This weeks British Medical Journal featured an interesting paper on digital health in hospitals. About a decade after most GPs have switched to largely electronic systems most hospitals are still struggling with mountains of paper.
Claims about electronic records are clear: better transfer of information should lead to smoother, less fragmented care and availability of important information should make care more efficient and safer. While there is surprisingly little evidence for this in the published literature (and more later about this in future blogs) another interesting theme is emerging: Current electronic patient records take time. Time to fill in, write, look at. Time that might be taking doctors and nurses away from patients. The Annals of Internal Medicine published a paper in December of last year (http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties): After observing doctors for over 400 hours came to the conclusion that ‘During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work.’ And this is after days for administration had been removed. A bit sobering! And understandably leads to some providers using dedicated scribes or dictation systems to free doctors time from the computer.
So what do Doctors do in this time: documentation and review of notes, ordering and reviewing test results, ordering medication and booking further appointments. Documentation makes up a big chunk of this, not that different from our findings of observing doctors working in hospital (http://www.clinmed.rcpjournal.org/content/16/4/320.full.pdf).
If we think for a moment about what might be documented: ‘Did you have a cough?’, ‘How is your appetite?’, ‘Have you lost weight?’ etc etc: all information that the patient holds. The patient might even reasonably expect to be asked these questions. My local surgical colleague Mr Lloyd Jenkinson decided in 2009 to find out (http://pmj.bmj.com/content/85/1010/634.long). He asked the doctors on his team to take the history from new admissions and gave patients forms with the standard questions. Would the patients documentation supplement the medical history by the doctor? Or just be a waste of time?
It turns out that patients were actually better in documenting what is wrong with them: where it hurts, aggravating and relieving factors, duration etc etc. Something that should have been clearly in favour of the doctors was the fact that patients were all admitted with abdominal pain. The doctors were pain free. But despite this the patients added more detail!
So it turns out that some surgical patients in pain are as competent as doctors in charting the crucial information that leads to a safe diagnosis, the right treatment. They are actively helping to create safety in their system. Could they do this during the hospital stay? Document whether pain is getting better? What treatment works? Whether the mobility has been affected? If they are passing urine after surgery?
If we are worried that electronic records take time away from patients for reasons of documentation: why don’t we ask patients to document what is THEIR story?
What could patients document and what not?