Very recently I had the opportunity to experience the paper clinical notes system from a patient point of view, when I was in Accident & Emergency (A&E) with a relative who required treatment. I must say at the outset of this article that this is not an opinion on the level of care received (which was excellent) or any actions of the hospital. However it did give me the opportunity to experience the paper clinical record system from a patient point of view.
This particular relative has a chronic illness and therefore their episodes of admission are regular, all with the same condition.
The series of events that followed was interesting. Over the period of the few hours after admission we were interviewed by approximately six different clinicians, ranging from doctors to nurses. All the questions asked were the exact same, repeated over and over again and recorded by varying methods, all on paper. About three hours into our stay in A&E the chart arrived from medical records, which upon review by the doctor on call instigated further questions.
From a patient point of view we could not figure out why all their medical history, details of their ongoing illness and previous admissions needed to be asked of us several times and then verified once the paper chart arrived. Throughout their illness treatment has always been in the same hospital where their medical history is already known and recorded - but it’s on paper.
I also understand that clinicians are in positions of needing to make critical medical decisions that may inevitably save lives and in doing this, they need to be very sure they have all the information required to make those decisions. So the source of the problem lies not in the hard working clinicians but in the lack of IT infrastructure and processes to support the clinicians in being able to do their job.
The reality is, that even from a patient’s perspective, the ongoing use of paper records in hospitals lends nothing to enhancing the patient experience. On arrival to an A&E department of a hospital where you have had ongoing previous admissions for the same illness, it would be refreshing that all this information is readily available in real time to the attending clinician on duty, when you are first being triaged. The sets of questions would be more limited if this was the case. I believe this can only be the case with the use of electronic medical records.
While I have personally not had much direct experience in other Irish hospitals or worldwide I have heard the exact same stories from colleagues, friends and other relatives. This issue is certainly not limited to this particular hospital or even to Ireland.
Many arguments against moving to electronic records stem from aversion to change management, the concerns of increased clinical risk, ease of use etc, but rarely if ever is the decision taken with the patient experience in mind.
Food for thought...
Maeve Noonan - Former Chief Operations Officer, Sláinte Healthcare