Saturday, 13 January 2007

On using electronic notes in medicine

This week I saw a patient with a complicated medical history. To find out what this was I spent part of the consultation turned towards a computer trying to find the most recent electronic discharge summary from the surgical team. I managed to do this and then spent 30 minutes after the one hour appointment typing the notes into the computer.

This illustrates some of the advantages and disadvantages of using electronic notes. First they improve communication – there is no doubt about this and I would never want to go back to pen and paper notes. It is so much easier to find out what is happening to people – just log onto the nearest computer and there are all the notes. Clinically I work in an organisation which provides mental health care to 450,000 people - so the provision of care is complex involving different clinical teams and many different people. Having the narrative notes from all these people in one place available from any computer is great. However there are significant downsides.

Firstly you need to find a computer to log onto. They are not always available at places where patients are seen. Secondly there is the additional time spent typing in notes. With pen and paper notes I used to make notes when I was talking to patients. The advantage was that they were instantaneous and it was easy to capture verbatim comments. Now I have to set aside time to type in notes – usually about one hour per clinic which translates into one less new patient each week. For the organisation I work in this represents terrible value for money, I must be one of the best paid yet least efficient typists in the organisation. Then there are the physical effects of all this extra typing – I have for the first time developed an overuse syndrome in my wrist and several other colleagues are nursing sore backs. Another problem with electronic notes is that not all parts of the health service use them – I still need to track down paper notes on people seeing other physicians. This doesn’t exactly encourage joined up health care and emphasises the split between mind and body.

Lastly there is the effect electronic notes have on “dumbing down” health care. The problem is that the electronic notes are not blank screens. There are numerous forms to complete from assessment forms to risk and hazard forms. What this does is that it encourages a checklist approach to assessment so that the emphasis is on completing the forms rather than finding out what is important for the patient. Every assessment is the same no matter what the patient needs and it is a “good” assessment if all the boxes on the electronic forms are completed. The ability of health workers to prioritise needs and to understand why this person has this problem at this particular time is damaged. Also there is an emphasis on risk and “hazard” rather than needs. This is often simplistic so that assessment of risk emphasises predicting whether people are at high, medium or low risk of violence/self harm. Unfortunately it is clear that clinicians prediction of who is going to kill themselves is no better than chance and probably not worth doing, after all most people who commit suicide are low risk. The purpose of risk assessment is identifying modifiable risk factors rather than some vague prediction of the future. So health care is dumbed down – just fill in the forms and that is fine no matter what they mean.

So would I return to pen and paper notes – no. Can electronic notes be improved. Yes – find another way of entering the data rather then getting expensively trained clinicians to be typists; decrease the number of forms and make them more flexible as well as training in how to keep notes; and get the whole organisation to use the same system. Then the goal of joined up health care and better communication in a complex system will be one step closer.