Three papers in this week's Medical Journal of Australia have highlighted the ongoing complexities of integrating large health IT systems with clinical practice, particularly in the acute care sector.
In a retrospective study of the introduction of Cerner's FirstNet emergency department electronic medical record system at the Nepean Hospital ED in Sydney in 2009, researchers found that when the new system was introduced, there was a significant increase in the waiting time for all patients compared to the control period.
They also found an increase in the waiting time, treatment time and total time for discharged patients after the introduction of the system.
The researchers – Nepean Hospital emergency registrar Murugabalaji Mohan, director of emergency medicine Rod Bishop and director of emergency medicine training James Mallows – also found that there were statistically significant increases in the did not wait (DNW) rate and the proportion of ambulance offload times longer than 30 minutes.
The authors state the limitations of the study, which was conducted retrospectively and looked at a six-month period in 2009 compared to the similar period in 2008, when the hospital was still using the EDIS system from iSoft.
Some data could not be compared as it was not available in one or the other system, and as it was a retrospective observational study, the authors state it is not possible to directly control for confounding variables such as staff numbers, shifts worked and the time taken for inpatient reviews and acceptance of an admission.
However, the researchers found that overall, the implementation of the EMR was associated with a deterioration in ED key performance indicators.
In an accompanying commentary, University of Sydney professor of language technology Jon Patrick and emergency physician Sue Ieraci wrote that while the study was limited and could only show correlation with ED waiting times, not causation, the premise for the study delivers an important message.
“[The] work required to use the information system was perceived by the ED staff to directly conflict with time spent with patients,” Professor Patrick and Dr Ieraci wrote.
Professor Patrick has been a fierce critic of FirstNet in the past, with his research showing that it was perceived to have had a negative impact on the care of patients, as well as the productivity and morale of staff, in six EDs in NSW.
In their commentary, Professor Patrick and Dr Ieraci wrote that one of the key issues for high-volume, high-risk workplaces like EDs is the struggle of conflicting aims.
“While hospital managers need information systems for data collection and storage, clinicians need efficient clinical documentation, data retrieval and order-entry systems that save time rather than steal it from the patient,” they wrote.
“The work of clinicians is aided by reliable data but impaired by the delays of real-time input, difficult system navigation, suboptimal presentation of information, and other problems in the user experience of health information technology (HIT).”
They wrote that while an EMR system may be good HIT in some environments, the need to be “hypervigilant about the accuracy of the information” supplied by the EMR “compounds an already stressful clinical environment, which in turn leads to resentment towards the technology and the people who have imposed it”.
This turns "good" HIT into “bad” HIT, they wrote. “Unless this is corrected, HIT efforts will overuse precious health care resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.
“It is not enough just to identify problems: effort must be invested in transforming bad HIT into good HIT.”
In an editorial in the same issue of the MJA, Enrico Coiera, director of the Centre for Health Informatics at the University of NSW's Australian Institute of Health Innovation, discussed why eHealth is so hard.
Professor Coiera wrote that although the Nepean Hospital ED study was a valuable contribution, it only measured time as a system cost and only at ED rather than whole of hospital level.
“The study did not measure benefits of the new system, such as improved quality or safety of care, and for any intervention it is the balance of cost and benefit that makes the case,” Professor Coiera wrote.
However, with evidence for eHealth's potential to improve safety and quality care growing but still remaining patchy, Professor Coiera pointed to a “long list of disappointments and failures, locally and internationally … that is hard to ignore”.
“There is a real dissonance in the discourse between what research evidence tells us is possible and what often happens with large-scale e-health projects in practice,” he wrote.
Professor Coiera believes that eHealth “is hard because it is a complex intervention in a complex system”, and that a lack of a suitably trained health informatics workforce is compounding the problem.
“The very first rule of informatics tells us to start with the clinical problem we want solved rather than the technology we want to build. Yet, too often, large-scale e-health projects break this most basic rule, focusing on technology rather than compelling clinical problems.
“Despite the crucial role of the informatics workforce in e-health success, and the billions spent on e-health over the past decade by government, barely a dollar has been in direct support of informatics workforce training.”
However, he wrote that just because eHealth is hard does not mean we should ignore it, as the goal is worthy.
“We do, however, need to urgently invest in the informatics workforce, as this is no game for amateurs. We must also respect the basic rules of informatics. Like the laws of physics, they exist, whether you like them or not.”
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