The Pursuit of Electronic Medical Records (EMRs): A study of the implementation of an EMR in Canada Dr. Nina Boulus-Rødje Assistant Professor, IT University of Copenhagen
Context: empirical research q ACTION for Health: The role of technology in production, consumption and use of health information: implication for policy and practice. q $3 million grant= Canadian & international researchers partnering w/ organizations q Funded through Social Science Humanities Research Council of Canada (SSHRC). Nina Boulus, Research Assistant! ACTION for Health, School of Communication! 8888 University Drive, Burnaby. B.C.! Electronic Medical Records (EMR)!!
3 sub-projects 1) EMRs in other clinics o Aim: Explore experience of other clinics that implemented the same EMR system o Motivation: identify lessons learned 2) Patient study o Aim: Explore patients views about the EMR system o Motivation: inform about the planed transition+ address patients concerns 3) EMRs in community partner s clinic o Aim: Identify sociotechnical change brought about by the transition to EMR
Community partner & field site Clinic: Staff: Non-profit community health centre in Vancouver 6-8 GPs, chronic disease coordinator, clinical pharmacist, 2 nurses; medical office administrator, 3-4 secretaries, etc. Health care model: Medical + dental care Diverse services Multidisciplinary, team-based approach Patients: 5000; many with low SES; multicultural; complex patients
Interviews Observations 10 sessions (29 h) Participation in (in)formal meetings 16 Clinic staff (1-2.5 h); 22 patients (15-45 min); 2 IT vendor & decision maker (1 h); EMR meetings 29 meetings (1-2 h) Informal conversations Seminars 8 (1.5-2.5 h): clinical meetings; medical team meetings; meetings w/the vendor; meetings between vendor & clinic Various clinic staff & IT vendor EMR training 3 sessions (18.5 h) Document collection & analysis Empirical data 4 seminars (organized by the health authority/ vendor) (38 h) e.g., patient feedback, meeting minutes, emails, memos, reports, project plans, media coverage and policy documents.
exam room Exam room 138 sq. ft. Observation sessions WC Front desk, reception area 25 sq. ft. Charting room exam room Exam room 113 sq. ft. Office Enterance 94 sq. ft. exam room Exam room 113 sq. ft. Charting room exam room Exam room 106 sq. ft. exam room Exam room 94 sq. ft. Office Charting 244 room sq. ft. Charting room Scanning area office manager Office manager 106 sq. ft. Patient waiting area Patient waiting area 310 sq. ft.
Electronic Medical Records (EMR) What does an EMR mean? How does it look like?
o Annual cost reduction o Better access to patient information o Reducing medical error o Increase efficiency o Improve quality of health services = Benefits measurable in financial terms EMR visions
ICTs in healthcare: High investments Canada USA England Norway Sweden Denmark ICTs= A facilitator for, and measurement of, success More IT for better health care Australia The Netherland
EMR: Media & Policy discourse ICTs: spreading in various indurstries, but the health care sector is lagging behind o Health care practitioners have to manage complex 21st century medical information with a 19th century paperwork system (The White House, Technology agenda) o Converting medical records to electronic records will improve efficiency, save money, and save lives (The White House, 2009)
The electronic medical record [EMR] has been pursued as an ideal by so many, for so long, that some suggest that it has become the Holy Grail of Medical Informatics (Kay and Purves, 1996, p. 73).
EMRs- Portrayed as holy grail of health- care sector (Kay et al., 1996, p. 72) jewel in our crown (Romanow, 2002, p. 78) Despite billions of dollars spent every year on Canada s public health- care system, record keeping has remained largely rooted in the technological stone age (Mickleburgh,
Media & Policy discourse: Summary o Simplistic= Technology is reduced to a mere instrument Need better understanding of complex sociotechnical changes brought about by these technologies
What does an EMR mean? o Many different terms, e.g. Electronic medical record (EMR), Computerized patient record (CPR), Electronic patient record (EPR), Patient care information system (PCIS), etc. o The content of the medical record is not defined universallyà many terms are used inconsistently. o EMR: A record that focuses on medical care within one enterprise.
Unclear definition, but... Universal agreement about the need for EMRs: "Today we have documented evidence that because physicians at times just don't have the right information, we have between 9,000 to 24,000 deaths- a lot of that caused through adverse drug interaction" "Sadly enough, a lot of that is preventable" EMRs= Vehicles to saving lives (Richard Alvarez, the president and chief executive office of Canada Health Infoway. Avery, 2007).
5-year-cost-benefit analysis the net benefit of implementing a full electronic medical record system was $86,400 per provider. Of this amount, savings in drug expenditures made up the largest proportion of the benefits (33% of the total). Of the remaining categories, almost half of the total savings came from decreased radiology utilization (17%), decreased billing errors (15%), and improvements in charge capture (15%) (Wang, Middleton, Prosser, Bardon, Spurr, Carchidi, Kittler, Goldszer, Fairchild, Sussman, Kuperman, & Bates, 2003, p. 400)
EMR literature o Underestimates complexity of EMRs o Developing health care technologies are more complex than putting a man on the moon (Collen, 1995). o Therefore, we need more qualitative ethnographic research of real-life case studies
Underlying aims of this study o Move beyond measuring efficiency & cost to providing a more granular description of the role EMR is playing in delivery of care o The implementation of the EMR= dynamic process where the technology+ the organization (medical practice) affect each other and transform one another.
Research question: EMR How does the technology transform the medical practice, and how do the health care practitioners configure and adapt the technology to the existing situated work practices?
Sociotechnical Changes & Implications Initial changesà straightforward, direct and immediate effects. Emergent changesà higher and deeper level of impact, and broader implications in the long term.
Performance Amount, type & format of information Amount of tasks required to complete a patient trajectory Division of labour/distribution of work Presentation of workload Responsibilities & interdependencies Initial Changes: / Immediate implications: Documentation activities (implications: info becomes traceable) SOAP template: transition from free text à structured entry (intro of new charting practice) Decrease articulation work (informal work: coordinating & sorting information) especially for secretaries who are gradually exercising higher degree of responsibility for advanced tasks. Increase articulation work for doctors From paper pilesà electronic lists (masked behind the screen) Removal of sorting & buffering mechanisms (e.g., lab results sorted into normal/abnormal)
Free-text handwritten notesà SOAP
2.5 years later o Increased EMR-knowledge & experience o Stabilization o # of challenges decreased o Focus shifted: how to do things à this is how things can be done o More proactive engagement w/the EMR
Emergent changes o Beside changes in performance, workload, workflow, etc. o Emergent changes: higher & deeper level of impact & broader implications in the long term
o Practice search : function to run queries Emergent Changes: / Broad implications: o Overview of particular type of patient s population (e.g., diabetic patients) o Capture all patients+ inactive patients o The creation of rules for reminders o Practice search & rules o Graphs: Visual repr. of patient s progress over time (e.g., BP) o Automation of former coordination mechanism (e.g., follow-up exam) o Responsibilities delegated: from dr. & patients à EMR o Holistic & accurate view of a whole population; previously unseen o Enabling monitoring demographics & long-term changes in disease patterns o Shuffling through chartsà graphs o Type of data: numericalà visual info o Sheds a light on patters that were invisible. o Data interpretation/translation: delegated from Dr. & patients à Dr. & EMR
Graphs Wolf Medical Systems
Emergent Changes: / Broad implications: o Standardized charting & billing o SOAP template à structured content approach o Enhanced Point of Care Charting (POC) o Decrease in the number of tasks & staff involved in articulation work o Access to internet & graphs o Ensuring performance measures, medical legacy & outcomes analysis. o Constraining flexibility in charting practices o Contextualizing individual patients within the larger population. o But à limiting analyses of multiple problems o Fulfilling expected formal & legal charting practice o Quicker task-handling & increased accessibility to infoà lead to faster decisions & actions o Speed & intensity increased, but discouraging from conducting in-depth analysis. o Promoted active engagement of patients o Introduced new roles for doctors
Select findings 1. Impacting the structure & content carried by the technology o Away from free text handwritten notes structured entry o Limits General Practitioners (GPs) to 1 complaint per visit 2. Impacting the roles of those using the medium o Redefining roles of Medical Office Assistants (secretaries ) o Reorganized patient-provider interactions 3. Impacting the ways GPs think o Different reflection & cognitive skills (accurate & linear) o Increased speed & intensity of decision making process 4. Enabling new kinds of practices o Practice search : provides overview of particular patient populations
Summary & Concluding Remarks Some lessons to inform your project work: o Important to investigate visions but also to align them to practices o Sociotechnical: Can t focus solely on technical aspects (introduction of new practices). Technology changes not only work practices but also how doctors think! o Qualitative: Can t focus solely on measurable benefits o Context: important: Need a better understanding of the socially organized character of work setting
Thank you for listening! Questions/Comments? Dr. Nina Boulus-Rødje Assistant Professor Technologies in Practice (TiP) http://www.itu.dk/tip IT University of Copenhagen nbou@itu.dk