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Maudsley Hospital, South London and Maudsley Trust, Denmark Hill, London SE5 8AZ
This paper describes the implementation, merits and future potential of the eCPA — a computer-based Care Programme Approach (CPA) system for care planning. The system is designed to improve the quality of information in CPA care plans and, for the first time, to enable the rapid and standardised adoption of evidence-based good practice by all community mental health team (CMHT) staff.
The CPA is the central element of the Government's policy for the coordination and delivery of mental health services (Department of Health, 1999a, b). At the core of this approach are regular reviews of progress by a multi-disciplinary team and the compiling of a written care plan agreed by and to be acted on by all the team.
Past failures of communication between agencies have been noted all too frequently (Appleby, 2000). The care plan, properly used, provides an invaluable tool for improving the delivery of community mental health services. But there can be problems in using CPA forms. A recent audit into their use, conducted at the Maudsley Hospital, found shortcomings, including concerns about illegibility and a failure to complete sections in sufficient detail (further details available from the author upon request). The eCPA was introduced to ameliorate these shortcomings.
The community practice area
The team (St Giles Team 3) that has been developing the eCPA is based at the Maudsley Hospital in south London. It provides community mental health services in Peckham, an inner-city area of high socio-economic deprivation (population approximately 43 000). The CMHT comprises the standard professional disciplines of an integrated service. It has approximately 175 patients registered on Level 2 of the CPA.
How the eCPA is used
The care coordinator in the community types out the CPA care plan form using a Microsoft Word document template of the CPA form (see Box 1). This is then brought to the CMHT's weekly case review meeting either on a floppy disk or by e-mail. The CMHT reviews its patients around a table served by six flatscreen monitors connected to the trust's local area network. The team can all view the CPA care plan form as a document on screen. The team discusses each case section by section and amendments are keyed into the eCPA at the meeting. By the end of the meeting a completed and finalised CPA care plan document can be printed and distributed. Where a formal CPA or Section 117 review is held with the patient, carer and others present, the eCPA is produced in advance, circulated on paper and adjusted according to the outcome of the discussion, to provide an authoritative hard copy. The completed eCPA care plan is then e-mailed to the acute ward, the hospital's emergency clinic and any other involved agencies. The CPA manager is sent the original signed copy, a copy is filed in the case notes and the general practitioner (GP), the patient and/or his/her carer is given a copy.
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Incorporating ‘PracTips’
Recognising the need to get up-to-date evidence-based good practice implemented by our multi-disciplinary CMHT, we have introduced into the eCPA good practice points or ‘PracTips’ sourced from acknowledged experts in disciplines as varied as clinical psychology and welfare. A library of PracTips is provided, some of which are already placed within the eCPA template. Others are available as e-mailed updates for keyworkers to select depending on the patient's needs. PracTips are referenced and paper copies of these articles are kept (see Box 2 for an example).
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The system is evidence-based and can be updated whenever a new point of good practice emerges. Thus, in response to a paper demonstrating the benefits of motivational interviewing to improve compliance (Kemp et al, 1996), the form can be adapted by inserting a yes or no question whether motivational interviewing had or had not been considered. The evidence base is graded, presently using the system cited by Thornicroft (Thornicroft, 2000).
How has the eCPA been received?
The eCPA has been welcomed by staff — with a take-up rate of almost 100%. Patients also seem to welcome the legibility and detail of the forms and have, so far, expressed no concerns.
Benefits of the use of the eCPA
The benefits of the eCPA may be summarised as follows:
Issues arising
The move to electronic CPA record-keeping does give rise to additional legal and practical implications. The maintenance of information on the eCPA is covered by the Data Protection Act. Compliance with the Act has been ensured by following the Information Management and Technology Security Policy produced by our trust. It is not envisaged that eCPAs would be e-mailed outside a trust intranet. This policy follows the guidelines given in the Health Service Circular Data Protection 1998: Protection and Use of Patient Information (Department of Health, 2000).
The use of electronic media stored on different machines can give rise to issues of version control. A disciplined approach is needed to avoid confusion about which electronic version of the eCPA is the latest authoritative version. A disciplined approach is essential also to archiving the electronic files and the keeping of hard copies of the form.
Further applications and improvements
Promotion of good practice
The eCPA provides a powerful means of meeting the need
(Palmer & Lelliott, 2000) for dissemination of evidence-based good practice notes at the point of
service delivery. Our clinical and academic staff are continuing to compile
good practice points gleaned from the literature, supplemented by good sense
points where such literature does not exist. These PracTip points are
available to be added to the appropriate sections of the eCPA care plan
template. We believe it will be possible to include a footnote or hypertext
link to explain the importance of PracTips. It is now feasible to incorporate
hypertext links to an abstract or full online version of the article that
provides the evidence base for PracTips.
We hope that in due course the eCPA will be standardised nationally in an agreed format, providing country-wide dissemination of PracTips from a nationally recognised commissioning and reviewing body.
Use with primary services
As well as providing up-to-date information to front-line services such as
emergency psychiatric clinics, the eCPA can also improve communication with
primary care services by providing GPs with a concise and succinct summary of
the patients' problems and care plans, including relapse and risk information.
We intend working with our GPs to establish eCPA care plan registers on their
computer networks, once issues of data security have been addressed.
Automation of form completion
It may be found in the future that greater utility can be provided by
including a greater level of automation into the forms. Already staff use
‘Autotext’ to store commonly used words and sentences. Future
developments could include drop down menus so that the diagnosis or the drug
dosage can be chosen from an on-screen listing, instead of having to be looked
up and then typed in full. The form could be programmed with predictive text
entry. It may be possible to adapt the form to link to a relational database
to allow data to be drawn from or exported to patient or case records.
However, most of these advances would probably involve bespoke programming and would be difficult to implement while the eCPA form remains in its current format as a standard Microsoft Word template. For the present, the advantage of almost universal compatibility when e-mailing the documents probably outweighs the advantages that these innovations might offer.
Conclusion
The simple act of placing the paper-based CPA care plan form into an electronic format brings considerable benefits to CMHT staff and patients, providing an inexpensive, rapid method of improving the quality and communication of the care plans. Furthermore, these eCPA care plans provide an ideal medium for the dissemination and adoption of good practice by CMHT staff. Practice notes and form-based working will never replace the skill and experience of the team, but can provide a helpful tool to promote good practice — and reduce the potential for errors and omissions.
Acknowledgments
We wish to thank the staff of St Giles Team 3 and Ward ES2 for their support with this project, as well as Professor E. Kuipers and Mr Patrick Phokeerdoss, among others, for the provision of good practice points for conversion into PracTips.
References
APPLEBY, L. (2000) Safer services: conclusion from the
report of the National Confidential Inquiry. Advances in
Psychiatric Treatment, 6,
5-15.
DEPARTMENT OF HEALTH (1999a) Effective Care Co-ordination in Mental Health Services: Modernising the Care Programme Approach. London: Department of Health.
DEPARTMENT OF HEALTH (1999b) Mental Health, National Services Framework, Modern Standards and Service Models. London: Department of Health.
DEPARTMENT OF HEALTH (2000) Data Protection Act 1998. Protection and Use of Patient Information. Health Service Circular, HSC 2000/009. London: Stationery Office. (http://www.doh.gov.uk/pdfs/009hsc.pdf )
KEMP, R., HAYWARD, P., APPLEWHAITE, G., et al
(1996) Compliance therapy in psychotic patients.
BMJ, 312,
345-349.
PALMER, C. & LELLIOTT, P. (2000) Encouraging the
implementation of clinical standards into practice. Psychiatric
Bulletin, 24,
90-93.
THORNICROFT, G. (2000) National Service Framework for
Mental Health. Psychiatric Bulletin,
24,
203-206.
WORLD HEALTH ORGANIZATION (1992) The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO.
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