Sue Ieraci: IT doubts

THERE has been a lot of discussion recently about the Personally Controlled Electronic Health Record, particularly concerns about whether it is ready and who will manage it, privacy risks and potential errors.

However, overall there seems to be agreement that this is a step in the right direction.

It’s easy to get swept up in the enthusiasm for new technology. But can we be confident that the new is always better than the old? Is electronic always better than manual?

There are lessons from the live information system experiment that has been ongoing in Australian hospital emergency departments (EDs) since the early 1990s.

Creating an electronic information system for a complex workplace is no simple matter — but a few principles should be clarified from the outset.

The crucial question is: what is the aim of your system? An information system where the primary aim is to collect data will be quite different in design and functionality to one designed as a documentation system for clinical staff.

An attempt to compromise may result in a system that does neither job well.

A recent review of the ED information system used in NSW has documented a litany of complaints from users.

Professor Jon Patrick, of the University of Sydney Health Information Technology Research Laboratory, found serious problems with both software design and system implementation.

One of the main issues is that, as a documentation system, the input required from clinicians is both slower and more cumbersome than writing on paper, taking clinicians’ time away from patient care.

This has been worsened by a work-practice model that requires documentation, coding and letter-writing — all in real time and before patient discharge.

Even more concerning, however, is this finding from an addendum to Professor Patrick’s review: “All the evidence points to the fact that this clinical information system has not improved our ED services because it wastes staff time and increases risks to patient safety.”

Professor Patrick refers perceptively to the phenomenon of “secondary gain” — where an overall unsatisfactory system does produce some side benefits “that some parts of the enterprise obtain when another essential part is put at a disadvantage or deficit”.

He writes: “However, the real danger is that the gain becomes a structurally embedded advantage where the damage is ignored because of the benefit of the secondary gain. In the case of a dysfunctional clinical information system the secondary gain ensures the non-primary users of that system have some reward without them recognising their gain is produced from a system outside of their organisational area that is damaging to the primary user group. The separation enables the beneficiaries of the secondary gain to ignore or remain ignorant of the problems with the primary context. If this gain becomes too embedded for the beneficiaries then the dysfunctional situation will remain for many years without recourse for the penalised community.”

Let’s progress towards a fully electronic health system with caution.

As Professor Patrick observed, “There was a general belief that this move to a more modern system was a good thing.”

But is it?

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

Posted 20 August 2012