Jonathan Bloor on the burden created by the use of electronic patient records and how to digitally transform the NHS in a sustainable way.
The mainstream US medical literature is full of articles about physician burnout. Much of this is attributed not to workload, but to the burden created by the use of electronic patient records.
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One unexpected outcome of the US Meaningful Use initiative has been the emergence of a new role, the physician’s scribe. Individuals are now employed for the sole purpose of improving the efficiency of information gathering and documentation, freeing time for the doctor to be able to do what they are paid to do.
Last month Matt Hancock reiterated the UK government’s commitment to NHS digitisation and to providing more money to support this. With an already overstretched frontline workforce, are we in danger of making the same mistakes as the US?
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Robert Wachter has warned explicitly about the US problem. In an article published in Harvard Business Review in March this year, he and co-author Jeff Goldsmith wrote of EPRs:
“They are rightly seen as a major cause of professional burnout among physicians and nurses: Clinicians are spending almost half their professional time typing, clicking, and checking boxes on electronic records. They can and must be made into useful, easy-to-use tools that liberate, rather than oppress, clinicians.”
How do we ensure we heed these warnings and digitally transform the NHS in a sustainable way?
1. Understand that healthcare is already digital and there is no turning back. Primary care has been operating a fully digital operational environment for almost 15 years.
2. Our digital systems must be “useful, usable and used” and this means they must understand clinical workflow and clinical usability. Clinicians want to assimilate as much information as quickly as possible and take action immediately (document, prescribe, order). This should dictate the user experience.
3. Standardise clinical content around SNOMED-CT as much as possible, and where it is not possible, allow flexibility for free text but within standardised workflows. Why should the medical clerking process be different in Bristol, Bath and Birmingham? But what the doctor wants to say within that process will be different. Striking the sensitive balance between standardisation and clinical flexibility is key.
4. Make documentation quick, easy and automated where possible. We shouldn’t need to type information into a note when that information exists elsewhere. Yet it is also vital to support clinicians in the need to re-document observations or lab results which may have been instrumental in reaching a particular decision. Information from primary care should flow into the Emergency Department, which in turn should evolve and flow through to ward care, discharge and back to primary care. Not only will this improve the patient experience but, done right, it can reduce rather than increase data entry.
5. We must provide interoperability between systems and across health economies. We can’t have a digital hospital where you can’t see the GP record or have to interface with social care via fax. We need to define and adopt standards (SNOMED CT, FHIR) and procure and contract for those standards and penalise for non-delivery.
6. Use digitisation to claw back more time for care – not just avoiding duplication of documentation but also duplication of communication and review. Use digital to re-imagine workflows, improve transparency, reduce time spent on handover, make clerking and ward rounds more efficient. Smart user experience, voice and AI-based decision support have roles to play.
7. Understand healthcare delivery is mobile, team based and relies on good team based communication. If we are still using the pager as a primary form of clinical communication then we have missed the point.
8. Speed of access is crucial. This requires a combination of well designed software, good Wifi infrastructure and hardware, and single-sign-on.
9. We need to help our clinicians and trusts understand that the benefits of digitisation lie upstream and prove this with data and evidence. Clinicians need to be able to get meaningful data and insights out for audit, reporting, quality improvement and research purposes.
10. We must provide patients with access to their record and allow them to contribute. This will have an impact on the accuracy and quality of clinical information.
This is all easier said than done, but we now have an opportunity to digitise the NHS in a way that works for the NHS, our patients and the clinicians that serve both. We must avoid the mistakes that the US system has made. Indeed, with the current healthcare workforce crisis in the UK we can’t afford not to.