For the last 12 months, staff at Nanaimo Regional General Hospital in B.C. have been using a Cerner-based electronic health record (EHR). This includes computer physician order entry, linked to computerized order management, and fully electronic documentation.
Since shortly after the system was activated, physicians have consistently and increasingly expressed concerns about the safety of the system (with, for example, orders being mistranslated by the system or disappearing) and its inefficiency, which reduces patient access to care. As a consequence, with the support of the B.C. Ministry of Health, the Island Health Board has directed the Health Authority to suspend CPOE and related processes—though Island Health is delaying this.
While the primary issues with iHealth have focused on safety concerns, little attention has been paid to the human costs of the EHR and its implementation. Currently designed EHRs significantly alter processes of care. Computerised order entry is a laborious process, requiring multiple steps to perform simple tasks. As demonstrated in other settings (such as the airline industry), such complex processes are inherently error-prone. Moreover, the inputting of more intricate orders is even more difficult, resulting in “work-arounds” or inaccurate enactment of physician management plans, with additional safety risks.
“User error” has become a buzz phrase for system-based processes that result in inability to enact orders as intended by physicians—and physician users are the ones responsible, thus morally if not legally liable not just for order entry but for their management downstream. It is little wonder physicians in Nanaimo since the introduction of the EHR feel uncertain, anxious, frustrated and exhausted. This experience is not singular, as a number of studies in the U.S. suggest that EHRs are now the primary cause of physician burnout. This further jeopardises patient care since the presence of an EHR has become a barrier to recruitment and retention of healthcare workers—and not just of physicians.
Documentation changes have also affected patient care. A patient’s journey through illness and during their stay in hospital is a story or narrative—hence our documentation of that narrative as a history. Our understanding of it in this manner is critical not only to diagnosis and management, but to contextualizing it for the individual patient.
Checklists and data points
“Progress notes” in the EHR no longer describe progression of disease, but document it rather as an episodic and disjointed accounting of the patient’s condition. And the nursing narrative has been eliminated in favour of checklists of patient experience as data points. As a result, we have lost our holistic knowledge of the patient and his/her illness and are unable to transmit this understanding clearly from one provider to another. This is detrimental to providing high-quality patient care.
Focus on the collection and inputting of clinical data or struggling with order entry and documentation further dehumanizes patient care. The interaction of healthcare providers and patients is perhaps the most intimate of relationships outside personal or familial ones. This therapeutic relationship is crucial to providing care, whether for cure or for comfort. An episode of patient care is now primarily defined by interaction with the computer, which detracts from the provision of care. This experience has been corroborated in a recent study from Calgary, documenting that healthcare workers operating in an EHR environment spend up to 90% of their time during clinical work on the computer rather than with the patient.
Because of the inefficiency and error-prone nature of computer order entry, there is significant reliance on order sets. Order sets have been developed by practising physicians based on thorough clinical and academic content knowledge about management of specific disease states and years of experience generating management plans repetitively for patients with similar conditions. Order sets can foster standardized care, can improve efficiency and can help to ensure it is evidence-based.
But loss of flexibility in development of management plans, coupled with the complexity of order entry, impairs individualization of care management plans for physicians and patients. In addition, order sets are made more immutable in iHealth, as updates of order sets delete saved templates altered to individual physicians’ needs, sometimes after hours of work to generate them.
Reliance on order sets developed by experienced practitioners is potentially detrimental for trainees, who do not then have the opportunity to learn the clinical thinking processes that underpin them. Given the reliance on order sets to address inefficiency and safety concerns inherent to the ordering processes in an EHR, physicians at the most crucial stages of learning are not able to develop these critical thinking processes that form the basis for the practice of medicine.
Moreover, given the inefficiency of EHR processes, there is reduced time available for clinical teaching. This has been a universal experience (and complaint) of trainees in Nanaimo. In other jurisdictions, trainees have become effective scribes to unburden staff physicians—an activity I do not believe contributes to the educational experience. Additionally, trainees focus on learning to navigate and use the EHR, rather than attending to patient care or clinical education. We are at risk of producing a generation of physicians with poor clinical skills and who are disconnected from patients.
A disconnected team
The loss of bond with patients is mirrored by disconnection within the healthcare team. EHR processes serve to isolate rather than enhance personal interactions between physicians and nurses, pharmacists and allied health professionals. Healthcare requires collaboration and coordination between many types of providers, a process that is not just crucial to optimal patient care but necessary to support and enhance the performance of individual team members. Disruption of the team approach impairs patient care and has demoralized the healthcare community in Nanaimo.
This has been made worse by the adversarial relationship created when a majority of medical staff who have found continued use of the computerized order management processes unacceptable are opposed by physicians, some allied health professionals and administrators who do not. Some of our most experienced physicians and allied health professionals have retired or changed practice. To say the effects on the health care community in Nanaimo have been destructive is not an understatement. This also means that collaborative work on care needs for our community beyond iHealth has largely stalled.
Island Health argues that iHealth has made care safer in Nanaimo. The data to support this contention have not been collected. But it is a near universal experience among physicians and reported by many allied health professionals that the quality of our own provision of care has suffered since the introduction of the EHR and that the quality of care NRGH provides to the 180,000 people we serve has deteriorated. Many of these quality indicators simply have not been assessed or considered.
I firmly believe EHRs can improve quality of care, ensure it is provided more safely and enhance the efficiency of its delivery. But EHRs that are not designed as clinical tools, and which do not specifically address the issues outlined above, fail to improve care and indeed diminish it.
Written by Dr. David Forrest on March 22, 2017 for CanadianHealthcareNetwork.ca
Dr. David Forrest is a Nanaimo internist and the president of the Nanaimo Medical Staff Association.