination of patients’ experiences of online booking will aid understanding how to improve such services. As the UK government continues to invest in a service which has low levels of uptake, robust evidence identifying barriers to online booking for some groups is vital information that can help to improve the quality of services and overcome any potential problems. This evidence will also be of practical use to practices when considering how to implement online booking services for all their patients effectively and efficiently.

Awareness and use of online appointment booking in general practice: analysis of GP Patient Survey data

Mayam Gomez Cano(1), Helen Atherton(2), John Campbell(1), Jeremy Dale(2), Abi Eccles(2), Leon Poltawski(1), Gary Abel(1)
(1)University of Exeter, (2)University of Warwick

Background: General practices are required to provide online booking to patients in line with policy to digitise access. Online booking services offer the option of booking an appointment 24/7 using the internet. However, uptake of online booking by patients is currently low and there is little evidence about awareness and use by different patient groups.

Methods: As part of the OBoE (Online Booking Experience) study, we performed a secondary analysis of GP Patient Survey data (2018) making use of two questions, one asking about awareness of online booking of appointments and another asking about use. Multivariate logistic regression was used to examine associations between both awareness and use in relation to age, gender, ethnicity, deprivation, the presence of a long-term condition, long-term sickness and being deaf. Comparison of models accounting for and not accounting for clustering by practice was used to illustrate the extent to which disparities reflect the clustering of certain types of patients in practices where awareness and use of online booking is high or low for all patient groups.

Results: Of 647,064 patients answering the relevant question, 277,278 (43.3%) reported being aware of being able to book appointments online. In contrast, only 14% (93,671 /641,073) reported having actually booked an appointment online. There was evidence of variation by all factors considered. In particular, strong deprivation gradients in both awareness and use were evident (e.g. most vs. least deprived quintile OR for use=0.63 95%CI 0.61-0.65). There was a strong drop off in both awareness and use in patients over 75 (e.g. 85+ vs. 65-74 years OR for awareness=0.33 95%CI 0.32-0.35). Patients with long-term conditions were more aware and more likely to use online booking, however, deaf patients were less likely to be aware, but more likely to use online booking (not-deaf vs deaf OR for awareness= 0.78, 95%CI 0.70-0.86, OR for use= 1.29, 95%CI 1.14-1.46). Adjustment for practice suggest that around a third of the deprivation gradient in awareness and a fifth of the deprivation gradient in use is attributable to deprived patients being clustered in practices with low awareness/use for all patients.

Implications: Whilst over 40% of patients know that they can book appointment online, the number that actually do so is far lower. Furthermore, awareness and use of online appointment booking varies by patient group. Some of this variability is reassuring, for example that patients with long-term conditions are using the service, whilst other variability is more concerning, for example the strong deprivation gradient and drop off in old age. With the constant push for online services within the NHS, practices need to be aware that not all patient groups will book appointments online and that other routes of access need to be maintained to avoid widening health inequalities.

Mental capacity assessment in care homes: could the MCAST facilitate practice?

Mark Jayes(1), Lynn Austin(1), Laura Brown(2)
(1)Manchester Metropolitan University, (2)University of Manchester

Background: An estimated 60-75% care home residents are likely to lack the mental capacity to make major decisions (Wade, 2019). Incapacity is often associated with cognitive or communication difficulties secondary to dementia, stroke or other neurological conditions. Health and social care staff need evidence-based assessment tools to help them to assess residents’ mental capacity and provide decision-making support (NICE, 2018). The Mental Capacity Assessment Support Toolkit (MCAST) is a paper-based toolkit that includes guidance and practical resources to support staff from any discipline to identify patients’ specific support needs (e.g., communication) and to prepare, complete and document legally-compliant mental capacity assessments. The MCAST was developed in acute hospital and intermediate care settings and has not yet been trialled in care homes. The aims of this qualitative study were to: i) explore how care home staff support decision-making and assess mental capacity; ii) determine whether the MCAST could be adapted in order to meet the specific needs of care home staff and residents. 


Methods: A purposive sample of health and social care staff working in care homes across Greater Manchester and Cheshire was recruited to participate in five focus groups. A topic guide was used to collect data relating to: participants’ experiences of supporting decision-making and assessing mental capacity; perceived barriers and facilitators to good practice in this area; participants’ support needs in developing good practice; and participants’ perspectives about the feasibility of using the MCAST in these settings. Data were analysed thematically using the process described by Braun and Clarke (2006). 


Results: Twenty-nine participants were recruited. Participants were employed as managers (n=18), nurses (n=7) or care assistants (n=4). They had varied direct and indirect experience of mental capacity assessment. Participants worked in a range of care homes: homes varied in terms of the type of care provided (residential and/or nursing), their size and their Care Quality Commission inspection rating. Five overarching themes were identified from the data: i) general approaches to resident decision-making / mental capacity assessment; ii) participants’ experiences of and feelings about this area of practice; iii) challenges to good practice; iv) supporting residents who have communication disabilities; and v) participants’ reflections on the use of the MCAST in this context. Participants reported practice that appeared consistent with the principles of the Mental Capacity Act (OPSI, 2005). They appeared competent and confident but recognised the complexity of this area of practice and identified a need for further support. Participants reported variable access to specialist support from speech and language therapy for residents with communication needs. They responded positively to the MCAST and were keen to trial it in practice; they were able to suggest minor changes to its design to increase its usability in care homes.


Implications: Care home residents with communication needs may not receive adequate support to make decisions. Care home staff would benefit from and welcome support to develop their practice. The MCAST appears usable in this context and further feasibility testing is warranted. 




Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.


National Institute for Health and Care Excellence (2018) Decision-making and mental capacity [NICE guideline NG108], Available from: 


Office of Public Sector Information (2005) Mental Capacity Act 2005. London: OPSI.


Wade, D. T. (2019) Determining whether someone has mental capacity to make a decision: clinical guidance based on a review of the evidence. Clinical rehabilitation, 33(10), 1561–1570.

Emergency Admission Risk Prediction (EARP) tools in primary care to reduce emergency admissions to hospital: the gap between evidence and practice

Alison Porter, Helen Snooks, Mark Kingston
Swansea University

Background: Policy initiatives have incentivised primary care clinicians in the UK to identify patients at high risk of emergency admission to hospital and to deliver proactive care to reduce the risk. A range of software tools to support Emergency Admission Risk Prediction (EARP) have been developed by commercial and public sector providers to support primary care clinicians in this task. A recent trial in South Wales provided some of the first evidence on impact of EARP: it found that EARP increased emergency admissions and Emergency Department attendances without clear benefits, and cost the NHS an additional £76 per patient per year. We aimed to assess the use of EARP in primary care across the UK.

Aim: To describe access to EARS tools and their use across the four UK nations; and identify factors perceived to influence access and use.

Methods: Online survey of all 235 organisations responsible for primary care across the UK: 209 Clinical Commissioning Groups in England, 14 Health Boards in Scotland and 7 in Wales, and 5 Local Commissioning Groups in Northern Ireland. We conducted analysis using descriptive statistics for closed questions and by theme for open questions. 

Results: We received responses from 171 (73%) organisations, of whom 148 (87%) reported that risk tools were available in their areas. We identified 39 different EARS tools in use. Access to EARP tools varied widely by country: Northern Ireland (100%), Scotland (91%), England (76%) and Wales (14%).

Promotion by NHS commissioners, involvement of clinical leaders, and engagement of practice managers were identified as the most important factors in encouraging use of EARS tools by general practices. Conversely we identified high workloads of general practice and community staff and information governance as important barriers. Tools were most frequently used to identify individual patients, but also for service planning. Nearly 40% of areas using EARS tools reported that they had introduced or realigned services as a result, but relatively few areas reported use of tools for service evaluation.

Implications: Although there is no strong evidence supporting the clinical or cost effectiveness of interventions incorporating EARS tools, there has been concerted political and practical investment in EARS across the developed world. Though EARP tools are widely available in primary care, new evidence shows that they are counter-productive. We estimate that by delaying the dissemination of EARP for evaluation NHS Wales saved >£200 million per year. We encourage further research and discussion about next steps in use of EARP tools in emergency admission prevention in the UK

How does health information technology impact on patients and staff within urgent hospital care pathways? 

Katharine Abba, Rabee’ah Aslam, Mike Pearson, Tony Marson, Keith Bodger
University of Liverpool

Background: The NHS Five Year Forward View sets the target that “by 2020, all care records will be digital, real-time and interoperable”, predicated on the belief that by combining and sharing key patient and service use data, health services can provide more timely, rational and integrated care. However, the anticipated benefits of health information technology (HIT) remain largely unproven, with the mechanisms by which health systems can realise the gains yet to be fully described.

To allow the potential benefits of HIT to be better visualised, we conducted a qualitative study exploring views of NHS clinical staff on the impact of current HIT in the context of unscheduled hospital care and follow-up for three different chronic ambulatory care sensitive conditions; chronic obstructive pulmonary disease (COPD), epilepsy, and alcohol dependency.

Method: The study was conducted primarily within four NHS acute trusts in the North West Coast region of England; two of which used mainly hand-written case notes supported by various HIT packages, two of which used mainly digital health records within an integrated HIT package.  Semi-structured interviews were conducted with 33 clinicians within the ambulance service, A&E units, medical assessment wards, outpatient clinics, specialist nursing services, Regional Neuroscience Centres and GP practices.

Findings: Participants at sites with primarily hand-written case notes and poorly integrated HIT packages expressed frustration at what they saw as unnecessary time spent searching for internal information, logging in and out of different HIT packages, and recording the same information on multiple systems. Occasionally information could not be found when needed, or was illegible, potentially impacting on patient care.  In contrast, participants at sites with integrated digital health records were very happy with the way the systems functioned internally. 

Participants at all sites described problems in obtaining timely access to parts of the patient health record held by other organisations.  This included unnecessary time spent requesting and providing information, duplication of diagnostic tests, negative impacts on patient care, and missed opportunities to intervene to improve health. Examples of impacts on patients included: 

  • people with exacerbations of COPD being inappropriately treated with high-flow oxygen, worsening their condition

  • people with alcohol-related liver diseased being admitted to hospital on the basis of a single blood test, when access to previous result would have shown that the condition was stable

  • discussions about end of life or ceilings of care being had more than once, or inappropriate treatment given because this information is not available

  • people with multiple alcohol-related A&E attendances across different hospitals not identified and therefore not targeted for intervention 

Participants at two sites had limited direct access to GP summaries, which they described as very useful, especially in A&E. 

Referral processes varied widely, and were often described as time-consuming, potentially unreliable, and ineffective in optimising the information transferred. The processes viewed as most efficient and effective used a structured form sent via a digital link directly from the patient record system, and were available only to specific services within digitised sites. 

Implications: Our findings tend to confirm that within a hospital, introducing fully digitised health records and well-integrated HIT can have positive impacts on health service quality and staff satisfaction. These capabilities also appear to be the foundation on which a more connected, integrated health system can be created. However, effective communication and data-sharing across organisations remains a major challenge even in the presence of the necessary digital technology, and it will take time to identify priorities, forge agreements between providers, design systems and processes, and overcome continuing problems with interoperability.