The electronic patient record in primary care—regression or progression? A cross sectional study
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7404.1439 (Published 26 June 2003) Cite this as: BMJ 2003;326:1439All rapid responses
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It appears from the report presented here that there is a serious
flaw in the design of this study that is actually noted by the authors and
then, unfortunately, ignored.
The authors commence their ‘Participants and Methods’ section with
the statement that they had originally intended to differentiate between
“manual (all records kept on paper) and combination (part electronic and
part paper record keeping), but piloting made it clear that the
appropriate comparison was between paperless records, where all patients’
clinical notes were entered on to and stored on computer, and paper based
records, where either a combination of manual electronic records or only
manual records were kept.”
This change in comparative groups is significant. The authors’ claims
as to the differences observed between the two groups are therefore
questionable. Given that the majority of all English GPs routinely use
electronic systems for prescribing (both repeat and acute) it is extremely
hard to believe that “paperless records were significantly more likely to
specify the drug dose” unless the authors were only reviewing the paper-
based components of their ‘paper-based group’ as opposed to the full
record.
Assuming therefore, that the authors were comparing the printout from
the electronic record for their paperless group and a copy of the paper-
based record for the paper-based groups they were not comparing like with
like. By designing the study in this way, they ignored the fact that many
practitioners use a combination of methods to record the consultation.
Most commonly, paper-based GPs will record symptoms, diagnosis and
observations on paper but prescribe using their electronic system.
Therefore, a fair comparison would have required that the full record for
both groups be reviewed. This would have meant that the paper-based group
would have included the electronic record printouts as well as the copy of
the paper record.
Giving the authors the benefit of the doubt for the moment and
assuming that this is indeed what they did do, and that for some unknown
reason their paper-based GPs did not use their electronic systems to
prescribe, there are two further issues of concern:
The first is that the authors conclude “paperless records compare
favourably with manual records”. This is an interesting and very positive
conclusion given that they actually specify one of the main reasons as to
why GPs may prefer to use manual records during the consultation –
diagrams. Whilst only 7 drawings were observed in their study the lack of
drawings in the electronic systems is surely due to the inability of such
systems to facilitate such recording rather than that their value was not
important? Admittedly, the increase in legibility and understanding gained
from using paperless systems from a medico-legal perspective is great.
However, from a patient perspective I wonder how much more valuable that
little drawing is? Can such drawings be disregarded as having such little
value so easily?
Secondly, the authors suggest that the “doctor-patient relationship
may not be as personal as many suppose” based on a textual analysis of
references to specific patients. I would be interested in seeing what
would happen if those same doctors had been presented with a picture of
the patients in question. I suspect that their recall and specific
reference would substantially increase, as like many of us, doctors are
known to respond very heavily to visual cues as opposed to verbal recall.
Competing interests:
None declared
Competing interests: No competing interests
Assuming the previous prescription referred to above had
been dispensed, asking the local Pharmacy to look at their
computer record would have been an alternate approach to
finding the information required.
We rarely move our major systems, but for insurance
against various causes of embarrassment, having a backup
of the live system made and running on a separate machine
is sometimes handy. It also demonstrates that the backup
actually works - something we hate to find out by loading
it back onto a broken server's replacement!
I am amazed by the assumption - the hypothesis - that
typed notes on a computer system would be terser or less
good than those on Lloyd George cards. it is exactly the
opposite I would make, and I am pleased to see the
demonstration that this is so.
In the UK general practice systems range from moderate use
of templates and pro formas to very little use of them, a
large proportion of the entered record is commonly
free-form narrative, including from time to time items
that might usefully be added in a codified form. The
extensive use of forms whether as paper or as screens is
more typical of the secondary sector, and I assert that it
does not of itself improve usability of the machine,
quality, uptake, job-satisfaction, later re-usability of
the record or anything much else that doctors do to
anything like the extent that some people think.
In particular, the use of extensive templating and coding
does not improve the robustness of the medical record
against later changes of system, supplier, coding library
or any of the undesirable interruptions to the permanence
of the record which are encouraged by commercial
considerations and closed source code programs.
Legibility and retrievability are huge advantages easily
obtained with simple approaches to electronic records,
there are many others, but the effort to procure all of
them should not ignore the merit of the easy ones.
Competing interests:
None declared
Competing interests: No competing interests
We
are pleased to see evidence of the benefits of electronic patient
records. Integrated electronic patient care records (IRCS) is one of
the main projects of the National Programme for IT (NPfIT). This
programme will involve £2.3bn capital investment in information
and technology infrastructure within the NHS over the next 3 years.
Selection of suppliers for the programme is scheduled for this
calendar year.
We
conducted a survey of 1115 medical doctors in England in June 2003
about their views of the programme; 1001 responded. The survey was
carried out via the internet from a pre-recruited panel of doctors
registered with the GMC. We make no claims as to how representative
the panel is for this particular subject, but 501 GPs drawn from the
panel predicted a 76% “yes” vote for the General Practice
contract election (19 June 2003) against an actual 79% “yes”
vote (20 June 2003).
Key
findings of the survey
The
majority of respondents appear favourably disposed towards the
programme in terms of its expected effect on clinical care:
What |
All |
GP |
Non-GP |
|||
N |
% |
N |
% |
N |
% |
|
Significant |
257 |
26% |
105 |
21% |
152 |
30% |
Slight |
338 |
34% |
159 |
32% |
179 |
36% |
No |
122 |
12% |
82 |
17% |
40 |
8% |
Slight |
20 |
2% |
12 |
2% |
8 |
2% |
Significant |
14 |
1% |
10 |
2% |
4 |
1% |
Unsure |
241 |
24% |
125 |
25% |
116 |
23% |
Respondents
feel that consultation with individual clinicians is an important
aspect of the programme:
How |
All |
GP |
nonGP |
|||
N |
% |
N |
% |
N |
% |
|
Very |
421 |
42% |
197 |
40% |
224 |
45% |
Important |
431 |
43% |
225 |
46% |
206 |
41% |
Neither |
55 |
6% |
30 |
6% |
25 |
5% |
Unimportant |
24 |
2% |
8 |
2% |
16 |
3% |
Very |
18 |
2% |
8 |
2% |
10 |
2% |
Unsure |
43 |
4% |
25 |
5% |
18 |
4% |
None |
1 |
0% |
0 |
0% |
1 |
0% |
Most
respondents, however, claim to know little or nothing about the
programme:
How |
All |
GP |
Non-GP |
|||
N |
% |
N |
% |
N |
% |
|
Fully |
6 |
1% |
4 |
1% |
2 |
0% |
Reasonably |
52 |
5% |
32 |
6% |
20 |
4% |
Inadequate |
146 |
15% |
82 |
17% |
64 |
13% |
No |
173 |
17% |
96 |
19% |
77 |
15% |
No |
245 |
25% |
113 |
23% |
132 |
26% |
This |
339 |
34% |
150 |
30% |
189 |
38% |
Only |
36 |
4% |
18 |
4% |
18 |
4% |
And
consultation appears not to have commenced:
What |
All |
GP |
Non-GP |
|||
N |
% |
N |
% |
N |
% |
|
More |
4 |
0% |
2 |
0% |
2 |
0% |
Adequate |
13 |
1% |
7 |
1% |
6 |
1% |
Barely |
62 |
6% |
29 |
6% |
33 |
7% |
Inadequate |
99 |
10% |
53 |
11% |
46 |
9% |
None |
806 |
81% |
399 |
81% |
407 |
82% |
Unsure |
10 |
1% |
5 |
1% |
5 |
1% |
Comments
From
these tables and the complete survey (available at
http://www.medix-uk.com), we
observe that respondents expect positive benefits from the programme
in terms of clinical practice and working conditions for doctors.
Respondents generally view the programme as a responsible investment
and one of suitably high priority. Consultation with clinicians is
seen as an important aspect, but consultation and communication about
the programme appear not to have made a significant impact on the
responding doctors at this time.
Competing interests:
The authors have material financial interests in Medix UK.
Competing interests: No competing interests
It is an interesting study. However the fact that the paperless
records had the same detail as the paper records is not necessarily a
cause for joy.
Electronic Medical Records are obviously going to be more legible and
more detailed due to the fact that they include a proforma to collect
data. If the paper records were also collected in the same manner, the two
would have been equal.
The advantages of electronic medical records go way beyond that fo
mere paperlessness. The structured, refernced pattern of collection and
the portability and speed of transfer to distance places where the patient
could be needing them, the ability to search and analyse, the ability to
prevent errors and clinical decision support make the real difference.
To get this we must collect data in a manner quite different to the
way it is being done. The computer works different to the brain. To get
their benefit we must understand how they handle data.
Competing interests:
None declared
Competing interests: No competing interests
I wholly concur with the authors findings regarding the superiority
of electronic records; indeed I and a few colleagues are exploring the use
of electronic pharmaceutical care plans within our Trust.
However, I was significantly stymied the other week when I needed to
check a dose of an important medication prescribed by a patient's GP prior
to admission. The dose (and form) of the drug were unclear from the
patient (and the admission notes) but it did need resolving swiftly.
As the authors point out, and is borne out in practice in my
experience, drug details are usually accurately recorded in the electronic
practice records. I duly contacted the patient's GP by telephone. He was
rather shamefaced when he had to admit that the practice computer was
'down' for the weekend due the relocating of premises, and that he had
absolutely no way of giving me the information I needed.
However, I don't raise this point in a Luddite way. Rather the
reverse: I think we need to address the knotty problem of adequate and
reliable backup when the technology 'fails' - or in this instance, was
being moved!
Competing interests:
None declared
Competing interests: No competing interests
Politically correct?
Is there a point in comparing whether you write more information on
stone compared to a papyrus? At the end of the day, this article reflects
just the same principle that could have instigated research to Egyptians
4000 years ago to please the pharaohs. Perhaps nowadays the journal, which
is forced to decline thousands of articles every year due to lack of
space, is forced by the political class to show to the general public the
radical change the NHS is under is evidence based and provide us with such
irrelevant piece of work.
Is it possible to believe that in the present litigation-prone society we
live GPs are going to provide less information by using new technologies?
Very doubtful. On the other hand, how can you question whether
information is more accessible with a computer? What is the whole purpose
of IT but to allow handling of large quantities of data quickly and
efficiently.
We are aiming to move to new millenium technologies, many practices are
setting up web sites (over half of the practices in England) [1] and some
of them are already exploring the issue of e-prescribing [2].
It is irrelevant if computer records at present are better or worse
compared to old records. There is no way back. The force behind good
record keeping is not where and how you write them, but whether it will be
good enough in litigation.
More interesting to me is to read how GPs are dealing with the imposed
changes because new generations of GPs will do nothing but work in
paperless practices, whether they like computers or not. And it does not
even matter whether you are in any other business. Can you imagine any
successful business renouncing to process their data in the fastest
computers?
_________________________________________
Bibliography:
[1]. Millares-Martin P, Bobet-Reyes R. "Putting primary care on the web"
GP, 31/03/03, page 46.
[2] Millares-Martin P, Bobet-Reyes R. "Repeat Prescribing online", GP,
17/02/03, page 63.
Competing interests:
None declared
Competing interests: No competing interests