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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
Spot on Sue, they are systems for administrative data not clinical systems.
A good friend of mine in the USA Dr Lyle Berkowitz and North Western University in Chicago has been doing some very interesting work on what sort of interfaces are best for clinicians, and the classic accounting grid we currently see in most EMR systems is not it.
My argument is that, until we have clinicians in senior leadership roles in the IT departments in hospitals and departments of health, this is what we will continue to see.
We also need proper training for clinicians on ehealth, and a career path for clinicians who want to spend time in this area. I have completed a certificate at the Harvard School of Public Health on “Leadership Strategies for Information technology in Health Care”. It had clinicians from around the world, but only me from Australia. US clinicians could then go on and do a residency in medical informatics, and even receive board certification in it. No such opportunity in Australia.
Bryan – I don’t think the ED projects have “fallen over” – it’s just that they have achieved what the “other stakeholders” wanted and not what clinicians need. They are information systems, not clinical documentation systems. Hospital managers want to be able to track interactions with the data, and measure KPIs. The system does that for them just fine. It’s just that there is no prioritisation of the time of clinicians – it’s just not seen as valuable – despite that fact that the clinical times drive the KPIs. COntrast the Nth AMerican culture that works around the clinicians with things like dictation and scribes – putting the clinician back at the bedside rather than at the computer.
Why do so many health IT projects fall over?
The banks do IT brilliantly, Medicare is good, but most hospital digital medical records (DMR) are hopeless. The old A4 history, with its tabs for OP, ED,GP letter, admission, progress notes with latest on top, means that in a minute one can get a real feel for a patient’s problems, and often find the solution, consultant to call (or GP) for info really easily.
Takes 3 times as long with the DMR. I have seen brilliant clinically driven systems in USA, with built in dictation, short cuts, auto-generated discharge letters faxed, and cross references to drug manuals, prescription software, integrates with path/imaging/ECG .
For some reason health (hospital) IT rarely really listens to clinicians, and when they do, it’s so often “cant be done” cost, compatibility, privacy, engineering, yet the business community, driven by finance, do it well.
I am fearful of the PECHR, as it is voluntary enrolment and patients will be able to delete/edit it. Why can’t each patient have a record integrated with Medicare data in the “cloud” backed up/accessed on a personally held USB?
I remember very well the “good old days” when clinicians played a much more active role in the design, selection and implementation of “ehealth” in our hospitals and clinics. The first decent GP application was written by a GP for GPs and in the hospital we developed systems around what the clinicians needed. This was often led by a few of us well intentioned but very overworked clinicians who saw patients and then went home and wrote code.
Unfortunately the ehealth agenda has been overtaken by the technologists and corporate types, and if you look at the ehealth departments of most hospitals and even worse, in state and federal health departments, you will find very few clinicians.
What we need is a resurgence of clinical leadership in these departments. In the USA they have Chief Medical Information Officers who work within the executive leadership of the hospitals and health departments to ensure the systems are clinically useful and relevant. We do not see that in Australia, and as a result we get ehealth implementations that are under utilsed, under powered, and even potentially dangerous. Time for us to take control of what is an integral part of the way we deliver healthcare in the 21st century.
Perhaps Dr Margelis is not aware of the years of work, submissions, development, committees and documentation done by emergency physicians and nurses in this area. The very first ED information systems in Australia were built with the knowledge and skill of clinicians. Unfortunately, the promised development has never taken the course that was promised, largely due to the issues Prof Patrick describes so well. We should not underestimate the effect of conflicting aims and secondary gain.
Dr Ieraci makes some relevant points, but I believe we should not be too quick to lay blame on these technology based solutions. We as clinicians should be taking a much more active role in the development and roll out of these information technology based solutions.
I know we are often not asked to be involved, or as is more often the case brought in as a last minute after thought, but that does not release us from our obligation to make more noise early on to ensure that these projects are both clinically focussed and also clinically led.
Complaining after the event does not help us or our patients. We need to take a more active role is defining what we want and need these systems to do, work with the developers to make sure the systems are safe, and then develop better models of care that utilise these technologies to provide our patients with better care.
We can no longer sit back and complain about these systems, it is time for us to take control of these systems and make sure they live up to their promise.