EHRs in aged care: the good, the bad and the unintended

A research team from the University of Wollongong investigating the experience of nursing staff in aged care facilities following the introduction of an electronic health record has followed up research from last year describing the benefits of the EHR with new research on the unintended adverse consequences they also experienced.

The UOW team, led by Associate Professor Ping Yu, has a formal research partnership with nine residential aged care facilities (RACFs) run by RSL Care, UnitingCare Ageing and Warrigal Care in various locations in NSW, Queensland and the ACT.

Last year, Dr Yu and her team published a paper in the International Journal of Medical Informatics (IJMI) looking at the benefits of introducing unnamed electronic health records in residential aged care facilities conducted at the same two data points – January 2009 to December 2009, and December 2010 to February 2011.

This year, the team has published a paper in the same journal on the unintended adverse consequences of the introduction of the EHR. The recent paper found that the main problems were avoidance in using the system, difficulty in access, increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up.

Semi-structured interviews were conducted with 110 care staff members selected through theoretical sampling, representing all levels of care staff who worked in those facilities.

Last year's paper found three categories of benefits perceived by the care staff members according to who gained the benefits: individual care staff members, residents and the facilities themselves.

The benefits to individual staff members included an improvement of documentation efficiency, information and knowledge growth as well as empowering the staff.

The benefits to residents were an improvement in the quality of individual residents’ health records, the higher quality of care and smoother communication between the residents and aged care staff.

For the facility itself, the benefits were perceived to be an improvement in the ability to manage information and acquire funding, an increase in their ability to control care quality, and improvements in the working environment and educational benefits.

The two aged care EHR systems used by the RACFs contained resident demographics, assessments, care plans, progress notes, vital signs, past medical history and current medical diagnosis.

For aged care staff, most of those interviewed reported their satisfaction with the EHR and the process of implementing the system. Eighty-seven percent reported good acceptance of the EHR and a reduction of paperwork after the system was implemented, with 81 per cent saying the EHR had improved time efficiency in documentation.

Easy and quick data entry was another benefit, as was quick data distribution and retrieval.

The staff also appeared to be able to get a broader and more holistic view of residents, as well as quite simple things like photos for each resident allowing new staff members to more quickly become familiar with each resident.

Staff found they were able to respond more quickly to residents’ care needs due to up-to-date information and significantly improved internal communication, and they were also able to communicate with outside healthcare providers with the timely information and quick responses facilitated by the system.

However, this was also a sticking point in the unintended adverse consequences paper for some of the staff interviewed. For some, the external communication benefits were not fully facilitated by the EHR system simply because some GPs would not use it.

“The outside health care providers, such as doctors, were the group of people who were most likely to not use the EHR system,” the researchers write.

“The reasons for GPs not using the system included: wanting to use their own electronic or paper-based system instead of recording duplicate information in [two] systems, which showed their concerns about system interoperability because of the data entered in the EHR systems in [RACFs] being unable to be sent back to their own offices and systems; having concerns about information security; lacking familiarity with computers; forgetting their account name and/or password or being too busy to record data.”

Fifteen members of the nursing staff (14 per cent) mentioned that they thought there was still a small number of staff members who were reluctant to use the system, due to either age, a lack of computer skills, lack of documentation skills or a combination of time limitations and staff preference for spending time with residents.

The researchers have designed a comparison table showing the number and percentage of participants saying there were either benefits or adverse consequences or both. For example, while 81 per cent said a major benefit was the convenience and efficiency in data entry, distribution, storage and retrieval, the highest percentage of those saying there was an adverse consequence was 40 per cent. Their main concern was inadequate functionality and poor interface design of the EHR systems.

Forty-four per cent said the EHR improved the quality of nursing documentation, but 22 per cent said it increased their documentation burden.

The benefits or unintended adverse consequences were caused by the initial conditions, the nature of the EHR system and the way the system was implemented and used by nursing staff members.

The researchers say that more research can focus on investigating how the unintended adverse consequences can be mitigated or eliminated by understanding more about nurses' work as well as the information flow in aged care facilities. Governance of EHR systems and risk management also need to be improved by organisations.

“Further research should focus on investigating how the [unintended adverse consequences] can be controlled or eliminated by understanding more about nursing staff’s workflow as well as the information flow in [aged care facilities] for the purpose of improving the design of the EHR system to fit with nursing staff’s work process and information needs,” they write.

“This requires a constant software update in response to end users’ feedback. Implementation strategies should be improved to promote user engagement, acceptance and usage of the system to optimise the value of the EHR systems.”

Posted in Aged Care

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