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A recipe for failure
- Jacob Urkin, Mohammed Morad and Joav Merrick (4 December 2005)
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Well done KP
- Vaughan P Smith (5 December 2005)
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Jacob Urkin, Director Pediatric Primary Care Unit, Ben Gurion University, Box 653, 84105 Beer-Sheva, Israel, Mohammed Morad and Joav Merrick
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EDITOR---This communication in response to the paper on Kaiser Permanente’s experience with the implementation of an electronic medical record (1). The study describes the attitude of 26 clinicians, managers and project team members to the failed implementation of an electronic medical record. The limitations of electronic medical records to address the expectations of its users are the main reason for negative feelings. The design and user-friendliness of any electronic record are important, but there is much more than that. Any electronic record is inferior, compared to paper record, in at least the following items: 1. The amount of textual information presented on one screen is about a fifth of information presented on one hand-written folio paper. For many clinicians this is a major difficulty when they review a record. Browsing through five folio pages is much easier than through twenty five screens. 2. Entering data by typing is slower than handwriting and choosing from menus expose the users to lists of items that are irrelevant to the current patient. By that, the clinician's flow of ideas and the thread of mind are jeopardized. 3. By documenting in the electronic record, the clinician has to look alternately between the keyboard, and the screen. It is necessary to check for mistakes and correct them. When using a pen, the clinician has to look only at the tip of the pen. The presence of a patient adds another point in space for the clinician to look at. The end result is that while using a computer, eye contact between the patient and the clinician is of short duration at a time and of less total time for each encounter. This is a major drawback to the patient-clinician communication that adds to the dissatisfaction of both. 4. The electronic medical record is generating a plethora of unrealistic expectations that the paper record users do not dare to dream about. These include the idea that the electronic medical record will enable clinicians to better serve more patients at the same amount of time. 5. The electronic medical record threatens the sense of autonomy and privacy of the clinician. With the electronic record, administrators, colleagues and quality assurance personnel can easily access and criticize one's behavior. This is actually happening. 6. For many good reasons, an electronic medical record is structured and demands high level of uniformity. These result in limitation of the diversity that is needed by clinicians as a result of their medical backgrounds, specialties or personal style. Electronic medial records are already in use for many years. They are getting more users friendly and their abilities to accommodate their users dreams are in progress. Technical innovations, as increased in computers speed, memory and communication are of great help. The major difficulties with electronic medical records are in the change that they impose on the users. Primarily, this is not related to technology, but rather to human psychology. The basic rules of implementing a technology are well established. These include a design that addresses user's needs and expectations. Communication with the users, flexibility of the design and local tailoring are important. This is a continuous process, which also means that investments in maintenance of electronic medical record in never ending. Failure to recognize the inferiorities of the electronic record as described above and failure in compensating them by addressing the user's needs and expectations are the recipe for failure. AFFILIATION Jacob Urkin, MD, MPH, is a primary pediatrician and also director of the Pediatric Primary Care Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. E-mail: jacobur@clalit.org.il Mohammed Morad, MD, is a family physician, the medical director of a large area clinic in the city of Beer-Sheva, Israel. E-mail: morad62@barak-online.net Joav Merrick, MD, DMSc is professor of child health and human development, director of the National Institute of Child Health and Human Development and the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. E-mail: jmerrick@internet-zahav.net. Website: www.nichd-israel.com REFERENCES 1. Scott JT, Rundall TG, Vogt TM, Hsu J. Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study. BMJ 2005;331:1313-6. 2. Urkin J, Goldfarb D, Weintraub D. Introduction of computerized medical records. A survey of primary physicians. Int J Adolesc Med Health. 2003;15(2):153-60. 3. Warshawsky SS, Pliskin JS, Urkin J, Cohen N, Sharon A, Binztok M, Margolis CZ. Physician use of a computerized medical record system during the patient encounter: a descriptive study. Comput Methods Programs Biomed 1994;43(3-4):269-73. Competing interests: None declared |
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Vaughan P Smith, General Medical Practitioner Taunton, Somerset TA2 7SZ
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Kaiser Permanente should be congratulated for allowing such an honest examination of the way they adopted their new IT (Information Technology) system. It seems that their managers were, ultimately, open to grass- roots criticism, and courageous in admitting that their first choice had been wrong. This contrasts with my 30-year experience in the British NHS (National Health Service). Here I have seen several IT systems implemented in a "top-down" fashion without any real consultation with those whose daily work became more stressful and inefficient as a result - and I have never, ever, heard a manager admit to being fallible. Whilst accepting that "mistake" can be an ethically-neutral word, I feel that your headline, "Learning from Kaiser Permanente's mistakes" on the cover of the print journal, puts a derogatory spin on a positive and useful paper. In my opinion this reflects your Journal's institutional anti-American bias (see BMJ 22/1/05, p155). Yours sincerely - Vaughan Smith. Competing interests: None declared |
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