Patient encounter history discovery report

Supporting Information

Appendix 1. Demographic breakdown of patients

Have called 111 or used 111 online in the past 3 months
Mixed ethnic backgrounds
- B (middle middle class) - 5 participants
- C1 (lower middle class) - 7 participants
- C2 (skilled working class) 5 participants
- D (working class) - 3 participant
Mixed socio-economic background and occupation (not employed in NHS)
A mix of urban/rural
Mix of genders
- 10 females
- 10 males
Within this group, we have interviewed 3 participants who had a mental of physical disability
Mix of ethnicities
- Arab - 1 participant
- Black & mixed race - 3 participants
- Indian and Bangladeshi -- 3 participants
- White British -- 9 participants
- White other -- 4 participants
A wide spread of ages

Appendix 2. Patient Interview Discussion Guide

This is an example of the discussion guide that we used when interviewing patients who had used the 111 Service in the last three months:

Intro

Introduce the project and PEH information

About the user:

At what point did you decide to use the 111 service? Why?
Have you used the telephone, online or a mixture of services?
Why did you did you decide to use this service? Did you consider using the online / telephone service instead (why / why not)
Which part of the country where you in, when you contacted the emergency service? Is this where you normally live?

111 telephony

Who did you speak to first?
Did they pass you onto another person? What was their (medical) role?
What happened next?
When you contacted the/were contacted by next service, were they aware of your condition / reason for calling?
How did you feel about them knowing / not knowing about your condition / reason for calling? Why?
What happened next?
Were you aware of your information being passed onto the next service?
How did you feel about going through that service?
Was there anything that stood out to you?
How would describe this process?
Did anything feel satisfying / good?
Did anything feel frustrating / difficult?
How did your emergency care end?
Was there anything else that stood out / we haven't discussed?

Online

What was the outcome of the 111 online assessment service?
What happened next?
What service were you referred to?
What did you do next?
When you contacted the/were contacted by next service, were they aware of your condition / reason for calling?
How did you feel about them knowing / not knowing about your condition / reason for calling? Why?
What happened next?
Were you aware of your information being passed onto the next service?
How did you feel about going through that service?
Was there anything that stood out to you?
How would describe this process?
Did anything feel satisfying / good?
Did anything feel frustrating / difficult?
How did your emergency care end?
Was there anything else that stood out / we haven't discussed?
(Depending on previous answers) Have you ever used 111 online/telephone?

Future

If you had a need for urgent care again, what would you do?
How do you think your experience could have been improved?

Appendix 3. Organisations that took part in user research for PEH discovery.

Cheadle Medical Practice
Cumbria Health on Call
Derbyshire Health United Health Care
Dorset Healthcare
Hertfordshire Urgent Care
Hull and CIO
Integrated Care 24
Isle of Wight Trust
Lincolnshire Community Health Service
Local Care Direct Yorkshire
London Ambulance Service
London Central and West Unscheduled Care Collaborative
Mastercall Healthcare
Medvivo
NHS Digital - 111
NHS Digital - Pathways
NHS England
NHS Improvement
NHS Kernow
Northern Doctors Urgent Care, part of Vocare
Practice Plus Group
South Central Ambulance
UEC Greater Manchester and NW

Appendix 4. Clinician Interview Discussion Guide

This is an example of the discussion guide that we used when interviewing clinicians. We adapted the discussion guide depending on the role of the clinician that we were speaking to.

Intro

Introduce the project and PEH information

About the research participant:

Tell me about your role
Do you work across different services? Which services?
How do you go about diagnosing people in urgent care at the moment?

Current Practice

When a patient presents themselves, currently, what information is available to you?
How do you use this information? Do you need to retrieve it or is automatically presented?
Where do you find the information? What systems do you use?
What are the biggest challenges when using this information?
What patient information is missing, that you think should be included?
What are the risks connected to this information in your current practice?
When you have no information what do you do then?
What do you currently do after a patient encounter?
What information is generated?
What is done with that information?

Handover

Tell me about handing over the patient to another service? (What happens to the patient\s information)
Do you do anything differently if you are at the end of that patient's journey (in emergency care)?

Alerts

How are you alerted that a patient has been to emergency care recently? What if they presented themselves in another emergency setting (not in your practice)?
Would these alerts be helpful? Why?
Are you aware if the patient has triggered the RCS (repeat caller service (3 calls in 96hrs))?
How did RCS change your clinical practice?
If you see a patient 3-4 times in a short period of time, does that change how you treat or assess them?
What are the current limitations of RCS?
What thresholds (for time / number of contacts) would you set?

PEH Information

Which patient encounter history information would you find most helpful to see?
What features of Patient Encounter History would you like to see, that would help your clinical decision-making?
What are the features that PEH would need to safeguard patients safety?
Which information is critical?
Which information would be "nice to have"?
Which information would be irrelevant or unnecessary?
How would you expect it to be presented so you can easily see pertinent information?
What would be the benefits of having patient encounter history?
How would you use that information?
What would be the risk connected with having a patient encounter history? What clinical risk might it cause?
Have you been in a setting where a more detailed patient encounter history has been available to you? How did that change your interaction with the patient?
How do you think your interaction with the patient may change if you had richer encounter history?
How would capturing patient encounters change your way of working?
Do you see any challenges with doing that?

Timeframes

How far back should the patient encounter history go?
Why did you come to this conclusion? Can you give us an example of when this timeframe wouldn't work?
Do you see any risk with having or using PEH? What types?

Risk stratification

What does risk stratification mean to you?
How do / would you use risk stratification in your clinical practice? How does it impact your clinical care?
How would the introduction of patient encounter history impact positively and negatively the following areas?
Individual, the risk of the patient coming to avoidable harm
Population, events presenting harm to the population as a whole (Covid-19, flu etc.)
Service, the information available in the service being unsafe
System overload, the risk of balancing demand versus safety

Appendix 5. Clinician Survey Questions

What is your role within Urgent and Emergency Care?

call handler (non-clinician)
clinical support
paramedic
nurse
GP
junior doctor
consultant
registrar
I don't work for Urgent and Emergency Care
Other

Which UEC settings do you work in?

CAS (clinical assessment centre)
111 centre
Emergency Department
Minor Injury Unit
Walk-in centre
Out of hours GP
Same day emergency care
Urgent Treatment Centre
Other

Which organisation are you working for?
When triaging or diagnosing patients in Urgent and Emergency Care what information is usually available to you?
What patient information is most helpful in recognising patients worsening conditions in Urgent and Emergency Care?
What relevant patient information is most often missing when you are assessing patients in Urgent and Emergency care?
What are the challenges of not having rich patient encounter history within Urgent and Emergency Care setting?
What would be the benefits of having more patient encounter history?
How would capturing patient encounters within Urgent and Emergency Care change your ways of working?
How far back would it be useful to have patient's encounter history in the UEC setting?

last 96 hours
last week
last 2 weeks
last month
last 2 months
Other

Categorise which patient information is very relevant, nice-to-have or not relevant for clinical decision-making in Urgent and Emergency Care settings:

mental health history
hospital discharge
notes
recent procedures
Pathways assessment
long-term conditions
recent GP referrals
allergies
history of recent
contacts / visits to UEC
immunisations
current medicines
UEC referral history
history of violence
treatment plans from
other clinicians within
UEC
end-of-life plans
repeat caller flag
recent prescriptions

Are there any other types of very relevant patient information that you think should be available Urgent and Emergency Care settings for clinical decision making?

Appendix 6. Patient information that is most important for clinical decision-making in UEC settings

Information named as most important in the UEC settings

Presenting complaint
Previous encounter’s clinical outcome (a diagnosis/ suspected diagnosis is preferred)
Safeguarding and special notes information
Primary Care record (including pre-existing conditions, medications and allergies)

Additional information that clinicians in UEC settings would like to have

Recent blood test results
Other recent test results (x-ray, scans etc)
Acuity score
The narrative leading to the UEC encounter
Psychological parameters/mental health history
Correct contact details including next of kin
Role and grade of the person who has seen the patient previously
All medical and social information
Discharge summaries
Care plans (including end-of-life care)
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