Shifting Toward Electronic Patient Records

By Dr. Irene Coulson, Joyce Johnson, Dr. Elaine Stokes, Queenie Choo

Technology is changing the way in which health care professionals document care practices. The Advisory Council on Health Infostructure in their 1999 report titled The Canada Health Infoway: Paths to Better Health, recognized that electronic health and patient records are fundamental to provincial and territorial health infrastructures and will become the key information and communication foundation in the 21st century (Advisory Council on Health Infostructure, 1999). In addition, the importance of electronic patient care records should not be underestimated because they have direct applications in patient care and can improve health system management and patient care outcomes (Annual Premiers Conference, 1999).

Introduction

The focus of this paper is on the electronic patient record (EPR), defined as a complete patient record accessible from a single, automated provider based system. In contrast, “an electronic health record is the record of an individual that is accessible online from many separate, interoperable automated systems within an electronic network” (Health Canada, 2001, p. 7). An overview of the challenges faced by long term care organizations in nurturing the adoption of EPRs, including training and support for users and the development of standards and practice will be presented.

The ideal EPR includes all the tools necessary to process, complete and view charts at a single workstation, without relying on multiple manuals or automated systems. Electronic patient records are expected to perform faster and provide greater productivity, convenience and seamless integration, and are often judged to a higher standard, when compared with the traditional paper chart.

The Movement toward Patient Electronic Records

The major factors promoting the transition from paper records to the EPR, include the demand by governments, health care providers and patients for increased continuity and accountability for the outcomes of care provided and the integration and sharing of information between health care professionals and/or organizations. In addition, there is greater mobility in tracking health information no matter regardless of where a person is located and when a health intervention is required (Health Canada, 2001). The literature proposes that governments and organizations in the future, may provide patients easier access to their own electronic files on a need to know basis, in order to promote a more comprehensive picture of their own health and to make informed decisions about their care (Mandl, Szolovits, Kohane, 2001). Lastly, EPRs provide easier and greater opportunities to conduct clinical and health research.

The National Health Service in the United Kingdom report that the benefits for their health care professionals are:

“Records are more likely to be legible, accurate, safe, secure, and available when required, and they can be readily and rapidly retrieved and communicated. They better integrate the latest information about a patient’s care, for example, from different departmental clinical systems in a hospital. In addition, they can be more readily analysed for audit, research and quality assurance purposes.” (Information for Health: An Information Strategy for the Modern NHS, 1998 in Health Canada, 2001, p. 12).

While there are many benefits in adopting EPRs, it is important to assure physicians and health care professionals that, until the system is completely implemented, the results and benefits cannot be fully evaluated and appreciated.

While these benefits are convincing, governments and health care providers are still grappling with best approaches to instituting EPRs in an organization, including the exclusion of some parts of the patient record not being converting to electronic. Issues such as understanding and ensuring the involvement of key stakeholders, training and support for users, and the development of standards and quality monitoring all play an important role, in how successful an organization will be in instituting EPRs.

Moreover, frequent developments in information technology bring rapid increasing processor power and greater storage capacity at ever reducing costs making it easier to depart from the traditional paper system (Health Canada , 2001, p. 6). The issue is no longer, should we do it, but how soon?

Purpose of Electronic Patient Records

The purpose of the patient record is to record health events that support clinical care provided to the patient. While there are many similarities between long term care and acute care institutions, care delivery models and processes are so different and unique they require different technology solutions and information management approaches when implementing the EPR (Catz, Bernardo, Phillips, Podolak, 2002). Care providers with different levels of education and expertise must input into a system that then gives the “essence” of a patient’s chronic care needs and progress and allows the interdisciplinary team to quickly review multiple aspects of care in order to reformulate a standardized care plan multiple times over a patient’s stay.

The medical, functional, psychological and social needs of the resident are within the context of the family/caregiver and the environment where the care is provided and the record should reflect the complexity and uniqueness of this care and the interdisciplinary nature of the care.

The record has to be current but also allow for the ability to review previous data easily, to follow progress over time, to allow examination of whether a particular standard of care has been achieved and to integrate with outside agencies to facilitate transfers or discharges. Often documentation must reflect the level of care required for specific clinical characteristics in order to maximize financial reimbursement. Most importantly data entry into the record has to be efficient and effective and not detract from direct patient care by any interdisciplinary team member including physicians.

Obtaining Key Stakeholder Support

The major key stakeholders in an organization include physicians and health care professionals who will use the electronic record system on a regular basis. Without involvement of key stakeholders in the adoption of EPRs, it will be difficult to convince them to use the system. Health Canada (2001) supports that a structured-change approach is required to support the implementation by bringing providers and users onside in the early stages, in order to accommodate a shift in thinking.

Physicians have been slow to adopt the electronic health record for a variety of reasons (Laerum, Ellingsen, Faxvaag, 2001). Physicians in long-term care face additional challenges in documentation whether using paper or electronic records. Often systems in long term care have been created to expedite the physician based processes and minimize the time required to document the patient/physician/team interaction with little understanding of why a particular decision was made.

Computerization is often viewed by the physician as increasing the time required for documentation without improving the quality of information in the record or quality of care provided to the patient. They are more likely to accept a system that involves their input from the beginning and that ultimately is seen as improving their productivity without jeopardizing the physician/patient relationship. The Canadian Medical Association in partnership with the Health Information Technology Committee has set out a discussion paper that identifies broad based principles and recommendations to guide the evolution of the electronic health record in Canada (Canadian Medical Association, 2002).

Electronic records ideally should integrate previous information into the admission database allowing efficient review by the admitting physician and should assist in the development of a clinical problem list that can be referred to over time with supporting data from the interdisciplinary team and investigations. Ongoing documentation should support the clinical rationale for decisions easily and should assist with clinical decision supports (e.g. medication ordering for specific conditions or specific formulary requirements).

The diversity of physician practice may be challenging and require unique coding characteristics in order to capture pertinent information into the active clinical problem list used by the entire care team. Use of physician alerts may actually improve the information reviewed, which may influence a particular clinical decision. Ultimately physicians like other health professionals need to feel that the computerized record is not getting rid of clinical reasoning but rather is a useful tool to follow patients with complex medical problems easily over a prolonged time frame.

Training and Support

Training and support can be expensive. One of the biggest challenges an organization faces in instituting EPRs is to ensure that users will have all the requisite skills necessary to use the system safely and effectively. Support includes those materials or areas that are required in order to support a user throughout the learning process. “In order for an individual to be computer literate, they need to define what a computer is, know how to operate a computer in order to perform professional tasks, and be aware of the social and ethical impact that the use of computer technology may have in individuals and society” (Anderson, 1992, p.10). While the adoption of EPRs is an exciting undertaking to institute, it is important that the organization commit resources to training and supporting users on an on-going basis.

People learning how to use computers for the first time can experience computer phobia, which produces anxiety and fear (Anderson, 1992). Although a new user can experience these feelings, they overcome them quickly and go on to enjoy the benefits of using the EPR. Users with no computer experience require a slightly longer training period to introduce them to the basic concepts of a computer, such as a mouse, keyboard and how to log in and out of a computer. In addition, a computer game can enhance inexperienced users on how to use a mouse effectively. Users who have a poor command of the English language will experience even greater challenges in using the keyboard and understanding the EPR. It is advisable when advertising for new staff to state that computer experience is an asset.

Although users can receive their training in one session, they may not necessarily use all of their newly formed skills once they return to work, leading to a loss of knowledge. A staged-developmental approach is effective in providing the user the time to integrate the skills into their practice. The staged-developmental approach includes one short training session in a computer lab, followed with several short practice sessions at the work-site. At the end of each session, the user is shadowed by an experienced user to ensure that the new user can demonstrate competency of the system accurately.

Users must have access to support systems to promote the learning and use of the EPR, when problems arise. While training is important, the use of support materials promotes users to maintain their computer skills. Support systems can include:

  1. EPR Quick Reference Help Manuals located near all computer terminals. Users should become familiar with them by using the manual during training sessions. Instruct users that they are expected to firstly refer to the Help Manual should a problem arise, then they call a co-worker for help.
  2. Advertise in the organization a list of EPR Coaches near the computer terminal to communicate to new users that they can call upon these people to assist them.
  3. Institute a User Hot Line to support users.
  4. Identify an email address where users can express their concerns and suggestions for improvements.

While training and support form the basic foundational framework toward the successful adoption of EPRs, the development of EPR standards is an important activity in ensuring that policies and procedures govern best practice throughout the organization.

Standards and Practice

Before instituting an EPR system it is advisable to develop a Standards and Practice Advisory Committee which aims to develop standards and policies that identify issues and concerns by users, to ensure consistency and continuity of practice through an auditing process, and to evaluate the system for its completeness and effectiveness in promoting the highest quality of care. The result of audits can be used for process improvement, as well as for future learning opportunities. The Standards and Practice Advisory Committee can include smaller subgroups to work on various issues that report to the larger committee. Areas such as privacy concerns, user procedures, access control and hardware requirements are important considerations.

Privacy is one of the most important policy areas that needs to be addressed in relation to EPRs (Health Canada, 2001). Mandl, Szolvovits, Kohane (2001, p. 2) express their concerns that patients are becoming more concerned about their EPR because data is being “shared with insurance companies, governments, researchers, employers, bureaus of vital statistics and pharmacy agencies”. Maintaining a very high level of security and confidentiality, including the detailed surveillance of system use, is of paramount importance to the successful implementation of the EPR.

Ensure that your organization has well-defined security policies in place to protect and recognize the rights of patients on the privacy of their record. Health Canada (2001) stipulates that practice must prevent accidental or deliberate access to the records it holds by unauthorized people or organizations. Policies should contain provisions that protect the interests of the institution and, at the same time, safeguard the rights of users and the legitimate interests of the public. Security measures must prevent unauthorised access to computer workstations and communication equipment through the use of:

Other standard and practice considerations should include:

Conclusion

The adoption of the EPR in an organization is challenging and can be costly. Catz et al. (2002) support that research to date has shown that the benefits of the EPR cannot be measured on a return on-investment basis. However the EPR provides increased accountability for the outcomes of care provided and the integration and sharing of information between organizations. Before starting out on this exciting adventure, ensure that you have the support of key stakeholders, that competent training and support have been established and that your organization has embarked on standards to ensure best practice approaches. While employees are inducted formally to the organization through an orientation process, physicians also need to experience the benefits, and have a stake in ensuring their clients are receiving high quality of care when visiting or using the EPR in their office.

Although not a focus of this paper, it is critically important to note that governments and health care organizations need to work collaboratively together to promote the development of potentially compatible systems. There is a “shared concern by most stakeholders that a lack of overall leadership, including national leadership, is resulting in the development of potentially incompatible systems” (Health Canada, 2001, p. 18).

Alberta Wellnet, the umbrella for regional initiatives, is currently building an integrated health information network in Alberta, which will facilitate improvements to the delivery of health services to Albertans by improving access to health information. It is hoped that such a network will promote information exchange in health care in order to foster the well-being of Albertans (www.albertawellnet.org/prjects4.html).

In conclusion, the EPR will always be judged to a higher standard when compared to a paper system, because of the achievements and progress organizations can make to improve quality of care using the system. Technological advances are also making it easier to institute the EPR; however, standards and practice must align itself with technology and implementation. No longer do we need to be confined by the structure and processes of a paper system.

References

Advisory Council on Health Infostructure. (1999) Canada Health Infoway: Paths to Better Health. Final Report, The Council's final report on the role of the Canada Health Infoway in the improvement of Canada's health care system.

Anderson, S. (1992). Computer Literacy for Health Care Professionals, Delmar Publishers Inc., United States of America.

Annual Premiers' Conference. (1999) Press Release. Québec City.

Canadian Medical Association. 2002. Advancing Electronic Health Records in Canada, Canadian Medical Association, www.cma.ca.

Catz, M. Bernardo, A. Phillips, A. Podolak, I. (2002). An Aging Population: Challenges to the Electronic Health Record Development and Health Informatics Community, Electronic Healthcare, Vol. 1, No. 3, 16- 23.

Health Canada (2001) Towards Electronic Health Records, Office of Health and the Information Highway, Health Canada, Ottawa.

Laerum, H. Ellingsen, G. Faxvaag, A. (2001). Doctors’ use of electronic medical records systems in hospitals: cross sectional survey, British Medical Journal, Vol. 323, pp. 1344-1348.

Mandl, K. Szolovits, P. Kohane, I. (2001). Public standards and patients’ control: how to keep electronic medical records accessible but private, British Medical Journal, Vol. 322, 283-287.

www.albertawellnet.org/prjects4.html: Alberta Wellnet, Improve health system management and accountability.