ABC of health informaticsCommunication and navigation around the healthcare systemJeremy C Wyatt, Frank Sullivan

However good a doctor’s clinical skills, record keeping abilities,and mastery of evidence, before they can start work they needdirectory information. This is the information patients andprofessionals use to find their way around the healthcaresystem. Different grades of staff have different demands for thisinformation, and all staff are often interrupted by colleagues’requests for this information.

Directory informationDirectory information includes information about localservices, how to book them, contact details, and specialists’preferences for tests that they need patients to have had donebefore they see them. Variations in stationery, laboratory andtherapeutic services, and how those services are organised(including what type of bottle specimens should go in) meanthat most expert clinicians cannot work properly when they aremoved from their base 100 km in any direction.

Initiatives from the national programme for informationtechnology (NPfIT), such as “Choose and book” with itselectronic directories of specialists and their preferences forwhich tests should be done before a patient is referred, shouldprovide a few types of directory information.

CommunicationDirectory information has always been needed. In the past,doctors could rely on informal networks built up over years, andthere were fewer subspecialists to swell clinical teams. Now,health systems change more often, members of staff are moremobile, and the scope of health has widened so that doctorsregularly communicate with local authorities, expert patients,carers, a variety of hospitals, and voluntary agencies. Also, thenumber of staff in each health centre has increased.

Although new technologies may reduce the need fordoctors to memorise information, they raise new problems—forexample, access to a directory is needed to check qualificationsof remote telecarers and identify them reliably so that doctorscan hand over responsibilities and information to them.

Little is known about the patterns of communication withinand beyond clinical teams, although interesting results have

A hospital switchboard in 1995—shows the operators’ directory andtemporary notes. With permission from Martin Loach

Directory information used to support primary care tasks

Primary care task Directory information SourceRoutine surgicalreferral

List of surgeons withinterests and waitingtimes at local hospitals

Colleagues, humanresourcesdepartment atlocal acute trust,trust website,Dr Foster

Urgent psychiatricreferral

Telephone number oflocal mental health trust,person on duty and theirmobile number

Hospital and HealthServices Yearbook,local mental healthtrust

Therapy referral List of therapists bylocation, days they work,and their contact details

Local primary caretrust

Test ordering Type of specimen, tubeneeded, suggestedindications

Local laboratoryhandbook

Test interpretation Reference range, who tocall for advice

Local laboratoryhandbook

Advice to patients For example, details oflocal diabetes self helpgroup, or details of anAsperger’s self helpgroup

Primary care trust,Diabetes UKwebsite,Contact-a-Familywebsite

Inquiry about newgeneral practicecontract

List of local primary carepriorities

Primary care trustheadquarters

Writing jobdescription forpractice manager

Salary scales BMA regionaladviser

This is the 11th in a series of 12 articlesA glossary of terms is available athttp://bmj.bmjjournals.com/cgi/content/full/331/7516/566/DC1

You are a general practice locum and need to fix anoutpatient assessment for Mrs Smith’s bronchitis. Thereceptionist mentions that before you organise theassessment you need to book certain tests that varyaccording to which chest physician you refer Mrs Smithto. The receptionist does not know the names of localchest physicians nor their investigation preferences. Youspend 15 minutes trying to call the chest clinic in thenearest hospital before discovering it moved six weeksago to another site 15 miles (24 km) away. Your phone isnot cleared for long distance calls, and the practicemanager is not around, so you wait to use a colleague’sphone. Mrs Smith takes umbrage at the delay and walksout while shouting across the waiting room, “Call yourselfa doctor. You don’t even know what goes on in thehospitals round here.”

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emerged from a small study of hospital communication and astudy of emails sent between primary care centres and trusts.The best evidence for taking a proactive approach to managingcommunication comes from the field of mental health.

Studies of case workers show the benefit of a formalapproach to exchanging information when dealing with acomplex chronic disease that has a relapsing and remitting timecourse. To understand what happens during communicationbetween different parts of a health system, reflect on the mainelements of any communication. It requires at least two parties(sender and receiver) who share some similar understanding ofthe world (common ground). Communication also needs amessage, which may be short and simple, or complex (such as adrug formulary), and a channel over which the message cantravel. Communication channels can vary in important ways.Some channels require the simultaneous attention of bothparties (for example, face to face conversations), other channelsautomatically provide a permanent record of the message (forexample, faxes or emails). In any communication, the personwhom the message is for, and the nature of the message mustbe established. In some situations, such as the scenario in thebox on page 1325, assembling and using reliable directoryinformation is difficult.

Collecting and using directoryinformationCollecting and using such information can be difficult forseveral reasons. Clinicians rely heavily on printed lists andhandbooks. This hard copy often needs to be corrected orannotated, and then photocopied because some staff cannotaccess the original electronic copy. Another reason for therebeing problems with collecting and using directory informationis that clinicians often rely on their fallible memories.Fragmentation of information sources can also causedifficulties. Sometimes work related contact numbers are storedin diaries or mobile phones, and either could be lost or stolen.Also, if stored in a phone or diary, this information is notautomatically available to others in the healthcare team orbeyond.

NHS HealthSpace (www.healthspace.nhs.uk) allows patientsto record these data. Patients can store their own information inthe section called “Health Tracker,” and will have access to theirelectronic health records.

External agencies often manage directory informationbetter than the NHS. For example, Binley’s directory providesinformation from contact details for NHS trusts, departments,and health centres, to pharmacy opening times. Privatehealthcare organisations also manage information better thanthe NHS because they realise that there is a business need andthat benefits will accrue if their clients have easy access toinformation on how to use their services.

Assembling, maintaining, andaccessing directory informationOne of the reasons that any clinician could face a situation likethe one described in the scenario is because the people andorganisations in healthcare services change fast. In the futurethey will change even faster, making directory informationmore important, but more difficult to assemble.

Communication channels used in healthcare

Channel Sender andreceiverneeded atsame time

Type andlongevity ofrecord

Comment

Face to faceconversation

Yes Usually none, butcan be partial orfull

Can make noteslater, tape recordwhole encounter

Telephoneconversation

Yes Usually none, butcan be partial orfull

Can make notesduring or after, orrecord in full forpermanent record(for example,NHSDirect)

Voicemail No None ortemporary

Can delete or savefor 28 days

Textmessages

No None ortemporary, or canbe full

Can archive textmessagespermanently

Email No Permanent Can forward toothers and attachpictures

Instantmessaging

Nearly, replyneededwithin aminute

Permanent Can save chat todisk

Ward round Yes Partial Record findingsand decisions incase notes

Meeting Yes (even ifdone bytelephone orvideo)

Partial Minutes ofmeeting

Telemedicineusing storeand forward

No Permanent Similar to email

Telemedicineusing videolink

Yes Usually none, butcan be partial orfull

Like a wardround. Recordresults anddecisions in casenotes, or videorecord the session

Interactivedigitaltelevision

Yes No Slow with poorfunctionality, butwill improve

Exchange ofletters or fax

No Yes Oldertechnologies thathave a continuingrole

NHS HealthSpace website allows patients to store information and will allowthem to private access to their personal electronic health records

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SummaryDirectory information is vital for people to navigate healthcareservices and to allow clinicians to do their work, but in manyhealthcare organisations directory information is under-rated,or even non-existent.

Directory information changes quickly, and originateslocally. It also needs to be accurate, up to date, and availablenationally to support greater use of eHealth. Some of theinformation can be distilled from local sources of data, and oneapproach might be to expect it to be everyone’s business toensure that these sources are kept up to date—just as cliniciansmaintain a patient’s record.

Unfortunately, this idea leads to a “collusion of anonymity”where “everyone agreed that someone should do it, but no onedid.” A solution might be to have a designated person for eachorganisation—for example, a laboratory or primary carecentre—whose job it is to maintain this information.Maintaining directory information can be seen as“organisational governance.” It is an intrinsic part of being ateam member and central to being a responsible employee.

It seems ironic that when accurate, comprehensive, up todate contact information is needed by NHS organisations, theypay for directories and databases published by externalorganisations—for example, Binleys directory, NHSConfederation, and Medical Directory. Perhaps the NHS shouldoutsource this activity and set up central service levelagreements with these organisations for less money than NHSTrusts currently spend on paper directories. Pressure from anexternal contracted organisation might persuade organisationsthat are funded by the state to provide the necessary data in atimely way, which has often defeated internal efforts to capturethese data in the past. In future, pre-referral investigationprotocols for each consultant might be readily available andpotential Mrs Smiths need not be so disappointed.

Collecting and using directory information

Problem SolutionSource of directory information isoften obscure

Identify key data and mostaccurate source

It is nobody’s job to maintain thesource

Include directory information ininformation governance role

Too many sources, no coherentmap

Map and reduce the number ofsources

No single format for directoryinformation

Develop a national standard dataformat for all relevant kinds ofdirectory information

Cannot rely on peers ortraditional networks in view ofshorter working week, rapid staffchanges

Use electronic media

Directory information changesfast—for example, contacts,laboratory tests, opening hours ofpharmacy

Someone must keep it up to dateon a central site; discourage printouts

Maintaining accurate, up to datecontact information takes a lot ofwork

Reward those who succeed byincluding it in their jobdescription

Most directories are designed forlocal users in a local context, butdata increasingly needed atnational level

Ensure national standard format,context seen as national not local

Local NHS regularly reorganised Include directory informationmanagement as a function inevery new organisation; anticipateand manage risks of disruption

Plurality of NHS serviceprovision—private sector,overseas, other providers

Encourage all service providers touse and contribute to NHSdirectory information

Disruption to work caused by useof synchronous communicationchannels

Encourage use of asynchronouschannels instead by providingemail or voicemail details

Loss of key directory informationcaused by use of transientchannels, such as mobile phones,Post It notes

Use permanent channels

Print outs of electronic copy getout of date, and corrections arerarely propagated

Do not print out

Data in diary or handheldcomputer is hidden from otherteam members and can get lost

Download data, never modify iton handheld computer

Variable quality of NHS directoryinformation

Raise awareness of importance ofdirectory information; use it;allow users to improve it;outsource capture and provisionof other providers

The series will be published as a book by Blackwell Publishing inspring 2006.

Competing interests: None declared.BMJ 2005;331:1325–7

Further readingx Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe ME.

Communication loads on clinical staff in the emergencydepartment. Med J Aust 2002;176:415-8

x Coiera E, Tombs V. Communication behaviours in a hospitalsetting: an observational study. BMJ 1998;316:673-6

x Ziguras SJ, Stuart GW, Jackson AC. Assessing the evidence on casemanagement. Br J Psychiatry 2002;181:17-21

x Coulter A. When I’m 64: Health choices. Health Expect 2004;7:95-7

Jeremy C Wyatt is professor of health informatics, and Frank Sullivanis NHS Tayside professor of research and development in generalpractice and primary care, University of Dundee.

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