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!
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I suggested ICPC coding be considered when Ontario first began using billing codes decades ago…..was told such data would never be used for research?!
Glad I’ve survived to know I wasn’t making a lone barmy suggestion.
Hi. Dumb question, but can you remind me (and perhaps others) what ICPC coding is?
the international classification for primary care is wifely used in Europe.
As a family physician with over 30 year’s experience of electronic records in Scotland who has recently had to start using a Canadian Electronic Medical Record(EMR) I can sympathise with Dr. Muldoon’s pleas. The use of a classification system (ICD-10) which is incompatible with primary care seems incomprehensible to someone used to READ and familiar with ICPC. The predictable consequence of unsustainable demand for data entry is that clinicians cannot use the functionality of their EMRs as effectively as they would wish. This contributes to the lack of continuity of information for patient care which afflicts family practice here. As a result patients in Canada fail to benefit from the advantages of EMRs which include :
More complete health records and more accurate health data;
Faster, interoperable access to patient records by health care providers;
Reduced errors within individual records and across records;
Reduced redundant testing and diagnostic procedures;
Satisfying the growing demand of patients for flexible access to their own health information;
Better longitudinal tracking of patients and patient groups;
Better communication among health care providers and patients;
Improved tracking of health care costs and benefits, thereby enhancing understanding of the economics of health care delivery.
The basic principles of good care for long-term disease have been known for more than 20 years: Register, Recall and Regular Review.
Family practice in Canada has come late to the meaningful use of EMRs but that should enable us to learn from painful lessons learnt elsewhere to achieve the better care and lower costs that good data effectively and securely shared can bring. For example, GPs in the UK made recording less onerous by agreeing to limited lists of codes which would be used, and civil servants insisted that vendors adhere to interoperability standards.
The only recommendation made by Dr. Muldoon which I would disagree with is her 6th : ‘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’.
Clearly no-one is in a better position to record information about a consultation than the family physician, apart perhaps from the patient. Both perspectives are important. If EMRs in Canada are to make a significant contribution to patient care, then the ability to record as accurately and completely as possible within the time constraints of a consultation is likely to remain the responsibility of the clinician for some time.
No country which has achieved these gains has been able to avoid the early pain of data recording. Many have had more functional EMRs and less onerous coding systems than Canada currently enjoys.
From a patient’s perspective they may feel better served if connectivity of their care is facilitated by the diagnostic classification system being used being synchronous along their journey – i.e. hospitals use the ICD system here in Ontario – interoperability may be better facilitated if primary care does the same. Whereas there may be reason for comparison with others in the world, this is less of a priority to patients. On that point I am not sure if anyone other than the UK uses READ?
In 1992 a Data Standards work group reported their recommendations on this issue and for the above reason recommended ICD as the preferred diagnostic classification system in primary care. They did recommend ICPC to capture reason for visit.
I think things have moved on Phil,
ontology engines can map codes back and forth between different controlled vocabularies to UMLS. I’ll send you an email with a diagram and a couple of projects I am involved with which do that.
Best
Why can the patient not complete their own (hopefully Electronic Adjunct to existing record) questionnaire/survey before seeing the clinician? If there is an increasing drive for EMR a module for patient driven entry of their own data makes sense to me. Workload solved and Patients often appreciate the feeling of control over their own health information even if it is entered into the same record and ‘private’, standard medical recording takes place.
Well done, Laura.
There are two important issues here: volume of data gathering and the quality of EMR interfaces.
With respect to data gathering, I have often said that healthcare system administrators and researchers never met a data element that they didn’t like. As a result, they lobby hard for clinicians to collect data beyond what we require to safely care for our patients. If they are successful at imposing their desires for data collection, clinicians spend more time per encounter, reducing their efficiency.
However, it’s not just the clinicians who pay the price for allowing administrative priorities to take precedence over sensible care: the additional data collection interferes with the flow of the patient encounter, intrudes on the clinician-patient relationship and in reducing provider efficiency, leads to less availability of the clinician to the patient.
That’s why we clinicians need to strenuously advocate for policies that properly recognize the primary use of clinical data collection: to care for the patient and to document that the provider has met the standard of care. Secondary uses – research and administration – should have to prove the worth of gathering anything more. And claims of data “need” should be evaluated in terms of both quality and expectations that the data will have durable value.
With respect to the EMR interface, all clinicians continue to be subjected to inexcusable data-entry demands by almost all products. I’ve written extensively about this in the eHealth section of on my own blog: http://www.healthcareinsighter.com.
Mark Dermer, MD, CCFP
Sorry!
I think this one will work…
http://www.cihi.ca/cihi-ext-portal/pdf/internet/lessons_phc_vrs_proto_en
Hi Laura,
The CIHI link is not working, could you please repost it?
Regards,
Tina Nguyen