Hospital physicians' tasks and the use and nonuse of EHR-system functions

Transcription

1 Hospital physicians' tasks and the use and nonuse of EHR-system functions Associate professor Arild Faxvaag Norwegian centre for electronic health records research (NSEP) Faculty of medicine, NTNU 1

2 learning aims (suggested) get basic insight in some characteristics of hospital physicians work and its relevance to hospital physicians use of EHR-systems get insight in a survey method for collecting data from EHR-system users on their use of the system strengths and weaknesses of this method get insight in example results from the application of this method on Norwegian hospital physicians and what these results may imply for the further development of hospital EHR-systems 2

3 content (1) brief history of (hospital) medical records health records vs. EHR-systems EHR-systems epidemiology the situation of hospital EHR-systems at the global level hospital EHR-systems from the perspective of the users hospital physicians use of EHR-systems the use of EHR-systems by other personnel hospital EHR-systems from other perspectives the motivation for our research hospital physicians functions and functionings other characteristics of hospital work 3

4 content (2) what we did what we found how we interpret the results Implications for implications for developers / EHR-system developers what we plan to do next 4

5 some terms and definitions EHR = repository of information regarding the health of a subject of care in computer processable form EHR-system = computer application for obtaining, archiving and distributing EHR s 5

6 very brief history of (hospital) medical records from earliest times, the ideas of ill health and its treatment have been wedded to those of the observation and interpretation of data * in the beginning, one medical record per department / senior physician (physicians kept their own records) then development towards hospital-wide medical records but records tailored to particular departments still common subsequent widening of scope of record -> health record as more professions started using the record also: development from medical record to patient record patient-centered *Shortcliffe et al. medical informatics 6

7 health records vs. EHR-systems the distinction between EHR s and EHR-systems very often become obfuscated therefore AGAIN: EHR (the record, the information) EHR-systems (systems for obtaining, storing and using EHRs) 7

8 means of presenting knowledge on (the effect of) hospital EHR s / EHR-systems from the epidemiologist s perspective the incidence and prevalence of EHR-systems i Norway from the perspective of the actors centred around the EHR and the EHRsystem the ecosystem around EHR-systems (actor-network theory) with an anatomist s and physiologist s perspective an EHR-system has the following components, and these components have the following functions from a life-cycle perspective how EHR-systems get born, grow up and die with the perspective of the aim / purpose of the entire healthcare system patient-centred, informed, based on consence from the patient, knowledge based, of highest possible quality, cost-effective, continuous, same access for poor as for rich 8

9 EHR-systems epidemiology people have envisioned the potential of EHR s and EHR-systems since the 1960 s has the potential to become the most important Electronic Health Record (EHR) systems provide the kernel application of health information systems and health networks which should be independent of complexity, localisation constraints, platforms, protocols, etc. The Electronic Health Record (EHR) is a secure, real-time, point-of-care, patientcentric information resource for clinicians. The EHR aids clinicians decisionmaking by providing access to patient health record information where and when they need it and by incorporating evidence-based decision support. The EHR automates and streamlines the clinician s workflow, closing loops in communication and response that result in delays or gaps in care. The EHR also supports the collection of data for uses other than direct clinical care, such as billing, quality management, outcomes reporting, resource planning, and public health disease surveillance and reporting. 9

10 the situation of hospital EHR-systems at the global level Norway England Japan Denmark Holland Finland Australia France Begium Clinical support services Clinical decision support systems Non National Non Pilots National National Pilots Non Pilots Clinical data collection from EPR Pilots Nat/Loc Local National Regional National National Nat/Loc National EHR dissemination Hospitals >90 <10 ~20 ~20 ~50 >90 ~10 <10 >90 General practice >90 ~80 ~10 >90 >90 ~50 ~80 ~30 ~80 10

11 hospital EHR-systems from the perspective of the users the tools perspective: An EHR-system is a tool that assists the user when he conducts his job EHR-systems shall support the users so that they can perform their work according to national laws and international standards the role / actor perspective the EHR-system has a role, it is an actor at the healthcare scenario introduction of this role changes the roles of the other actors 11

12 hospital physicians two principal functions medical problem solving the act of analyzing symptoms, signs and laboratory analysis results to (1) determine whether these are caused by an underlying disease, (2) to postulate a candidate disease and (3) to identify the associated health risks clinical decision making to seek to manage the risks by planning and undertaking a disease intervention 12

13 hospital physicians two principal functions medical problem solving the act of analyzing symptoms, signs and laboratory analysis results to (1) determine whether these are caused by an underlying disease, (2) to postulate a candidate disease and (3) to identify the associated health risks clinical decision making to seek to manage the risks by planning and undertaking a disease intervention 13

14 more on medical problem solving Three major medical trends have escalated the problem of finding and making inferences from patient data. First, the rise of chronic diseases due partly to the ageing population means that the average patient now has more data in their files than ever before only some of which will be relevant to each consultation and decision. Second, the technology revolution has expanded the number of medical tests which can be ordered and used during diagnosis or monitoring of illness. Third, the development and spread of medical imaging techniques increases their use in routine clinical practice. More information potentially leads to more precise medical judgements, but also challenges the retrieval and interpretation capacities of the information user 14

15 more on clinical decision making During clinical decision making, health professionals collect and use three principal types of information: evidence distilled from the medical knowledge base, information collected from the patient in real-time and information about the patient which has been collected previously (and archived in electronic records) Numerous studies have shown that the clinical decision process underpins a high quality of care but is time consuming and prone to error. Tools that simplify the identification and use of relevant medical knowledge are being developed under the umbrella of evidence-based medicine. Health professionals train for years to develop the skills necessary to capture relevant subjective and objective findings from their patients. What lags behind is techniques to help doctors and other health professionals find and then interpret relevant patient information from records 15

16 more characteristics of hospital physicians functionings healthcare services are provided by individuals not by institutions poor quality of work may have very bad consequences for the care recipient.. and possibly also for the caregiver having a disease implies to be exposed to risk of losing one s health to be the subject of a disease intervention implies to be exposed to risks of adverse events and other unfavourable outcomes it is of the uttermost importance that those who make the crucial decisions have the best available tools. 16

17 therefore the most important perspective on the EHR-system is that of the user (as problem solver and decision maker) (and I tend to get mad at those that don t understand) users experiences are important outcomes of EHR-system implementation projects which leads us to the problem on how to achieve insight in users use of EHR-systems 17

18 whom The KVALIS project, (it s www remains are located at Hallvard Lærum, Gunnar Ellingsen, Eric Monteiro, Stein Samstad, Aksel H Tjora, Arild Faxvaag Jan-Tore Lium 18

19 what we did developed and a questionnaire with 22 questions / items that (a) are representative for hospital physicians information-related tasks (b) interrogates whether the user uses the EHR-system when conducting that particular task and (c) whether the EHR-system assist the user when he conducts the task. 19

20 national survey in 2001 Large variation between different hospitals and EHR systems! Many functions were not in use. Lærum H, Ellingsen G, Faxvaag A. Doctors' use of electronic medical records systems in hospitals: cross sectional survey BMJ 2001; 323: ( 20

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23 from 2001 (paper record still present) to 2002 (in a hospital where the paper record was withdrawn from clinical workflow) EHR-system becomes more important More functions are used when physicians have access to the paper record, the old habits prevail Lærum H, Karlsen T, Faxvaag A. Effects of scanning and eliminating paper-based medical records on hospital physicians' clinical work practice.jamia 2003; Nov-Dec;10(6):

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25 25 the use of EHR-systems by nurses

26 26 the use of EHR-systems by medical secretaries

27 removing the paper requires good basic EHRsystem functionality Change of ease of performing task Task 1 Task 2 Task 1 Task 2 Task 1 Task 2 Task 1 Task 2 Task 1 Task 2 Task 1 Task 2 Internal medicine Internal med and surg. Internal medicine Dermatology Dermatology Dermatology Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 27

28 results from interviews with users Greater benefits when everybody use the system As long as I ve been a physician here I ve used Dips so I don t know about other systems at all. I did my internship at another hospital that also had Dips, but they didn t use all the functionality we do here [at Hospital North]. And it was definitively things I missed at that hospital which I use here. For instance, we didn t enter medications in Dips and didn t write medical charts in the same way (Hospital North, resident 1) Better support of freshmen than of more experienced physicians Logging onto the EMR-system is the first thing I do when I come to work. To check which patients have arrived at the ward, I can read up on the patients before I go to the morning briefing, read the arrival notes, I can read the nurses report if I want to. [...] Various test results [and] medications I get from the arrival note, but I can check [in the EMR] if I want to (Hospital North, resident 1) 28

29 29 The EMR-system was useful in regard to professional learning The EMR-system made it easy to either call a chief physician who could look up the patient s case history in the EMR, or (in less urgent cases) send an electronic note to a chief physician who would see the memo in his work-list and could look up the case when he had time. Further, if someone needed a specialist to interpret an x-ray image and the physician in question was at the operating theatre, the picture could be displayed on screen in the theatre. So, in the same way as the EMR-system was useful to support quick answers to external calls about inpatients, they also were useful to facilitate questions amongst professionals within the hospital. On learning to use the system When we arrived, a resident at the surgical department gave us a short introduction to Dips. This was nice, since a lot of us didn t know anything about the system to begin with. And then it becomes sort of gradually.., you sit next to someone who knows a lot, and suddenly.., things go even smoother [in regard to using the system]. (Hospital South, intern 1)

30 30 Yongsters vs. the elderly We youngsters might catch certain computer issues faster than they do [senior physicians]. That s just the way it is. However, it s nice to have the advantage there compared to a lot of other stuff... (Hospital South, intern 3) More text, less information? For the patients who have been at the ward for a long time there are a lot of documents named journal notes. And that could be anything from those two lines beginning with [medication] because of this or that, to long comprehensive notes that are very useful. [ ] The thing with Dips is that for patients moving in and out the hospital a lot, it s hard to find what you look for. You get these long lists of notes. And journal notes are hard to find, so then the paper journal might be easier, because you often have a summary up front. And yes, you browse faster through paper compared to opening note after note on the computer, which also might be a slow one... (Hospital South, intern 2) Little or no support for mobile work As for mobile platforms, both departments had earlier tested the use of laptop computers and wireless network. However, the physicians reported that walking around with these laptops hindered rather than supported their work, and such solutions were rarely used. Also, they said that while the medical chart was still on paper, mobile solutions were of modest benefit.

31 comparison with the past Well, I like to focus on the positive aspects, so I think that life.., by having the information available at any time, that s, it s a completely new life. I mean, as a specialist, in an area with a lot of patients, you get a lot of questions from physicians out there [GP s etc], and by not having to request the paper medical record, but having the information instantly, it s a totally different situation, a completely new world. (Hospital South, senior 1) 31

32 conclusion feel free to contact for more info. 32