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Article Excerpt
Abstract. In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of "the" EPR needs to be replaced by an "unpacking" of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed individually. Following from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three "models of patienthood" implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship.
Key words: doctor-patient relations, electronic patient records, models of patienthood, patient-centeredness
Introduction
The need for increasing efficiency in administration as well as for improving cooperation between medical professionals requires ongoing investment in the realization of the potential of information technology (IT). The conviction that one of the focal points in this development is the design and implementation of electronic patient records (EPRs) is shared among politicians and health care practitioners all over Europe. Consequently, the realization of comprehensive EPRs throughout the healthcare delivery process is stated as top priority by virtually every organization, department and authority involved in setting policy goals (NHS 1998; Sundheds Ministeriet 1999; Ministerie van Volksgezondheid 2000; Raad voor de Volksgezondheid en Zorg 2002; Sundhedsministeriet 2003).
One of the dominant visions in medical informatics has been to develop one medical record per patient. A major argument is that this makes possible shared care, meaning that all healthcare providers related to a single patient can access and register information about a patient in the same record. Attempts are therefore made to integrate different record systems and information tools so that shared care initiatives can be realized on the basis of one common standard (http://medinfo.dk/epj/gepj/).
The terminology here causes confusions, however, for in spite of what terms like "patient-oriented", or even "patient-centered" records (Berg 2003) may suggest, the EPR has primarily been a tool owned and used by the health care professionals, not by patients. The patient has been a stakeholder of a secondary order, more than a direct user of the system. The potential for confusion rises from the term "patient-centered record" which appears to be associated with current policy goals of developing more patient-centered care, but which merely refers to the organizing principle of the record, to contrast it with, e.g. work-oriented, or doctor-centered records.
Nevertheless, patients are claimed to benefit from integrated medical records. For example, patients are expected to benefit from increased efficiency and quality control achievable through seamless information exchange among care providers (Pritchard and Hughes 1995; Lee 1998; van Walraven, Laupacis et al. 1999). More specifically, the facilitation of information exchange between caregivers involved in a patient's care may prevent patients from having to tell their story over and over again, and from undergoing redundant tests. Waiting times may be reduced, if caregivers share information more, as patients can be examined in one place and guided to a care provider in a different place immediately.
Other, perhaps more indirect, benefits are hoped to follow from a shared record in particular and from EPR-use in general. The quality of care is expected to improve due to the possibilities for enforcing standards and protocols by building them into the record, resulting in an improvement of following clinical guidelines and in stimulating care providers to give preventive care. Moreover, it is hoped that routinely registered information in an EPR may increasingly be used as the foundational information source of clinical databases (1) (Mainz 2003).
Patients are also said to benefit from the use of ICTs in a more abstract and idealistic sense. It is often claimed that the shift from paper-based to electronic record keeping enhances patient autonomy and empowerment. Specific initiatives to stimulate patient autonomy and empowerment, such as increased possibilities of patients to control, or even access their personal medical file are taken. This, the claim continues, would finally put some practical flesh to the theoretical bones of the legal rights of patients to see and control what information about them is stored and retrieved by various care providers. For instance, a recent Danish initiative to position patients as users of their own electronically stored health information takes the form of an Internet-based health portal. The ambition is to have patients as well as care providers use this portal to get access to patients' health information as well as to more general, but certified, health information. Individual patients can thus download their own personal health profile as well as an overview of all medication he/she currently gets.
In this paper we focus on the more direct effects of EPR-use in the care provider-patient relationship itself, such as found throughout the healthcare domain, ranging from general practice, hospital based specialist care, to midwifery or physiotherapy. Our main focus lies on the doctor-patient relation, but we argue that the dynamics found here can be generalized to other parts of the health care domain. Here, several issues have come to the fore in a range of studies of the role and effect of computers on interpersonal interactions between patient and caregiver. For example, changes in communication patterns, and patient's presentation of complaints, or in doctors' attention and information gathering strategies have been identified as potential areas of interest.
This paper has a dual goal. The first is to identify what exactly, according to recent research and comments on effects of EPR use in the consultation room, are the ways in which EPRs affect the position of patients vis-a-vis their care provider. The second is to identify and discuss the implicit normative ideals and of patienthood found in this literature.
The effects of EPR use on the doctor-patient relationship is hardly a straightforward matter. Over the past years, the impact of EPRs on various aspects of doctor-patient interaction have been studied with varying results; different aspects of EPRs have been attributed with normative or interactional impact. With habituation to the presence of computers in most professional service relations generally, debates have shifted in focus as well.
Although in general an "EPR" refers to an electronic system to record and access individual patient data, the term may cover highly divergent systems. There is, for example, a large gap between the EPR that is the subject of countless governmental and other healthcare authority policy documents on IT strategies, and the average EPR encountered in practices and clinics on a local level. In the first case, usually something far more ambitious is meant: this "EPR", to which positive, empowering effects for patients are routinely attributed, refers to a (future) digital comprehensive recording system for every patient that is based on (inter)national standards and infrastructure, and used throughout the healthcare system. The EPR encountered in actual practice, in contrast, is--at least compared to the grand visions--usually a system with limited functionality. If we look at EPRs for midwives, for instance, it is often used only locally in one particular practice,...
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