computer methods and programs in bbmedicine

ELSEVIER Computer Methods and Programs in Biomedicine 48 (1995) 127- 131 -

The paper-based patient record: Is it really so bad?

I-3. J. Tange

Drpartnwnr of Medical Infomatics, University of Lwnburg, P.0.B 616, NL-6200 MD Maasrricht, The Nrtherlands

Abstract

In a recent review of literature, a committee of the American Institute of Medicine found much support of the weakness of the paper-based patient record. Inspired by these results, a local survey was held a.mong practicing clinicians to test, whether they could subscribe the Committee’s conclusions. The clinicians turned out to be far more positive about the quality of the paper-based patient record. Possible explanations for this discrepancy are discussed, as well as the question, whether the results of the Committee’ s review may be used as a basis for the implementation of computer-based patient records.

Keyword.s: Paper-based patient record

1. Introduction

Modern health care is an information-intensive industry. Clinicians are confronted with an explo- sion of medical knowledge, too much to keep pace with. New subspecialisms are born, which lead to a growing need to cooperate in multi-disci- plinary teams. This results in thicker patient records and a growing importance of communica- tion between health care professionals. On the other hand, also others than professionals (e.g., researchers, administrators, third party payers, lawyers) get more interested in the content of the patient record. The growing impact of confiden- tiality makes the information processing of pa- tient data even more complex. Information processing can be considered as a critical success- factor for the quality of care.

In 1989, the Academy of Medicine in the United States charged a Committee to examine the problems with the existing medical record systems and to propose actions and research for improvement. This Committee lproduced a report ‘The computer-based record’ [l], which grew out to one of the most cited books about medical record keeping at present. Although the Commit- tee’s charge was limited to the situation in the IJnited States, the impact of its report will be worldwide. However, health care differs from na- tion to nation, so it can be questioned, whether the Committee’s conclusions and recommenda- tions can be extended to other countries, e.g., to countries in Europe. It can also be questioned, how far the Committee’s conclusions deviate from practioners’ opinions.

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128 H.J. Tange 1 Computer Methods arid Programs in Biomedicine 48 (1995) 127-131

2. The Committee’s review concerning the paper-hawed patient record

To emphasize the need for integrated record keeping, the committee preferred to use the term patlent record as ‘the repository of infor-, mation about a single patient, generated by health care professionals as the direct result of the interaction with the patient or his relatives” [I, p. f 11. Part of the report is a literature re.. view on quality aspects of the paper-based pa- tient record (PPR), which actually should be considered as the virtual combination of inpa- tient record, outpatient record, nursing record, etc. This quality review supported a major ar- gument of the committee to strive after the im- plementation of computer-based patient records (CPR) all over the USA.

The Committee’s literature review did not re- veal any substantial documentation of strengths of the PPR. Instead, the Committee formulated some aspects, based on their own experience: PPR are familiar to the users; are portable to the bedside: never break down like computers. Besides, the user is free to record which data, how, and where in the PPR (a necessity for the recording of ‘soft’ data), and the PPR can be browsed through easily [l, p. 141.

Weaknesses of the PPR were found in many publications. Unfortunately, the reference lists in the report were not always correct, or con- tained ran-public reports and articles from re- gional journals, so tracking the original publicat:ions was problematic. Critique was found on the content of the PPR: data were often missing, illegible or inaccurate: and con- cerning the format: the paper-based patient record had a poor organization which leads to ineffective and time-consuming use. Further- more, the availability of the patient record is Zocat.ion bound, and the retrieval of inform- ation from the record is difficult. And las’t, a real integration of information cannot be achieved when a PPR is used. This can be considered an impediment for continuity of care between different kinds of care, bet- ween care and third party payers, etc. [l, pp. 15- 191.

3. Objectives, materials and method

Purpose of this study was to investigate, wh.ether the results of the Committee’s review ab’out the quality of the PPR could be general- ized to a Dutch hospital. Therefore, a survey was held among practicing clinicians in the hospital to test, whether they could sub- scribe the Committee’s conclusions about the PPR. They were asked to express level of their agreement on the following aspects of the PF’R: - familiarity, portability, availability - ease, speed, flexibility, structure, legibility

completeness, accuracy - integration, security, confidentiality

For each aspect, one or more statements were derived from the Committee’s conclusions and gathered into a questionnaire. The total questionnaire contained 55 statements, of which 31 were directly related to the Committee’s re- view of the quality of the PPR. To avoid a trigger from the Committee’s conclusions, we ‘blinded’ the conclusions by expressmg ali state- ments positive, as if all aspects of the PPR were satisfying.

The questionnaire was distributed among clinical specialists and residents of the University Hospital of Maastricht. The results presented in this contribution are from the larger departments of the .hospital. The smaller departments are still under study. Fill- ing the questionnaire would cost 20-30 min, so the cooperativeness of the physicians was cru- cial to get a proper response. To eliminate the danger of selective response, the heads of the clinical departments were asked to distribute them.

Agreement could be scored along a five points ordinal scale, from 1 (total disagreement) to 5 (total agreement). The score 3 was neutral (don’t know). For the analyses in this contribu- tion, the values 1 and 2 were interpreted as ‘disagree’, the values 4 and 5 as ‘agree’, and the value 3 as ‘don’t know’. On two variables (discipline and expertise level) the Kruskal-Wal- lis-test (KW-test) for one way variance analysis on nonparametric data was performed.

H.J. Tange / Computer Methods nnti Programs in Biomedicine 48 (199$ 127- 131 129

Table I Response of physicians per discipline, divided into expertise level

Discipline -.

present responding

specialists residents

anesthesiology 33 general surgery 33 gynaeciobstetrics 25 internal medicine 57 neurology 21 pediatrics 29 pulmonology IO radrology ‘0 urology 12

17% 33% 38% 12% 14% 18% 31% 27% 22% 0% 17% 45% 67% 14% 30% 30% 40% 29%

of the participants agreed. In particular, the clini- cians agreed strongly ( > 75%) with the conclu- sions, that the PPR is easy to carry to the bedside, and that the PPR is flexible enough to allow freedom of expression concerning what to record, to which level of detail, and how to describe it. Only the group of anesthesiologists did not agree with the conclusion, that there is enough freedom to choose which data to record (KW-test). How- ever, there was no consensus about the browsing capabilities of the PPR.

4. Results

A total of 60 physicians from 9 disciplines filled the questionnaire, which is a total response of 25%. The departments of cardiology and orthope- dics were not able to cooperate. When these non- responding departments are included in the calculation, the total response was 21%. The spe- cific response of each discipline is showed in Ta.ble 1. In Tables 2 and 3 is shown, how well the physiclam agree with the Committee’s conclu- sions about the quality of the paper-based patient record. Table 2 holds the strong aspects, while Table 3 holds the weak aspects of the medical record, according to the Committee.

Totally different was the level of agreement with the suggested weak aspects of the PPR. Only the difficulty to read others’ handwriting, and the time spent to determine, that certain data are not present, could meet agreement of a significant majority of the clinicians. A restriction must be made for general surgery, where 60% of the clini- cians considered the legibility of others’ handwrit- ing not a problem (K W-test).

On most strong aspects of the PPR, a majority

Contrary to the Committee’s conclusions, a comfortable majority (73%) of the clinicians did not agree with the problem, that patient data were often inaccurate. Most of the clinicians denied, that there is a problem with missing diagnostic or therapeutic patient data. Problems with the PPR, caused by its poor organization, as suggested by the Committee, were not recogniz’ed by a majority of the clinicians. A small majority (51%) of the clinicians did not think that problems would oc- cur when the PPR is used as a tool for research.

Table 2 Percent;Lges of agreement with the conclusions of the Committee: strong aspects

Strong aspects, as considered by the Committee

The PPR is familiar to the users, and easy to learn The PPR can easily be carried to the point of care

The PPK allows flexibility in the choice to record . ..the kind of data -the level of detail of data -the choice of words to describe the content . ..the location where in the PPR to record data . ..the sorting order in which to record data

The PPR can be browsed through easily.... .-to get a first impression of trends . ..to get a first impression of the patient state

agree

54% 82%

disagree

20% 1%

don’t know

26% 11%

SO% 3% I 6% 79% 0% 21% 82% 7% 11% 62% 20% 18% 51% 18% 25%

130

Table 3

NJ. Tnnge / Computer Methods and Puogmms in Biornedicirle 48 (199.5) I27- 131

Percentages of agreement with the conclusions of the Committee: weak aspects

Weak aspects. as considered by the Committee agree disagree

The following PPR data are often missing or incomplete: . ..diagnostic interventions . ..therapeutic interventions . ..decisicns . ..appointments -plans . ..requests One’s own handwriting in the PPR is often illegible Other persons’ handwriting is often illegible Data in the PPR are often inaccurate The exclessiveness of irrelevant data is often impeding the retrieval of information The PPR is poorly organized for data entry The PPR is poorly organized for data retrieval The PPR is often not available at times one needs it The PPR is often not available at locations where one needs it

22% 20% 25% 30% 32% 33%

3% 63%

7% 3 7% 9%

18% 34% 51%

65% 63% 45% 43% 35’%, 40% 95% 18% 73% 37% 62% 61% 64% 41%

The retrieval of data from the PPR is time consuming... . ..when to gzt a full impression discourse -when to get a full impression patient status . ..when to search for specific data . ..when to search for specific data that are absent Using the PPR for research purposes is problematic

38% 37% 330/o 14% 51%

Integration is needed... . ..between medical and ancillary record . ..between medical and nursing record . ..between inpatient and outpatient record

38% 33% 48% 13% 23%

45% 28% 3 3%

There was no majority to agree or disagree with the problem of missing patient management data (d.ecisions, plans, requests and appointments). There was no consensus among the clinicians about retrieval problems: caused by the excessive presence Iof irrelevant data (information overload)1 in the PPR. The opinions about the availability of the PPR ((through time and space) were diverging,, although residents tended to the Committee’s con- clusions more than specialists did (KW-test). Fur- thermore, there was no common opinion about the Committee’s conclusion, that the retrieval of data from the PPR was time consuming. Only the time, needed to ascertain, that data were absent, was considered long.

5. Discussion

The response to our questionnaire is not a random sample from Dutch clinicians, not even from the clinicians from the Maastricht Univer- sity Hospital. This implies, that we can only draw conclusions about the validity of the Committee’s review results for the population under study. Both the Committee’s review and our own survey concerned the PPR in general. Conclusions about the quality of different parts of the PPR (such as history, laboratory results, etc.) or about the qual- ity of the PPR, when used for specific case mixes (e.g., short stay versus long stay patients) cannot be drawn from both these studies.

As suggested by the term ‘patient record’, the The most obvious conclusion of our study is, Committee considered it self-evident, that there that the clinicians were rather satisfied with the should be one, integrated patient record. How- PPR. This does not correspond with the results of ever, in our study we could not find a majority of the Committee’s review. Most striking was the clinicrans that agreed with this. clinicians’ confidence in the accuracy of data in

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H.J. Tange / Computer Methods azd Programs in Biomedicine 48 (1995) 127-131 131

the PPR. This is not only contrary to the Ca’m- mittee’s review results, but also to Komaroff [2], who d.;d not even regard the storage medium of these data. Also surprising was the moderate sat- isfaction with the PPR when used for research. The knowledge, that the PPR is a cumbersome tool for this purpose, is wide spread [3]. A reluc- tance to integration of medical and nursing record, although in contrast with the Committee’s opinion, is not unique (even Weed subscribed this position [4]). However, a resistance against an integration of inpatient and outpatient record can only be explained by practical, PPR-bound r’ea- sons.

Several explanations are possible for the clini- cians’ broad satisfaction with the PPR, although the results of our study do not indicate which of them is more likely. It could be caused by a difference in the object of evaluation. The Com- mittee’s review was based on evaluation studies of the PPR itself, while our survey evaluated the use of the PPR. These are two different and comple- mentary approaches to quality assessment [.5]. In daily use, the clinician’s memory is a proper com- plement to the patient record, so some shortcom- ings of the PPR could be compensated without notice of the user. Here, the Committee’s warn- ing. that the support by practitioners for the PI?R should not be underestimated [l, p. 141 is worth to be emphasized.

Another possible cause could be the fact, that the use of patient records as a legal tool to account for one’s acts is more developed in the USA than in the Netherlands. For example, in rJS legislation, acts that have not been registered, are accounted as if they did not take place [6]. Such an incentive to be complete in the registration of data, is absent in the Netherlands.

6. Conclusion

The real purpose of our study was to answer the question, whether the results from the Com- mittee’s review concerning the PP.R could be gen- eralized to our setting. The answer is negative. Of course, objective measures are a more valid ex- pression of the quality of the PPR than subjective satisfaction scores. However, if the clinicians are satisfied with the present PPR, it is not likely, that they will be very cooperative with respect to the implementation of a computer-based patient record. And, without cooperation of the potential users, a computerization project is likely to fail. Hence, the results of the Committee’s review should only be applied as one of the arguments to illustrate the need for computer-based patient records, not as the only and ulti.mate argument. To consider a computerized patient record supe- rior to a paper-based patient record is one thing, to convince the users of this is another thing. This will be a heavy task, and still is a long way to go.

7. References

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VI

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[41

[51

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R.S. Dick and E.B. Steen, The computer-based patient record - An essential technology for health care. Na- tional Academy Press, Washington DC, 1991. A.L. Komaroff, The variability and inacurracy of medical data, Proc IEEE 67, (1979) 119661207. M.F. Collen. Clinical research databases ~ a historical review, J. Med. Systems 14 (1990) 3233344. L.L. Weed, Medical records, medical education, and pa- tient care. Year Book Medical Publishers, Chicago, 1969. Donabedian, The Quality of care ~- how can it be assessed?, J. Am. Med. Assoc. 260 (1988) 1743-1748. E.H. Shortliffe and G.O. Barnett, Medical data: their acquisition, storage, and use, in Medical Informatics ~ computer applications in health care, eds, E.H. Shortliffe, L.E. Perreault (Addisson-Wesley, Reading, Massachu- setts, 1990).