As a primary care physician, I support using data for quality improvement and research. But when I recently helped a family medicine resident complete a research project, flaws in our current system became evident.
Her chart review was focused on women in prenatal care who had no health insurance at my workplace, the Somerset West Community Health Centre in Ottawa. Despite a very well-designed study and reasonable record keeping at our practice, we were unable to determine whether uninsured women received different care than women with insurance.
The issue was caused by scattered records of care and our difficulties keeping tack of the women’s insurance status, which often changed throughout the pregnancy. The resident and I wondered if in the future, the clinicians could make notes about each woman’s insurance status on the antenatal record. This thought led to a discussion with our clinical team about what information should be collected and recorded in our medical charts, when and by whom. It’s not the first time we’ve talked about this issue.
We work in a Community Health Centre (CHC), where our funders and provincial association insist that we complete many “required fields” in our electronic records each time we see a patient. The information we enter is used by our CHC and the provincial organization of CHCs for quality improvement, by our funders for accountability, and (with the appropriate ethical and privacy safeguards in place) by researchers.
Many of these fields, including the reason for the visit, the services provided, the language spoken in the encounter, the assessments and the procedures performed, require us to choose from a drop-down menu or search a list of diagnostic codes.
As clinicians, we grumble about this time-consuming process and question whether it contributes anything to clinical care. We would much rather write a free-text SOAP (Subjective Objective Analysis Plan) note. It’s faster, much more like what we did when we had paper records, and lets us use terminology and abbreviations that we already know.
However, what is easy and fast for us to do in the clinic may not be very useful for other purposes such as research and quality improvement. When the Canadian Institute for Health Information conducted a study that involved extracting data from electronic medical records in many different primary health care practices across the country, they discovered that most primary care practices free-texted, and that cleaning and making sense of the data were prohibitively expensive and time consuming. The Canadian Primary Care Sentinel Surveillance Network is a cross-Canada electronic medical record surveillance system and research network for participating family practices. The network has dealt with the conundrum of making sense of EMR records by limiting the number of conditions examined and developing algorithms to identify patients with these conditions.
How much standardized information should primary health care clinicians record? Or maybe the real question is, how much standardized information will primary health care clinicians record? I haven’t done any measurements of the time it takes to do free-text SOAP charting vs clicking and picking from menus, but I’m confident that the latter takes longer in almost every situation. Our days are already pretty full, and none of us wishes to spend more time with our computer than with our patients, unless we can see the value of the exercise to ourselves and to our patients, both now and in the future.
I’d propose the following standards for data fields clinicians are expected to complete:
- The information should be useful at the point of care, either now or in the future.
- Terminology should be consistent with usual point of care terminology in primary health care in Canada.
- Search engines for pick-lists should be as user friendly as possible (for example, they should be able to find words that are contained in a phrase, not only the first word of the phrase).
- Redundancy or double-entering data should be avoided at all costs.
- Standardized data entered by clinicians that is mandated by their organization or an outside body should actually be used regularly by the organization or the outside body.
- Entering the data should be done by the primary care provider only if no technologic process exists to generate it or no one else in the organization can do it.
I love data, research and improving care. And I love to be able to prove that I’ve done what I claim to be doing. But I also love getting home before midnight after a day in the clinic!