Table 3 Perceived impact on patient safety

“There are probably three or four hospitals that patients might go to that I won't be able to see anything. How it impacts, some of it is small things like having to repeat blood tests to make sure that somebody's safe. Sometimes it's […] repeating scans that you otherwise wouldn't have done if you'd have known that result… […]” – Participant 1

“So I think it's [poor interoperability] a major problem actually. So almost any sphere where you need patient information, there is a safety element to that and anywhere where that information is getting summarised, or handed over, or transcribed, or recoded, there's an element of error in all of that, and an element of loss in all of that. So almost any safety element is magnified by that lack of interoperability. The classic and most obvious one is around medication. So quite often when you get that transfer, you get a list of current medication. So for us quite often we know what medication somebody had before they went into hospital and what they came out on, but what you don't get so much of is why those changes were made. What was stopped, why it was stopped, what was restarted, why was it restarted, why the changes were made. So you don't know if they were to do with a patient factor or a system factor. So automatic switches for cost reasons. You don't know if the change was for a cost reason or because of a patient factor such as side-effects. Anything where you've got to hand over of a task as well. So it relies on someone reading a letter, so there's a manual process in reading it, in picking out the task, and ensuring the task will happen. Whereas if you're using the same system, actually the task comes and actually sits in an inbox for you and it doesn't go away until you action it. So again, it's quite easy to miss actions passing from one organisation to another or follow up as a result of those actions.” – Participant 5

“But now we've got the GP shared record, I can get an updated list of their previous attendance, recent attendances, medications, allergies, all from just sharing that record. So that's got to be beneficial for patient safety because if they're presented unconscious, but I know who they are, what their NHS identifiable is, who their record is. I can look in their GP record and look for allergies, what medications have been on recently, which may have caused them to deteriorate and also about end-of-life care wishes. […] Because we can share information about end of life care then I can maybe provide more appropriate care for the individual at the end of life, whereas before, if they've been very sick, we may not know what their end of life wishes are, but because we're sharing that information now, then we can provide more appropriate care targeted.” – Participant 7

“We have so many care systems which are now, rely on having information from the shared care record and they can make better decisions if they can see what's in the shared care record, so if it's not there then it's more risky. […] You can't rely on it having a complete set of data, so you still need to talk through with the patient, but it does alert you to things which are there. There are still risks. You still need to check that medications are correct because there's holes in the medication record there, because that's just the GP record, but it doesn't tell you anything about someone who might be under the drug and alcohol service for example, because that's a different service and doesn't feed into our record. It doesn't tell you if a secondary care physician, even in the same hospital, has given them medication on an outpatient discharge or anything like that, so the risks are more about the data that isn't there, and not being aware that that data isn't there.” – Participant 10

“We have had zero interoperability and now we have some. So I think my workflow, and all of my colleagues', accounts for that. Which is when I see you, whatever information I have, I will review with the patient, and I will fill in the blanks. So, I do not think the lack of interoperability and information impacts safety directly, for our service. I think it causes an efficiency problem. […] I think in terms of chronic disease management, I do not see huge safety risks. […] I struggle to think of direct harms that occur due to a lack of interoperability. I can see delays in ongoing care optimisation. I can see efficiency losses and I can see degradation to the staff and the patient experience.” – Participant 12

“How else, in terms of safety? I think the other thing is not having clarity on the management plan—so delays in information which comes through from hospital, from secondary care. […] We typically get patients coming back from a hospital appointment going, 'A doctor's given me a new yellow pill: can you prescribe it?' 'What is it?' We don't know. There's quite a number of issues in terms of medication errors.” – Participant 14