Week 4 Topic 1 Health Information Exchange

[Saranath]

You have learned the benefit of Health Information Exchange. The Electronic Medical Record (EMR) is one of basic structure in order to exchange information among different departments/organizations.

Recently, there are many reports stating that EMR is one of top leading cause of physician burnout. Here is an example: https://medcitynews.com/2019/03/physician-burnout-ehr-satisfaction/. EMR/EHR are the second-leading contributor to physician burnout, according to a survey of 6,849 physicians in the US.

What do you think about this finding? Have you ever heard any complaints from health officers (or yourself) on using EMR? Any suggestions to avoid or reduce this problem.

[tullaya.sita]

As a clinician, I totally agree with these findings. In the old days, clinician writes down what they want to describe for each patient freely in the blank paper including the provisional diagnosis which may be not categorized into the diagnosis code. Writing down in the paper doesn’t take a lot of time and it can be finished at the worksite.
When the EMR era has come, all inputs into the systems come from typing into the computer and when we need to draw a picture it usually difficult to draw and label on the picture for describing physical examination. Furthermore, entering the diagnosis to the system usually use ICD 10 code, that needs higher knowledge than basic diagnostic term, to fill in the blank. If the ICD code does not correct, users are not allowed to skip to another step and maybe cannot finish the EMR.
Also, the laboratory order and medication use the correct name that matches with the database in the system and may need to key 1 time for one order, not one set of order.
All of the above takes a lot of time for physicians to focus on the EMR not on the patients and may influence the physicians to lose eye contact and human touch for patients during the work. Some of the physicians leave the EMR job during the on-duty time and complete it after hour. As it takes a lot of time and decreases the duty-free time the physicians feel burnout for doing this, they think not important, things.

My suggestion to avoid burnout of physician on EMR is
– Use technology to create the input easily such as voices that can convert to typing, use the precise stylus to draw and label findings in physical examination
– Diagnosis term in the database should be a combination of medical diagnostic term and ICD 10 and also use the free text column if the diagnosis given by the physician is not matched to the database
– Laboratory order should be typed as an individual and a battery of common test, the list of the test should be list by frequency of use for easily findings
– Medication order should be allowed to type both generic and tradename to find the medication and have a standing dosage and frequency for easily order. In addition, if physicians want to correct the dosage it should be done easily with the physician’s common term, not the text book’s common term

[Saranath]

HI Tullaya, totally agree with you. It take a lot of time and afford to enter data into the EMR system. Most system does not design to assist physician’s work. I can imagine how hard it is to implement EMR in such a large hospital with lots of patient visits a day.

[tullaya.sita]

It’s very difficult especially for out patient department. Nowadays, the EMR of my hospital is the photocopy of paper-base medical record integrated with the link to previous prescription order, lab results and PACs system. which allow physician to easier retrieve the data of their interest.

[Chalermphon]

I totally agree with these findings because EMR doesn’t have anything more than in the pass but change system for collect the health data to standard of electronic file systems and structure data that are related to increase quality of treatment , diagnosis and follow up but every thing are very difficult to learning because take a time to complete cases and criteria of processes.

I don’t working in a field that relates to used The Electronic Medical Record but I worked with the data of surveillance system. I usually find out with the missing value of health information such as date define, date sick ,ICD10 that are related with the diseases situation.

Suggestions to avoid or reduce this problem. I think friendly use of application or programs is very important such as decrease human error by Choice more than type and date error by calendar choice.

[Saranath]

Hi Chalermphon, as data users side, you would see the quality of final dataset if the data input was not effectively implemented. This could limit the use of data for Public Health.

[Pacharapol Withayasakpunt]

In my experience, I totally agree with the findings. Other than typing, there are still many challenges that need to be research into.

– Drawing and video capturing should be easy, like LINE logging, or paper scanning.
– Typing in the wrong place is real. Must be fixed, maybe via UX research, or even perhaps Natural language processing.
– Bad at typing might be fixed with OCR or Speech Recognition. Even typing should not be forced, but there should be attempt to scan written doctor’s notes.
– Channeling the tasks and grunt works to IT personnel, if possible. Hire people as necessary.

I actually think that ICD10 should be extended to the countries and regions as deem necessary, but the need to be balance between filling a large form and completion of data. Again, Natural Language Processing and Speech Recognition, of wholly written string, or speech might make easier.

Anyways, I believe that the single most important thing is UX research, for friendly UI. Another research to be made into should be text body processing – Natural Language Processing, and Speech Recognition.

[Pacharapol Withayasakpunt]

Thinking deeper. I think it is about bad priorities.

http://disq.us/p/259qt0o

The EHR is good for capturing costs, Jones noted, adding that they’re more geared toward capturing the billing information for insurance companies.

I would say that EHR is systems first.
– quality of care, second
– patient satisfaction / PMR, third
– doctors’ feedback, last

It is mostly top down. They don’t care about feedback.

[Saranath]

Yes! This is the main problem. If the system was designed with the aim only to get as data as the organization want while does not think about people, the system is likely to be against by the users.

[Ameen]

I am not a clinician or even in a clinical setting. However, I have emotionally involved with that. I used to have a daily routine entering data into the system comparable to EHR. The data entry, at my company, is more than two systems plus spreadsheet occasionally. We were feeling like a machine, putting something into what we don’t know where it is going to go.

I felt that because I was not directly getting any immediate benefit from that.

I think many professions have been working with EHR-like systems for quite long compared to health care. The finance sector, for instance, has developed familiarity with EHR-like systems. The system has been merged into the field as work culture, so they do not feel burnt-out from that. It’s normal for the industry already.

I accept that the industry is incomparable to what physicians do in everyday life. The clinical field is more technical and more abstract.

I was burnt out too then. But now I am the one who can get benefit directly from the data entry. Without dedicated data entry, my report is nothing.

So to make sure that my report can have good data at all times, I often asked my junior to see my dashboard, and where the good data comes from. I could provide them such data for their personal interest or performance development if they need it. From my experience, they felt more energetic to do the routine when they know they can get immediate benefit from that personally not in general or as part of the whole.

I know this cannot compare to the hospital setting. Still, I would like to share the importance of communication and engagement within the organization. Hospitals should think more about how to motivate, reward, or encourage health professions, in general, by making the EHR be more friendly to health worker i.e., Professional development, particular own field interest, or maybe incentives to improve the satisfaction.

[Saranath]

Ameen, yes having potentially benefit both at individual and organization is really important for system implementation.

[Pyae Phyo Aung]

Most of the health care providers (Physicians, Nurses, Lab technician) complained about EMR that it is wasting their time. They do not satisfy the benefit of EMR comparing to their time spend. EMR is not user friendly and took more time to complete.
To avoid or reduce this problem,
We have to listen to their voice and get feedback. (Suggestion and autocompletion for faster data entry)
Make software development from feedback.
Ask what benefit do they want from EMR. (Reports, utilization tools to assist daily clinical work).
Make call centers for technical assistant.

[Saranath]

Hi Pyae, it would be great if the developers can listen to the users and modify the system accordingly. However, most hospitals (in Thailand) do buy a hospital management system package from somewhere. Unfortunately, many hospitals do not have a programmer that is capable to fix or modify the system. As I think the feedback or comments on the system might be varied from hospital to hospital. Having customized system would be great, but it might be difficult to do at current setting.

[supawat.cht]

In our hospital, EMR is not fully function yet so I think there must be some problems which may include physician burnout. Therefore, the paper based medical records are scanned instead. In the future, I hope to see the new EMR that more flexible such as can draw a picture of patient lesion.

[Saranath]

The problem of scanned records is that we cannot make use of those data effectively. With conventional analysis technique, it would be difficult to analyze this information.

[weerawan.hat]

I think it is true. For me, I have not personally heard any complaints on using EMRs. By the way, to reduce this problem, we may need
1. Personalization.
Most EHR systems have ways to personalize the user experience, for example, using text extenders/expanders. A short sequence of letters or a word can be used to auto-produce a longer string of text
2. Local expertise. If there is a clinician or staff member who is EHR-savvy, consider giving this person time to expand his or her EHR work for the practice. The person could provide support to other staffs in using the EHR, develop practice-level personalizations, interact with the internal technology group to report concerns and learn about new functionalities, and share EHR tips during practice meetings.
3. More training to effectively and efficiently use the EHR
4. Alternatives by using scribes or voice recognition software
5. Protocols/workflow shifts. Daily routines may benefit from a protocol that either can be automated or completed by support staff.

[w.thanachol]

Firstly, I agree with Mvidhyagorn that those who feel burnout do not satisfy what they are doing since they do not know the importance of their job. Especially, the frontline people who have multitasking in their routine job, they would burn out since they do not understand deeply why they have to put the data in electronical record rather than paper-based. Secondly, I also have heard that EMR software is not user-friendly. They cannot reduce their workload by converting to EMR because the software does not integrate into every taks they have, yet the redundancy is still. Lastly, frontline staff are not trained sufficiently before system is implemented, many of them do not realize that they could use the information from EMR, thus they cannot reduce their routine job. For example, they keep counting the key performance index manually instead of using that information from EMR. However, we can mitigate these complaints by three stakeholders.
1. The software developer should recruit health officers, doctor, pharmacist, nurse and anyone who have to enter the data to collect their insight and always update the program to satisfy the user experience.
2. The hospital director or executive staff in the hospital would better communicate with frontline officers about how EMR could benefit their organization and how can it can improve the quality of care.
3. EMR training should be conducted intensively to all staff when implementing the software, and give the training to all new staff before they start their job. Thus, they will feel less struggling to learn the EMR while doing their routine tasks.

[Saranath]

Thanachol, totally agree with you! People part is the most important for system implementation.

[tullaya.sita]

Thanachol, I’m agree with you that people at the frontline will be the first one to feel burnout, because they did not well understand the benefit of this system and not satisfied. By the way, the clinician who already knows the benefits also easily burnout, because they face with the stress of the patients wish (to have fast and complete service) and more workload on them that have the same results in terms of patient care.

[THONGCHAI]

I am not a clinician but i think so that The Electronic Medical Record (EMR) is cause of physician burnout. beacuse it make many workload to record every detail of health patient data to digital data.

My suggestions to health clinician to easily input The Electronic Medical Record (EMR) to used technic voice tranfer to input data or convert speech into data instead of typing , because voice or speech is normal and easy to work in all day and save time to work with computer.

[Saranath]

I’m just thinking what would it like to have voice transfer record for EMR. Doctors would need to record their voice describing patient’s findings. Still, this process should be done in extra of their routine work. Doctors might need to record after seeing the patients- this also create an extra work for them.

[Penpitcha Thawong]

I have no idea about it, so I ask my friend about how she thinks about EMR. She is a clinician in a local hospital. She told me that EMR can be one of physician burnout because most clinicians prefer writing in the paper follow what they want to explain. Although the EMR system allows her to draw the picture, but it is very difficult to use a mouse to do it. Also, the EMS system may lead to information missing because typing the number seems to be waste time more time than writing. Therefore, some clinicians will ignore some information that they think that is unnecessary.

In my opinion, if the EMR system is designed to follow the user requirement, it will be work. In fact, many health programs usually create from only IT staff and may not try with the real situation. Therefore, the system always not work.

[Dr.Watcharee Arunsodsai]

As a clinician, I totally agree with these findings. In the old days, clinician writes down what they want to describe for each patient freely in the blank paper including the provisional diagnosis which may be not categorized into the diagnosis code . Moreover, most clinician can not remember the exact clinical diagnosis code. Writing down in the paper doesn’t take a lot of time and it can be finished at the worksite.
When the EMR era has come, all inputs into the systems come from typing into the computer and when we need to draw a picture it usually difficult to draw and label on the picture for describing physical examination. Furthermore, entering the diagnosis to the system usually use ICD 10 code, that needs higher knowledge than basic and common diagnostic term, to fill in the blank. If the ICD code does not correct, users are not allowed to skip to another step and maybe cannot finish the EMR.
Also, the laboratory order and medication use the correct name that matches with the database in the system and may need to key 1 time for one order, not one pack of order.
All of the above takes a lot of time for physicians to focus on the EMR not on the patients and may influence the physicians to lose eye contact and human touch for patients during the work.
In my hospital, we have to handle both paper-based and EMR at the same time in OPD. So some doctor will skip EMR and pay more attention to paper-based record as more convenient and they can use acronym as they usually use or vise versa. As it takes a lot of time and decreases the duty-free time the physicians may feel burnout for doing this if they have to be perfect by completely fill in both record.

My suggestion to avoid burnout of physician on EMR is
– Use technology to create the input easily such as using the precise stylus to draw and label findings in physical examination or create more drop down menu which is user friendly in the system.
– Diagnosis term in the database should be a combination of medical diagnostic term and ICD 10 and also use the other coding system database.
– Laboratory order should be typed as an individual and a battery of common tests, the list of the tests should be listed by standard of care.
– Medication order should be allowed to type both generic and tradename to find the medication and have a standard dosage and frequency for easily order. In addition, if physicians want to adjust the dosage according to the patient’s condition, it should be done with help in an easy manner.

[imktd8]

Although I have no experience about EMR before, but as an IT implementor, there are a lot of factors that effect to user from software design that not support to the real working, for example, unclear user requrement, lack of hi-technology to support, the complex of input data etc. Then ease of use and user friendly are the important factor nowadays.

As a recently reports, state that EMR is one of top leading cause of physician burnout. This is the new thing for me because my work is not relate about EMR. I try to read more information and I totally agree with these findings which effect to physician’s efficiency and productivity.

For some suggestions to avoid or reduce this problem as below:
– Share issues or obstacle from EMR using to team for improvement.
– Integrate EMR to the releated legacy system. This can improve your practice efficiency and reduce your workload by automating certain task.
– Apply hi or new technology to automate/suggest data. This will decrease time to input data.
– Dedicate a few hours a week or a month to learn how to best use your EMR can increase physician’s efficiency, satisfaction and confidence in using the system)

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