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Vol.7, No.1 April 2001
Editorial | Contents

Issues in the Use of Electronic Patient Records

Student paper

Author

Deborah Robertson RN, BHSc, MRCNA
Student
The School of Nursing
Charles Sturt University Bathurst

Abstract

Electronic patient records (EPRs) are tools that can be used to assist in the provision of holistic, outcome focused, cost effective care and to support case management, outcomes analysis and quality improvement.

Introduction

Electronic patient records (EPRs), within Australia and in their present forms, are not vastly different from word-processed patient charts. They are not true electronic patient records because they ì...cannot support the needs that are driving computerization in health care, namely improving productivity, assuring and demonstrating quality, integrating organisations and facilitating research (Sujansky, 1998 p.180). At worst electronic patient records are a set of textual documents stored within a computer (Sujansky, 1998 p.176). Electronic patient records are not yet at a developmental stage where they have integrated facility options or create seamless care delivery, because of this they do not greatly impact on nursing care. EPRs, in their present form, offer only partial assistance in the provision of holistic, outcome focused, cost effective care and can only minimally support case management, outcome analysis and quality improvement.

The paper based patient record is the dominant form of patient record within the Australian health care environment at present (Teng Liaw, 1993). Whilst being the primary source of patient information (Metzger, 1995 p.2) and the main form of record keeping, there are many negative aspects to the paper based patient record.

Paper based patient records are described in a variety of negative ways by authors to highlight reasons why this current system of record keeping needs to change. Metzger (1995) describes paper based patient records as being a combination of oversized, disorganized, inaccurate, incomplete, fragmented, inaccessible, and sometimes missing patient information, holders. Teng Liaw (1993) adds illegible, containing unneeded information, and lacking information regarding important aspects of care, to this list. Hannan (1998) includes storage and retrieval difficulties, time consuming searching and handling, poorly indexed, being able to be utilised by only one user at a time, and expenses involved in the reproduction of the missing patient information.

The inadequacies of the paper based patient record are not difficult to document and are common complaints amongst health care professionals. Their ineffectiveness is further highlighted when comparisons are made with the ideal or true electronic patient record.

In 1991 the Institute of Medicine (IOM) of the American National Academy of Sciences developed a benchmark report which has established a definition and specific attributes that should be included in the establishment of electronic or computer-based patient records (CPR).

Andrew and Dick (1995, p.119) describe the Institute of Medicine’s definition of the electronic patient record as:

A similar definition is given for electronic patient records by Hannan (1998, p.135) as:

The Computer-based Record Institute (1996) supplies a similar though more extensive definition of what a computer-based patient record (CPR) should be. They further include the CPR should cover an individuals lifetime health status and any health interventions. The CPR should be able to integrate information from a variety of sources, give decision support to health care providers and become the primary source of information about how to care for the patient.

The current electronic or computer-based patient records in practice either do not meet, or only partially meet, the desired standards or abilities recommended by the Institute of Medicine or the Computer-based Patient Record Institute. Rather, they are described as being able to demonstrate the real and potential benefits of electronically stored medical information (Hannan, 1998 p.142). Whilst CPR in their present form are not yet at a level where they are able to fully realize their potential, they are the necessary incremental steps that need to be taken that will lead to the development of the ideal computer based patient record.

There are many reasons given for the need for computer-based patient records. Teng Liaw (1993) sums up quite succinctly what other authors (Metzger 1995; Andrew & Dick 1995; CPRI Work Group on CPR Description 1996;) have voluminously explained. He says:

Gabrieli (1997, p. S48) summises Electronic patient records are essential for clinical medicine and a fiscal imperative for our health care culture. Gabrieli is not alone in his comments on the financial aspects of implementing EPRs. Metzger (1995) and Andrew and Dick (1995) refer to the costs involved in the storage, handling and retrieval of paper based patient information. The time spent by health care workers searching for information, and how if the information was readily available it would basically allow the practitioner to get on with the job and thereby concurrently decrease the costs involved in delays, absences, searches and double ups involved in data replication. Andrew and Dick (1995) elaborate further by highlighting how the dramatic advances in technology and the user-computer interface, the affordability and variety of the hardware, and improved storage capacities can assist in the development of computer-based patient records.

Current electronic patient records are able to only partially assist in the provision of holistic, outcome focused, cost effective care. This is further dependent upon the quality or developmental stage of the variety of systems available.

Most of the systems available at present provide only fragmented sections of electronically captured patient information (Teng Liaw 1993). These are predominantly in the form of isolated databases or word-processed documentation. Examples of some of these are radiology reports, pathology results, consultation notes, nursing notes, and accounting systems.

Holistic, outcome focused, and cost effective care are some of the espoused benefits attainable with the introduction of the true form of an electronic patient record. Caring for patients is information-intensive (Metzger, 1995). Computer-based patient records that are fully integrated patient information systems will enable the health care professional to assess the patients multilevel needs, plan care, implement treatments and interventions and evaluate the care outcomes. Metzger (1995) describes studies that show improvements in nursing care when CPRs are involved. These include nursing documentation accuracy and quality improved, patient observations and care plan evaluations increased, and prompt treatment requests sent to relevant departments. Further, nursing time is freed up by decreased clerical and communication tasks, overtime is reduced and if bedside point of access terminals are available documenting of care occurs closer to the time when the care was actually provided.

In addition multi point access enables numerous health professionals to access patient data simultaneously, even at different locations. This is an important factor in CPRs as it enables easier multidisciplinary communication that in turn promotes an effective and efficient approach to patient care and patient treatments (Cranwell, 1999).

As well as these care benefits, Gabrieli (1997) relates looking at past data to find trends occurring, such as a slowly increasing blood pressure, and develop risk prediction if it is a negative trend. This would then allow for preventative measures to be taken, rather than waiting for an acute illness episode to respond to.

By taking a lifetime view on the capture patient information the healthcare practitioner is able to view the patient as a whole being rather than an acute illness. Prior episodes can be predictors of future needs and immediately managed or monitored. These along with the benefits already known about computer-based patient records naturally lead to holistic, outcome focused, and cost effective care.

Current electronic patient records are able to only minimally supported case management, outcome analysis and quality improvement. Again these are limitedly available, isolated and fragmented databases or word processor applications. The ability and functionality is restricted at present, though their potential is quite powerful.

CPRI (Aug. 1996) concisely describes the patient care processes that should be present within true CPRs, they ë...permit the integration of clinical information with administrative data to schedule events, assign responsibility, project resource utilization, project costs, initiate processes, and coordinate associated events.

True electronic patient records will improve the quality of care by being able to provide feedback to health carers regarding specific decisions made (Andrew & Dick, 1995; Gabrieli, 1997, p. S51). Decision support by way of reminders, alerts and recommendations as well as research (Metzger, 1995) are all strategies which the electronic patient record can supply to assist in case management, outcome analysis and quality improvement. CPRI (1995) recommends the user of the EPR will also have access to scientific knowledge and relevant literature. It describes a situation where the process and quality of healthcare delivery, administration, analysis and research become simplified and improved, whilst being cost effective.

True computer-based patient records will be,

These recommendations and the 12 attributes that are essential to CPRs proposed by the Institute of Medicine (IOM) as outlined by Andrew and Dick (1995, p.119), future computer-based patient records will be able to effectively and efficiently assist in the provision of holistic, outcome focused, cost effective care. Future computer-based patient records will also support case management, outcomes analysis and quality improvement.

The current electronic patient record is diverse, variant, ineffective and non-specific in design or ability. Authors and groups have provided a large amount of suggestions for ways to improve the current situation and to lead to the development of the true electronic patient record which is capable of so much more than its current manifestations.

The IOMs 12 attributes as described by Andrew and Dick (1995, p.119) include:

• Provides a problem list

• Measures health status

• Documents clinical reasoning

• Provides linkages

• Protects from unauthorized access

• Supports continuous access

• Supports simultaneous multi-user views

• Supports other clinical resources

• Facilitates clinical problem solving

• Supports direct entry by physicians

• Supports management of patient care

• Provides flexibility and expansibility.

Andrew and Dick (1995, p.121) add a further 5 underpinning support tools:

• Clinical data dictionary

• Clinical data repository

• Flexible input capabilities

• Ergonomically designed data presentation

• Automated support.

Teng Liaw (1993) proposes standards in information, language and classification, and the development of a generic system thus avoiding incompatibility problems. Metzger (1995) recommends benefits assessments and research to justify the investment of the institution in this technology.

The implementation of these recommendations will provide a technological tool that has the potential to revolutionize health care and health care practices. This will have universal benefit to health care professionals, the institutions, the community and the individual patient. Without these changes EMRs will lock patient data in electronic files, much the way that data are locked in paper charts today (Sujansky, 1998 p.182).

The presence of an electronic database or the word processing ability of a particular health care computer application does not necessitate an electronic patient record. For it to have significance in health care delivery and development the electronic patient record needs to be able to monitor, search, analyze, and compare clinical data with intelligence or reliability (Sujansky, 1998 p.180). Current electronic patient records are not yet at this developmental stage. Both Hannan (1996) and Sujansky (1998) recommend the developers and users of clinical information technology share their experiences, work with consumers, and utilise existing and evolving software tools, to create effective and appropriate products. Electronic patient records in their present form only partially assist in the provision holistic, outcome focused, cost effective care and are able to minimally support case management, outcomes analysis and quality improvement. The potential of the electronic patient record is quite revolutionary, powerful and innovative in today’s health care environment.

List of References

Andrew, W.F., & Dick, R.S. (1995). The computer-based patient record (Part 1).

Computers in Nursing, 13, (2), 80-84.

Andrew, W.F., & Dick, R.S. (1995). The computer-based patient record (Part 2).

Computers in Nursing, 13, (3), 118-122.

ANHA (30 Oct. 1999). Holistic nursing. Published in WholeNurse, (1996). (online).

HYPERLINK http://www.wholenurse.com/holistic.htm http://www.wholenurse.com/holistic.htm

CPRI Work Group on CPR Description (WDES). (29 Oct. 1999). Description of the computer-based patient record (CPR) and computer-based patient record system. Published in Computer-based patient record institute webpage, May. 1995. (online).

HYPERLINK http://www.cpri.org/resource/docs/function.html http://www.cpri.org/resource/docs/hldd.html

CPRI Work Group on CPR Description. (29 Oct. 1999). Computer-based patient record description of content. Published in Computer-based patient record institute webpage, May. 1996. (online).

HYPERLINK http://www.cpri.org/resource/docs/function.html http://www.cpri.org/resource/docs/content.html

CPRI Work Group on CPR Description. (29 Oct. 1999). Computer-based patient record ñ System description of functionality. Published in Computer-based patient record institute webpage, Aug. 1996. (online).

HYPERLINK http://www.cpri.org/resource/docs/function.html http://www.cpri.org/resource/docs/function.html

Cranwell, C. (1999). Assignment One B.3 number 3 - The medical records institute.

HLT200 Soapbox Forum, Charles Sturt University.

Gabrieli, E.R. (1997). Longitudinal electronic patient records: A challenge of our time. Computers in Nursing, 15, (2), Supplement S48-S52.

Hannan, T.J. (1998). Electronic medical records. In Health informatics, an overview, ed. E. Hovenga, M. Kidd, & B. Cesnik. Churchill Livingstone: Marrickville, Australia.

Metzger, J.B. (1995). The potential contributions of patient care information systems. In Patient care information systems: Successful design and implementation. Ed. E.L. Drazen, J.B. Metzger, J.L. Ritter, M.K. Schneider. Spring-Verlag: New York.

Murphy, J.A. (1998). Creating seamless care delivery using integrated EPRs. Informatics in health care Australia, 7, (4) pp.140-146.

Sujansky, W.V. (1998). The benefits and challenges of an electronic medical record: Much more than a word-processed patient chart. Western Journal of Medicine, 169, (3), pp.176-183.

Teng Liaw, S. (27 Oct. 1999). The computer-based patient record ñ an historical perspective. Published in HISA Vic, Nov. 1993. (online)

HYPERLINK http://www.hisavic.aus.net/hisa/mag/nov93/the.htm
http://www.hisavic.aus.net/hisa/mag/nov93/the.htm

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