Everyone wants to go digital; it’s good, it’s modern, we must all be paperless. Welcome then the Electronic Patient Record. Great moves are underway to help hospitals go paperless in England, the USA and elsewhere.
Well, if you think it’s such a great idea read the recent Lancet paper by Martin and Sinsky. They provide a thoughtful and well-referenced account of the shortcomings of electronic records in hospital care. You will find it hard to think that clinical care is improved by such systems once you have read the article. On the contrary, the evidence points the other way – these things actually impede good quality clinical care. One (perhaps the) reason is that they have become subverted. Instead of providing an information system for clinical care in real time, they have been heavily adapted to serve another master – the quality control industry.
The problem arises when clinical records (patient’s history, physical exam and progress) are digitised along with the easy stuff (electronic prescribing, laboratory results, scheduling) to create the all-singing, all-dancing electronic health record. There is a big difference between isolated systems performing particular tasks, such as digitising x-ray images, and going whole scale paperless. The critical point here concerns the ‘cognitive space’ where clinicians can show how their thought processes unfold. I guess that having the notes built around medical reasoning, rather than the tick box appetite of quality control procedures, helps in two ways. First, recording thoughts assists cognitive processes, as in writing down a list of differential diagnoses. Second, it helps others latch onto the story so far. These needs are brought out beautifully in the article, which chronicles the near unmitigated disaster that current electronic notes have become. The authors cite studies documenting the harm that modern electronic records do, and back these up with powerful anecdotes.
We health care professionals promote evidence-based decision-making, yet we are allowing ourselves to be sleepwalked into a poorly evaluated but massive intervention. Such evidence as the article can reference suggests that, far from assisting good care, electronic records (in their current form anyway) are inimical to it. We do enormous and expensive trials to find out whether we can extend life by a few months in an uncommon disease, but we let this potential monster intrude in a near evaluation vacuum. Maybe the question is how, rather than whether, electronic records should be used. In that case it seems clear that our target should be to find out how, since we clearly do not know how.
We need much more development and evaluation work on the design of electronic notes, configuration of services and the interaction between them. A way must be found to resolve the tension between all the other (‘secondary’) functions the notes perform and the real-time clinical care functions that current electronic systems have been shown to subvert. The suggestions made in the article are all extremely sensible. They privilege the clinical, and that is convivial to the clinical heart that beats inside my breast. But the constituencies who want to use notes for various organisational, quality control, and research purposes have not gone away. It seems that we cannot redesign the notes without at least considering these other putative needs. Our task is not complete if we just define what is needed for good clinical care in real time because social pressures to monitor health care providers in general, and doctors in particular, are not going away any time soon. There are three broad possibilities:
- Design the IT system so that it can both serve as a seamless record for real-time clinical care, and capture information for secondary purposes. This is unlikely to succeed given the evidence led in the article; a trade-off is all but inevitable between clinical prerogatives and wider organisational and social needs.
- Jettison the wider functions of audit and so on, and privilege the real time clinical care need. But we are not going to get away with this unless, at the very least, it can be shown that the ‘costs’ of collecting ancillary information exceeds its expected benefit.
- Change not just the structure of the electronic notes, but also work patterns and the personnel who enter different types of data. That is to say, it may be cost effective to re-engineer human resource and computer systems to separate, to a degree, entry and presentation of data for real time clinical care purposes and the data needed for ‘secondary’ purposes.
A great deal of research and development will be needed to achieve a near optimal system and the Industry would need to be incentivised to engage in such a process. That said, I suspect that much development and evaluation could be done off-line under simulation conditions. What is absolutely clear is that when coming to digitisation of health care records, we are embarking on one of the greatest socio-technical innovations ever undertaken. Information technology must interact with an extremely complex, subtle, and only partially understood healthcare environment. There is a clear role for CLAHRCs in this exercise, and our particular CLAHRC is collaborating with Prof Aziz Sheikh and colleagues in NIHR-sponsored work on introduction of IT systems in the NHS. In the meantime, people who implement IT systems should tread very gently – no place here for macho types who think they know it all. Careful, deliberate and patient R&D has produced, in the end, unimagined advances in medical care. Let the same sense of modesty guide our fledgling understanding of the information requirements of health care.
— Richard Lilford, CLAHRC WM Director
- Martin SA, & Sinsky CA. The map is not the territory: medical records and 21st century practice. Lancet. 2016; [ePub].