(HealthTech Wire / Interview) - GPs and psychiatrists alike, once wedded to pen and paper, have been catapulted into a ‘brave new world’ with clinical documentation with electronic patient records. In a month that sees the publication of ground-breaking new research on the subject, we asked consultant psychiatrist Joe McDonald, CCIO at Northumberland, Tyne and Wear NHS Foundation Trust and chairman of the DigitalHealth.net CCIO network, about the importance of clinical documentation for today’s healthcare professional.

What kind of role does clinical documentation play in your clinical practice – and in UK healthcare as a whole?

For a psychiatrist, it’s considerable. We’re basically recording people’s life stories, coming to some sort of formulation of the problem and then developing approaches on how to make things better. So we have to record a great deal of narrative material – and some structured data as well.

For the healthcare industry as a whole, it’s absolutely essential to have accurate information about patients. The quality of any decision you make is dependent on the information you have – and the more detailed it is, the better. If you look at any of the newsworthy tragedies in my field, the phrase that always comes up in reports is, “failure to communicate” – and that’s usually about important information about risk not being communicated between professionals or institutions. Documentation is extremely important. 

Can you give some examples from your experience and in particular from within your specialty of the implications for clinicians and patients, when clinical documentation is not of the right quality?

The example that springs to mind is a case some years ago of a charity worker who was murdered by a psychiatric patient on a home visit. My organisation had historical information about the threat that the person concerned posed – in terms of his having been very violent in the past – but this information was unfortunately not shared across care boundaries at that time. This is a very sad example and one that has really been uppermost in my mind in our own attempts to get joined-up information systems here in the north east. 

What are the key attributes of clinical documentation that enable healthcare professionals to practice/consult more effectively?

First and foremost the system has to be easy to use. If it’s clunky and difficult, with a million clicks, it just won’t be adopted – or if it’s got to be typed, then clinicians of a certain age may record much less information than, say, if it’s speech-recognition-aided, or if it’s handwritten.

So usability is the key to any clinical documentation system. And systems in healthcare are often not as user-friendly as those that you might find, say, in your own home-computing environment – often because the operator has not been sufficiently involved in the design of the system. There’s a lesson to be learnt there! 

How does the fact that many clinical systems are now electronic (and many Trusts are now deploying EPR systems and portals, bringing information from disparate systems together in electronic form) impact upon clinical documentation, from a clinician’s perspective?

I think the problem is that handwriting is really hard to beat. It’s a really fast way to record something. As a man of a certain age, I never really learnt to type – not like the junior doctors of today – so it was a showstopper for me, when we went onto electronic patient records. What used to take me an hour – I’d write notes in the consultation then write them up – would take me two hours when we went electronic.

You get some of that time back, of course – because it’s stored electronically, you don’t have to search for the information – and other professionals don’t have to take down that story again every time they see the patient – but it can feel like you’ve gone backwards for a while with electronic records. If the system’s really intuitive and the clinician understands it, however, it can change things for the better, though, of course!

Do you think clinical documentation is helping meet the goals of a ‘paperless NHS’ (and for each citizen to have access to their own patient record by 2020)?

It’s not just about becoming paperless: we need to use the electronic patient records to do some of the work! And I think that patient access is really important in that respect because, first, it’s a quality check on what’s in the notes (the patient knows what’s right about them better than any professional) and, second, as we move towards more patient access, the patient will be able to do more of the ‘admin work’.

In the same way as, if you want a cheap flight, you go to EasyJet – but they make you print your own boarding pass, check yourself in and do all your demographic input – once you have access to your own patient record, rather than an army of clerks that the NHS employs to do all that for you, the patient can do most of the admin themselves – and save the NHS a whole lot of money! And of course the patient feels a whole lot more involved and engaged in the process, too. 

How do you envisage an increasingly integrated healthcare system impacting on clinical documentation needs?

I think the integration with social care is important in terms of making healthcare more efficient. I think it is difficult to share documentation across such a wide group, however, as there are different cultures within social services and the health service – around confidentiality, for example – and it’s going to take a whole lot of work.

I think the technology is there to share the information, but I think the cultures of the various institutions will need some bringing together – and I think that will take a lot of time. There are a lot of local information sharing agreements going on now – one of the best examples being the Hampshire Health Record, where a number of different hospitals and social care institutions have come together to agree how to share information across institutional boundaries, with considerable success.

Can you give some examples from your experience and in particular from within your specialty of the implications for clinicians and patients, when clinical documentation is not of the right quality (ie timely, accurate and complete)?

The example that springs to mind is the case of charity worker who was murdered by a psychiatric patient on a home visit in 2006. My organisation had historical information about the threat that the gentleman concerned posed – in terms of his having been very violent in the past – but this information was unfortunately not shared with the charitable association the patient worked for – and they died because of that. This is a very sad example of when information doesn’t cross a boundary people can die. And that case has really been uppermost in my mind in our own attempts to get joined-up information systems here in the north east. 

There has been much research on clinical documentation over the years, including studies that have looked at level and structure of clinical documentation. Do you think we are any nearer to having the kind of patient record that those working within the healthcare system can really begin to rely on?

We’ve been talking about getting some better structure into the record for a very long time. The Tunbridge report (1965) talked about it; and there’s this great Larry Weed video on the record – in black and white, so it shows how long ago this was – about how bad our patient record systems are.

I think that it’s only now that we are starting to get near the electronic record that we’re really beginning to really think about how we structure it. And I think that the work that the Royal College of Physicians is doing to get a standard around the record is very important, as well as the creation of a new professional national standards body, which has just been funded by the Government to try and get some standards around this.

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