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Physicians' Use of Clinical Information Systems in the Discharge Process: An Observational Study

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Abstract This study has been performed in order to categorize and measure usage of different information sources and types in a well defined stage of clinical work. The underlying motivation is to improve computer-supported presentation and retrieval
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  Physicians’ Use of Clinical InformationSystems in the Discharge Process:An Observational Study Inger Dybdahl Sørby a,b , Øystein Nytrø a,b , Amund Tveit a,b , Eivind Vedvik  a,c   a  Norwegian Centre for Electronic Patient Records, Trondheim, Norway   b  Department of Computer and Information Science, Norwegian University of Science and Technology, Trondheim, Norway   c  Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway   Abstract This study has been performed in order to categorize and measure usage of different information sources and types in a well defined stage of clinical work. The underlying motivation is to improve computer-supported presentation and retrieval of relevant infor-mation and to be able to evaluate the functionality of a future improved interface to theelectronic patient record (EPR). By observing and analyzing 52 discharge processes, wehave seen that the EPR is primarily used for background information and verification. Thereis a large potential for improved EPR systems that support the clinicians in the plan/future part of the discharge.  Keywords: Observational Study; Clinical Information Systems; Electronic Patient Records; The Discharge Process 1. Introduction The study presented in this paper was conducted in order to investigate to what extent clinicalinformation systems – in particular the EPR system – support clinicians in critical and informationintensive tasks such as the discharge process. The discharge process includes writing a preliminarysummary, having a discharge conversation with the patient, and writing or dictating a final sum-mary. The discharge summary serves as a basis for further treatment and follow-up of the patientwhen transferred from the hospital specialist to primary care. By studying how and where relevantinformation is represented in current clinical information systems and the cost of retrieving theinformation, we can get an impression of how the EPR supports (or does not support) the physicians in the discharge process. This is a step towards a more complete survey of informationusage in specific situations, which is necessary for future situation-aware and helpful user inter-faces to clinical information systems. 2. Background  EPR systems have been used in Norwegian hospitals for several years, but paper-based informationsystems are still essential in most patient-centred work [1]. The most apparent reasons are thattoday’s EPR systems do not support the health-care workers’ real needs as the systems are notalways available, they are not integrated with other clinical systems, they do not support theclinical procedures performed by the different health care workers, and they are not contextsensitive or adaptable to individual needs [2, 3]. The quality and content of discharge summarieshave been discussed in several studies [8,9,10,11]. However, few systematic evaluations have been performed to investigate why EPR systems are not more extensively used in the discharge process.In order to be able to develop EPR interfaces that really support physicians in the discharge of  patients, it is necessary to investigate how current information systems are used.The main research questions we wanted to answer by conducting this study were as follows:1. To what extent does the EPR system support the physicians in the discharge process?2. Is the physicians’ work related to the discharge of patients characterized by regularity?3. What areas of this process can be improved by appropriate computer support?Our main hypothesis was that the EPR system does not in particular support the physicians’information needs in the discharge process, and thus is not preferable to other information systems.We also presumed that the discharge process to a certain extent is characterized by regularity. Our third hypothesis was that certain areas of the discharge process can be improved by appropriatecomputer support. 3. Study design and methods The study was conducted at Department of Cardiology at a large Norwegian university hospital(922 beds) during the period March – June 2004. Two medical students performed non- participatory observations of physicians during the discharge process, including preparations,discharge conversations with the patients, and dictating discharge summaries. The students spenttotally 100 hours in one ward, observing the discharge of 52 patients. Every physician working inone particular ward (15 beds) during the study period participated in the study. The participantsincluded two chief physicians with many years experience in the ward, three medium experiencedresidents, three young residents who had just began working in the ward, and one house physician.The patients followed in this study were mainly suffering from angina pectoris or heart failure, andthe investigation of their heart diseases typically led to hospital stays of 3-5 days.In the initial phase of the study, the two observers worked together in order to co-ordinate their observation notes and to agree on a “standard” for the remaining observations. The observers useda note-taking form partly based on a form described in a textbook on task analysis for interfacedesign [4], pp. 270-271. The form was divided into three main parts. The first part included ninecolumns, one for each known/expected information source. The sources were  Patient record (paper-based), Electronic patient record (EPR), the patient chart, ICD-10 code overview, X-raysreports or pictures (including other picture results like CT and MR), Patient Administrative System(PAS, not integrated with the EPR), Physicians’ Desk Reference (PDR), Colleagues, and Patient  .Personal notes were an important additional information source for some physicians. During theobservations, the appropriate table cells were marked ‘X’ with an exception for the ICD-10 codesand the PDR which existed both on paper (‘P’) and electronic (‘E’) medium. In addition, thecolumns marked “Supplementary information” could be used if several sources were used to find,control, verify, or check consistency of some information.  However, in order to focus on patient-specific information, and eliminate regular use of static reference tools, we have omitted  PDR and ICD-10 usage from the further analysis.    The second main part of the form was used to describe the information that was retrieved from theselected information source. The last main part included a field for the observers’ personalcomments or questions, as it is important to separate their own thoughts and interpretations fromthe “objective” observations noted in the “Information” column [4]. The forms were filled inchronologically, from top to bottom. In addition to the notes taken by the observers, a few of thedischarge processes were videotaped for further analysis.The contents of the 52 observation forms were coded into matrices (one matrix per observation)containing information sources versus information categories. The information categories weretaken from a discharge summary template suggested by the Norwegian Centre for MedicalInformatics (KITH) [5]. During analysis of the results, the information categories were firstdivided into four disjunctive groups of different temporal significance: Future : Information that pertains to plans and future care. This group contains categoriesassessment, follow-up, medications, info to next of kin, and medical certificate. Present : Information about current state and hospital treatment. This group contains thecategories: Diagnosis and procedure, progress and treatment, findings and examination results. Past : Historic/permanent patient information. This group contains the categories: Allergies, previous illnesses, and reason for referral. Patient information: Information not related to the patient’s current hospital stay: Biographicaldata and family/social history.During the 52 discharge processes, a total of 735 information elements were identified, 688 of these were patient specific and belonged to one of the four information categories mentioned above.Figure 1 shows the relative distribution of the information elements retrieved from the differentsources. 4. Findings In the following sections we comment on some of our findings, ordered according to informationcategory and source. Figure 1 – Usage of human, paper-based, and electronic information sources.  Numbers are distinct information elements(totally 688). Column width indicates the total number of information elements in each information category.      4.1 Information categories Patient information is very static, and has surprisingly low reliance upon electronic sources(12%), main sources are the paper record and chart. The high percentage of human sources can beinterpreted as a validation of information (and patient identity). Past : Historic patient information is mainly from paper sources, which is costly and difficult tofind in old, and often large, records. Present : The paper chart is obviously the most convenient source of information, in addition toactually remembering the patient and the course of actions. Human sources are surprisingly littleused, even if they are easily available. There is considerable variation in work style; we have seenan effect of physicians writing personal notes, later used in addition to chart and other tools. Future : Much of this information is about plans and medication (involving colleagues and the patient), and the necessary assessment and decisions are often made during the discharge process.We have also seen that development of medication plans and prescriptions involve search in many  separate sources that frequently are inconsistent and incomplete [7]. 4.2 Information sources The EPR was used as information source in 27 of the 52 observed discharge situations, while the patient chart was used in 51 of 52 situations. The number of sources used in the discharge processesvaried from 1 to 9 (average: 3.77 sources). Figure 2 shows mean first use of the variousinformation source types in the observed discharge processes. The figure shows that paper basedinformation systems are most often selected as primary sources in the discharge process. Theelectronic sources were often used as secondary sources if the physicians could not find theexpected information in the papers. The confidence interval (CI) is quite large for theseinformation sources, and to what extent the electronic information sources were used varied a lot,depending on the individual physicians. The younger physicians showed a tendency to use the EPR as primary information source more often than the more experienced and older physicians. Thehuman information sources where mainly used as third choice, often in order to verify datacollected from other information sources. 5. Discussion The study presented in this paper was performed in order to investigate how physicians,exemplified by cardiologists, use various information sources in the discharge process. All the patients in the study had been treated for similar heart diseases like angina pectoris or heart failure, but there were large variations in their previous medical history and thus the volume of the patientrecords and for instance the amounts of medications of each patient. Consequently, these factorshad implications for how complicated the physicians’ work regarding the discharge process was.This is clearly shown in the individual observational notes, as they vary from only 2 informationelements to 25. Another aspect when analyzing the results is that due to limited time of the students performing the observations, not every observation included the entire discharge process. Most of the observations, however, included the physician’s preparation for the discharge conversation,including writing a preliminary discharge summary. Most observations also included the dischargeconversations, but due to time pressure of the physicians, the final discharge summaries were notalways written immediately after the discharge conversations, and hence some observations do notinclude the writing/dictating of these summaries. However, this also means that some discharge  summaries are written separately, some time after the patient left the hospital and possibly by adifferent physician than the one that performed the actual discharge of the patient. A few of thesesituations were also observed and are included in the analysis.The nine physicians that participated in the study varied in age, gender, and experience, both asclinicians and at the specific ward. Every physician had his or her own established working pattern,and this varied a lot from individual to individual. Even though the number of physicians participating in the study is limited, the sample is fairly representative as they included every physician working in the specific ward during the study period. In similar studies, prospective participants have been excluded if they had less than for instance one month of experience in theward being studied [6]. In our study, however, no such exclusion criteria were used, as we regard physicians with little experience of particular interest since they are even more dependent onappropriate information systems than the more experienced physicians.The quality of observational studies depends to a large extent on the observers; their knowledge of the domain, and their ability to transform the observations into data/written information that can beanalyzed. The subjects being observed might also be affected by the presence of the observers,however, by using medical students as observers this problem was hopefully minimized, as the physicians are used to being followed by students and house physicians. The note-taking form thatwas developed prior to and iterated during the study helped the students structuring their observations, and at the same time it allowed for comments and questions that could be discussedlater. The form was changed two times during the study, based on the students’ experiences andfeedback. The changes of the form only led to easier note-taking for the students, and had no effecton the content or the quality of the resulting observation forms. The observation forms were codedinto tables of information categories versus information sources. In order to ensure consistency,one of the students performed the coding of all the observation forms.Despite the weaknesses mentioned above about the methods used in the study, the analysis of more than 50 different discharge processes gives a good impression of how the various informationsources are used in the discharge process at the department of cardiology. Even though this is avery limited study based on only one hospital ward, this department is one of the most complexdepartments of the hospital, characterized by high activity and large variations in the patients’illness patterns, and thus hopefully it is fairly representative for several hospital departments.The analysis of the results has so far not been used for more qualitative descriptions of thedischarge process. However, the preliminary analysis shows that there is an obvious need for animproved interface to the EPR system that makes it easier for the physicians to retrieve and produce relevant information when preparing and performing the discharge of patients.  Figure 2 – Order of use per information source category
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