Perceived Usefulness of Data Entry Tools in Medical Encounters: A Survey

Abstract

Electronic Health Records allows direct data entry and is an important factor for accurate diagnosis. However, two drawbacks of this system is the time needed to create them, which can reduce health care professional productivity, and the fact that it is error prone. It is important, therefore, to select the most appropriate methods and tools for data entry by the health care providers at the point of care in order to minimize a loss of productivity. The study aims to understand health care professionals’ perceptions of the data entry process, and determine the appropriate methods, tools and functions that would facilitate the process, minimize loss of productivity and improve quality. A questionnaire which consisting of 18 basic questions (including demographic data) was posted on a web site which hosts questionnaires, on an established online community space and also mailed to health care professionals who are working in various hospitals for a duration of 10 months. Totally, 533 medical care professionals who are primarily from Turkey participated in the survey, of which 284 were medical doctors, 127 were nurses and the rest, other medical professionals. While the clear majority of participants involved in data entry use keyboard and mouse, most expressed a preference for more convenient methods, such as voice recognition or touch screen. Furthermore, physicians reported rarely spending more than 15 min for each consultation and conducting 21–30 examinations a day. The main motivation for creating an efficient direct data entry is to increase time allowed for patient examination, and to improve accuracy of diagnosis. Despite a heavy workload, health care professionals are very receptive to the idea of using a convenient data entry tool and keeping electronic patient records. Emergent data entry technologies in health sector can improve the quality of examinations, physicians’ productivity and can decrease the percentage of medical misdiagnosis.

Appendices

Appendix

Many of the questions in the survey included a section which allowed participants comment freely in free text format. These comments were a useful complement to multiple choice questions and provided a more detailed insight about the current problems faced by the health care professionals and patients during medical consultations (examinations), the expectations from technology and possible improvements to current EHR applications. Some of these comments are given here verbatim with authors’ position. The comments by the survey participants identified several factors that affect a patient-physician encounter, which can be organized into two main themes:

• i. data gathering and,

• ii. behavioral encounter.

Data gathering

Data gathering involves data entry methods, patient past medical history, reliability, availability, consistency and privacy of patient data.

Data entry methods

Several physicians reported using dictation as their data entry mechanism. Some hospitals are still completely un-computerized, using methods such as handwritten patient charts which are filed in cabinets.

• “dictation into a telephone and then this is typed into a note that is attached to the medical record” –Physician

• “My dictated letter is transcribed and filed in electronic records.” –Physician

• “Hand filled forms which are filed later” –Physician

In several other public and private hospitals that are somewhat computerized, a considerable number of medical professionals are using conventional tools such as keyboard and mouse to enter patients’ history into an EHR system. Emerging technologies such as voice recognition is gaining acceptance, due to the advances made in this technology.

• “However, if I would be a clinician, I would prefer voice recognition.” –Medical Clerk

• “Digital voice recognition with voice recognition + secretarial correction etc” –Physician

Medical clerks and transcriptionists are employed for data entry, however, under some type of quality control. It seems that reliability and privacy is of concern when a third party is involved in the medical encounter.

• “Services of the Medical Clerk/Medical Data Entry Operators should be used. The entered data should be double checked by sufficient QC steps” –Unspecified

• “Medical clerk under the supervision of a physician” –Physician

To ensure reliability and accuracy, it is essential that routine test results performed by lab devices such as blood pressure, height and weight are automatically entered into patient records. Human involvement must be eliminated in such cases, to save time and reduce data entry error. Lab Information System (LIS) is already being used in medical centers. The system interfaces between the laboratory instruments and health information systems to automate the provisioning of lab data.

• “LIS interfaces, middleware etc any where a lab system is providing data” –Physician

Lack of accessibility to patient historical data

Access to the medical history of a patient is crucial for a physician. In addition to the current, the physicians must be aware of existing illnesses, patient drug allergies, previous tests, and past operations performed. Often this information comes from sources other than the patient themselves, who may lack knowledge of, or not recall, details of their medical history, or who may not be able to provide the relevant records of past tests. This lack of information can hinder physicians in their work. Medical records should also include data about health conditions of close relatives.

• “They do not know the history of their test results and treatment they received for their chronic diseases” -Physician

• “They have limited amount of information about their medical history (the number of operations performed, diagnosis etc)” -Physician

• “They do not bring the previous diagnosis and prescriptions with them to the examination” -Physician

• “lack of access to previous tests and consultations done at different hospitals” -Physician

• “Patients may not have full knowledge of their family history - relevant in making full assessment of genetic risk” -Genetic Medicine

Digitizing patient health data makes it possible to access to the health records of immediate relatives. For certain genetic diseases, hereditary information is essential for accurate and fast diagnosis. Consolidation of past test and examination results performed at various locations is necessary to construct a full medical history of the patient. The availability of this information also has a direct effect on cost reduction, because unnecessary or duplicate tests may be avoided.

• “We are duplicating tests that have been done a week ago in another health center” -Physician

Reliability, availability and accuracy of data

The survey respondents indicated that the improved accuracy of information leading to better health care delivery is a motivational factor for using technological tools in data entry.

• “Access to patient data is faster and reliable”-Physician

• “Convenient access to patient demographic data and ensring data consistency” –Physician

• “easier retrieval of information; better organization of material over time” –Physician

• “Efficient data collection and I hope the automatic generation of letters” –Physician

The digitization of electronic patient records decreases access time, increases quality of care, increases the reliability and consistency of data and reduces medical errors. The rapid and complete access to data can increase confidence that health care professionals have in their work.

• “more confidence in my work based on rapid and complete access to information and clinical data.” -Nurse

• “more ACCURATE information for more fully informed decision-making” –Nurse

• “Reduce medical errors. More complete information” –Physician

It also reduces the risk of harm to patients by the omission of important data, and makes treatments and follow-ups easier. Since all information is archived, locating specific information consumes less time and energy, and reduces the chance of making mistakes. Thus, the stress and anxiety levels of the patient and physicians will be lessened.

• “-More accurate assessments and diagnoses -Better planning of care -Implementation of more appropriate treatments -Reduced risk of harm to the patient from the omission of important data” –Nurse

• “Patient safety, and less aggravation trying to track down information” –Physician

If a proper feedback mechanism is incorporated, a warning would be generated for an inconsistent diagnosis, such as pregnancy for a male patient, or a prostate for a female patient. Safety is improved, since patient plans made by the patient’s regular team and risk assessments are always available to the treating physician at any time.

• “Safety - having pt records out of hours means plans made by the pt's regular team and risk assessments are known to the treating dr” –Physician

• “There must be a feedback mechanism which must generate a warning for inconsistent diagnosises such as pregnancy diagnosis for a male patient or a prostate diagnosis for a female patient” –Physician

On one hand, health care professionals are unable to perform in-depth discovery of patient conditions due to lack of time, on the other, the loss of time caused by consolidating medical data from various sources adversely affects patient-physician communication by reducing the time available for consultation.

• “I worked with patients in past, with clinical neuro monitoring. Difficulty can be scheduling time to obtain records with patient and talk with patient” –Physician

• “Finding adequate time to do more longitudinal care” –Physician

• “Time loss because of lack of details or incorrect information from referring doctors” –Physician

Data privacy

Privacy of patient data is of concern to the physician when different emerging technologies are used. Some respondents reported that the protection of patient privacy is of greater concern than data entry in the long run because of the possibility that patient data may be accessed by individuals or institutions for unauthorized or illegal purposes. One opinion stated in the survey is that the medical data should be stored within the boundaries of a limited access environment. Another proposal was to store patient data on a patient owned storage media such as a smart card or telephone and make it available to the physician only with the permission of the patient. Because the storage media is always in the possession of the patient, a more effective control of personal data is assured.

• “Precautions must be taken to protect patient privacy” –Physician

• “I am much concerned about the protection of the patient privacy in the long run than data entry. It is very probable that patient data may be accessed by a person or an institution with bad intentions and be used for various ill purposes. For this reason, it is preferable for this data to be stored within a limited access environment. Storing patient data on a patient owned storage media such as a smart card or telephone and make it available to the physician with the permission of the patient is also a viable solution” –Physician

• “The idea is really interesting. My biggest concern would be the security of the private data on a network file. I would prefer to have the information stored on a card (such as a credit card), that you would always carry with you, so that you could better control the access to your private information” - Physician

Behavioral encounter

Behavioral encounter deals with interactions between physicians and patients, including language barriers, physician and patient cognitive styles and education.

Language barriers (speaking, comprehension problems)

Differences in first languages or dialects that are spoken between patients and physician present serious barriers to communication. While it is not possible to teach the language, using a translator is sometimes unavoidable, but creates privacy concerns, in addition to potential issues caused mistranslations. The following comments highlight such problems:

• “They fail to provide current medication use. At times, we have difficulty in verbal communication with the patients from Eastern and Southeastern part of the country (They do not know Turkish at all or not fluent). Sometimes it is very difficult to get detail anamnesis about their current illnesses (onset and progress of the disease, medications they are using, the duration of prescription use and time of switch from one medication to another, etc)” –Physician

• “…… Patients with Kurdish origin especially the women, does not know how to speak Turkish. This creates a communication barrier.” –Physician

Physician perspective, patient and physician cognitive and behavioral styles

Habits, articulation, manners and education plays important role in patient physician communication. The insufficient verbal communication between a patient and a physician can prolong the discovery process. A patient with poor listening skills can cause distress to health care professionals and make it difficult to obtain inaccurate information.

• “The patients would not listen anybody but themselves” - Nurse

• “The patients do not listen to even the clearest and most comprehendible questions and give irrelevant answers. For example when patients are asked -Describe your symptoms-, we get answers such as “KOAH” or -You should tell me-. The responses should have been like coughing, difficulty in breathing instead of KOAH” –Physician

• “They usually answer very accurte questions. For instance to the question Are you smoker? they may say no, when actually they quitted smoking few weeks ago.” -Physician

The intentional non-disclosure of information by the patients poses problems as well.

• “Patient may hide symptoms or does not know” -Other

However, it is often the case that deficiencies in education, and ability to articulate, or intimidation by the complexities or jargon of the medical field result in patient inability to express themselves. There are cases where the patient receives explanations from different physician that may seem contradictory causing confusion on the patient.

• “Limited understanding of previous and current co-morbidities”-Nurse

• “The patients have difficulty in expressing their symptoms in the correct chronological order. One reason for this could be their anxiety. However, the patients also think that the physician already knows or must know this data” –Physician

• “Some patients cannot even tell the name of the illness they have” –Physician

• “The patients cannot sort out relevant data from irrelevant data therefore they provide information that is not relevant and forget to tell the relevant” –Physician

• “Multiple conflicting explanations given to a patient by different health professionals (HP's) often cause confusion for the patient and frustration for the treating HP's” -Nurse

In rare cases, the communication is hampered because the patient behavior is very distracting to the physician:

• “The patients show excessive humility or intolerable rudeness and ill-manners” –Physician

Patients quiet often use other sources of information for explanations of their illnesses. In other words they act like their own doctors. If these sources used correctly it improves patient satisfaction and patient-physician communication. However, the public may not be able to select valid or complete information when the source is the internet, where information is frequently uncontrolled and unmonitored resulting in unauthenticated authorship and false claims of medical expertise [26].

• “Patients tend to self-diagnose on the internet” - Other

• “Generally, they try to gather information from the television shows”-Physician

Patient’s perspective

Patient physician communication must be a dialog in which the physician should try to understand the patient. The patient suffers from an illness and diseases. This adds a psychological and social dimension to the encounter, in addition to biological and physiological effects. The patient can become anxious, and forgetful because the mind is occupied or can either be overwhelmed by the amount information presented or may suffer from a lack of information.

• “Health care professionals provide inadequate information to the patient” –Nurse

The medical jargon or contradictory statements may also confuse the patient.

• “Speaking as a patient rather than a doctor - I can see that all of these would be a problem and I would rather have everything including prescriptions stored and seen by the doctors because I invariably forget something or don't know what is or is not relevant” –Medical Clerk

Even somebody who is considered to be well educated may be perplexed by the situation.

• “As patient, main difficulties arise in understanding physicians” –Professor

Some other motivational factors for digitizing patient health records which are not directly linked to diagnosis or treatment are as follows: access to records for academic studies, allowing convenient search and selection of important cases and the provision of evidence in the case of legal proceedings. However, despite all the advantages that technology offers, there still remains a level of skepticism, albeit a small one, as patient-physician intimacy can be violated, and the human relationship element will be eliminated from the process. In this view, medicine is seen as merely a business. Therefore, it can be said that a delicate balance exists between the use of technology and the human dimensions of medical care. Any adaption of technology in medical care must consider this balance.

• “….. I do believe these systems violate intimacy at certain level (subcontractors, not enough secure IT systems in national health systems)”- Other

• “None at all as I do believe these systems violate intimacy at certain level (subcontractors, not enough secure IT systems in national health systems)” –Other

• “The last question focused on productivity. Somewhere in this survey I would like to see something o quality. Patients are generally dissatisfied with the medical business, not seeing it as a profession any longer. Assembly line medicine and drug prescribing is not all there is to the human relationship that expedites the healing.” -Other