Australia’s first National study of Electronic Medical Record Systems (EMRs) has identified issues that contribute to fatigue, burnout and increased errors.
Medical records are a collection of complete and accurate information about a patient’s healthcare. Ready access to a patient’s medical record maximises the quality and efficiency of treatments healthcare professionals can provide.
Now part of the daily workflow in the acute and primary care sectors in Australia, EMRs are replacing paper-based medical records by electronically documenting the information relevant to a patient’s healthcare.
A large-scale study, led by Griffith University and published in The International Journal of Medical Informatics, captured views and highlighted issues experienced by medical, nursing and allied health professionals across the acute, primary and community care sectors. Results showed technical and quality features were more positively experienced by doctors in the primary care sector than nurses, as well as ease of obtaining patient information and prevention of errors.
In the hospital sector, nurses’ experiences with EMRs were more positive with regards to support for routine task completion, learnability, ease of obtaining patient information and entry of patient data.
Medical professional respondents working in the hospital sector were less satisfied with usability features than their primary care counterparts (routine task completion, prevention of errors, medication mistakes, patient data).
IMPEDIMENTS TO COLLABORATION
One of the key issues highlighted in the study is limitations to EMR system usability in the workplace.
“Usability features of information exchange and collaboration for clinicians across services and with patients is critical to reduce complications such as missed care, medication errors, compliance, and re-presentation,” said Dr Sheree Lloyd from Griffith University’s School of Applied Psychology. “As well as the likelihood of increased errors, problems with EMRs can lead to fatigue and burnout.”
A comment from Dr Chris Bain, a Professor of Practice in Digital Health at Monash University, suggests this may be a legacy issue. “EMRs have traditionally targeted the role of doctors and have been designed from a biomedical perspective but now there’s much more emphasis on a collaborative approach to health and wellbeing with a variety of clinicians providing medical care to patients.”
With hands-on experience, Adelaide’s Dr Ben LaHood has observed several shortfalls in the system design.
“I completely agree with the findings and concerns raised about EMR in the hospital sector. Having worked through the roll out of an EMR system in an ophthalmology outpatient clinic and theatre, the impact on workflow and decreased efficiency was significant and ongoing. Public hospital EMR systems generally have to be used in many settings; from operating theatres, to intensive care and outpatient clinics. This makes them bulky, slow and feel as though, as a specialist, you are a square peg being forced to fit in a round hole. There is some room for customisation but not to the extent that a single specialty primary healthcare setting could manage in order to increase efficiency and user experience,” said Dr LaHood.
He continued, “The study identified concerns with usability and one major part of that for ophthalmology is accessing and comparing medical imaging. We are one of the only specialties in the hospital that basically run our own medical imaging department with optical coherence tomography, visual fields, and an increasing number of other devices. These must be able to be rapidly viewed and compared. Unlike other departments of a hospital, which rely on their radiology departments and must have smooth integration of imaging, ophthalmology departments will rarely have this imaging integrated into their EMR and so must continuously be using parallel programs, describing findings in EMR records and yet no longer with the ability to draw findings in paper notes.”
This is something that also bothers Sydney Ophthalmologist Dr Daya Sharma.
While acknowledging that EMRs are a natural progression to record keeping and data management he said, “In my experience in ophthalmology, they have not been suitable for the diagrammatic notes that ophthalmic professionals are trained with and use to communicate information – ‘one picture is worth a thousand words’, as they say.”
Dr Sharma added, “Despite devising templates with leading and frequently used Australian medical EMR providers, I have found that paper records are much more efficient to write in and understand when working with other specialists. A page of text can translate into a quarter page diagram.”
Dr LaHood said the way clinic notes are presented and accessed could also be improved to deliver efficiencies.
“Another proposed improvement with EMR was more efficient collaboration. While it is great to see real time updates of clinic notes from various specialists, the EMR user is generally faced with screens of documents which must be clicked through to find what they are after. A cataract surgery produces over ten individual files and only one of these has information about the implanted lens. These may seem like minor inconveniences but when many of these inefficiencies are compounded, this means less face time with patients and ultimately fewer patients are seen.”
AGE A FACTOR
Another factor that researchers found may impede usability is respondents being largely older, more experienced clinicians who, prior to EMR implementation, were likely expert users of paper-based record systems.
This finding has been supported by NSW South Coast ophthalmologist Dr Smita Agarwal. “It was much easier and faster for us to use paper as we were trained that way, and our older colleagues struggled a lot to adapt to technology, which slowed them down when writing operative notes or ordering drugs etc. However, today’s generation gets tired if they have to use their pen instead of fingers to type. The EMR system is still evolving and while anything new has its teething problems, inevitably people find their way and adapt.”
Acknowledging the benefits of the EMR system, including legibility of notes which reduces the risk of mistakes, Dr Agarwal said, “Obviously with EMR, we need robust backups in case of hacking or breakdowns of computers. Personally, I have gotten used to it in the hospital systems, however in private rooms I still have a dual system to avoid electricity or network failure, which I have had twice in the past when we had to re-schedule the patients.”
Optometry has experienced the same teething problems with introducing EMRs, though optometrist and Head of Professional Services for George & Matilda, Dr Margaret Lam says the challenges of bedding down the system have been well worthwhile.
“Practitioners that have learned or, up until now, trained on paper record systems, can find it initially difficult to work with electronic recording systems. However once the benefits and useability are explained, they generally see the improvement in record keeping and potential for increased shared record keeping and collaboration with other health care professionals,” she said.
“EMRs definitely allow more consistent, legible, and higher quality record keeping to be upheld as a practice standard and with greater efficiency, especially through the use of hot keys, pick lists and other ways, they can customise or automate their record keeping.
“In the context of medicolegal protection, where your patient care is only as good as your record keeping practises, it is an important consideration for a practitioner to ensure they’re using the best record keeping resources and taking the best record keeping steps they have, whether it happens to be paper-based or electronic,” Dr Lam said.
HERE TO STAY
Dr LaHood acknowledged that EMR systems are here to stay.
“They clearly have their advantages in ophthalmology, such as reviewing records in multiple locations without fear of losing notes. However, with all of us now aware of the decreased efficiency it has caused, we need to change our ways of practising. We are not going to get a standalone EMR system designed purely for ophthalmology integrated into a public hospital system so we must make do with the suboptimal systems we are given. Options such as virtual glaucoma clinics, where electronic records are reviewed after patients have had their investigations and returned home, will likely become more common.
“Decreased face time between patient and doctor is unfortunately one place where efficiency can be picked up. I would much prefer that an EMR system made everything else more efficient so I can spend more time listening to the patient but what I am seeing is quite the opposite. This study confirms my concerns about EMR. I don’t want to sound like someone from the 1980s saying that personal computers won’t catch on but public hospital EMR systems still have a long way to go to improve efficiency for specialty clinics such as ophthalmology.”
TO BE REVIEWED
The study’s research partners included Monash University, Royal Melbourne Hospital, the University of Wollongong and the Australasian Institute of Digital Health. The team hopes to repeat the study in 2022.