But how it is done, by whom, and, for what purpose? This is a vast and specialized area that needs to be understood if the switch from pen and paper to computer and a digital record is going to be accomplished smoothly and successfully.
Dr. Marianne Tolar and Dr. Ina Wagner, both of the Vienna University of Technology, conducted a study to take a look at documentation systems within a large clinic in Vienna. This was done in order to better understand how people accomplished all these tasks with the idea that eventually it would all become part of an electronic process.
There are endless bits and pieces of information that get recorded when people are treated within a health care system, many of which patients never think about. These include:
- Making sure the right person gets the right treatment and medications
- Finding out what was done, when it was done, and by whom, perhaps even in which location
- Describing what is going on with the patient at any given time
- Recording what is planned, what is speculated, timelines (e.g. when discharge might occur
- Communicating information to others, locally and far away, perhaps even in another country
- Preserving an historical archive of what has happened in the past, not just this admission (these old charts re-appear on each admission)
- Articulating personal preferences, family situation, social aspects, other information that pertains to the condition (e.g. a mental illness or an allergy)
- Specifying where people are in their treatment trajectory, e.g. waiting for surgery, had surgery, waiting for long-term care, ready to go home
Obviously there’s a lot of things to keep track of and a huge number of things to co-ordinate. Sometimes just locating the chart can be a challenge as it travels from central storage areas to hospital wards where it is needed because the patient has now been admitted to the hospital. What is also crucial is that the information is accurate. We have all heard of health-care horror stories when the wrong treatment is conducted with the wrong patient. As in most systems, the wrong information can be worse than no information. In hospitals mistakes can be particularly frightening. Even doing the same test twice because someone forgot to record it can be costly and inefficient.
Tolar and Wagner did their work in two of five oncology clinics within the Vienna Hospital Association, one of the largest such organizations in the world. This health care system has a staff of 32,000 and an average of 400,000 patients seen yearly.
Observations were conducted in outpatient clinics, day clinics, wards, and many other sites. By looking at who did what, the types of forms and written records that were produced, how they were used, by whom and so on, they pieced together a comprehensive view of the entire documentation system. All of this in preparation for the time-honoured paper chart to become a digital record.
Patient documentation at the Vienna hospital has developed over many years, just like every other health care documentation system. Records are not only created, but also maintained, updated, filed in the right place, checked for accuracy—all things that will also need to be done in an electronic version. It’s a system that has come about through trial and error. So part of the problem is that it is not an easy task to switch quickly to a digital system when the paper-based on has evolved over such a long period of time. As with the introduction of anything new, there will be speed bumps along the way and things that work better than others. This might be in sharp contrast to expectations, which are usually high. And of course the flow of patients can’t be stopped just to put computers and keyboards into place.
Oddly enough, computerization introduces new limitations. For example, a paper chart can travel anywhere. But once all the information is online, a computer is needed to access that same chart. Perhaps a handheld device or table PC would help in this case.
The key to success, according to Tolar and Wagner, is to implement the system slowly, carefully, and continuing to observe and listen to users for their feedback. Everyone has to cooperate.