After this brief overview of GPs’ overall satisfaction levels with their EMR system, we invited respondents to further elaborate on any specific aspect of the systems that they perceived as useful or else, cumbersome or unhelpful. GP’s responses are here presented in the following 3 thematic dyads, using the eHealth system quality framework derived from DeLone & McLean’s model of information systems’ quality[27, 28]:
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(i)
information system and information quality
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(ii)
information usage and user satisfaction
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(iii)
individual and organisational impact
EMR & Information quality
Perceived benefits of information systems
n = 18 out of 25 GPs spontaneously reported some perceived benefits with their EMR, including the following features:
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the EMR provides adequate support for information access and searching, (n = 13/25)
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the EMR technology is up to date, stable and reliable, and functionalities are superior to that of previous systems, (n = 11/25)
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the EMR is flexible, adaptable, with a broad range of functionalities and provides adequate work-flow support, (n = 10/25)
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the EMR provides adequate support for data entry, clinical coding and record keeping, (n = 9/25)
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the EMR supports well electronic prescribing, (n = 3/25)
Improved access to information
As one would perhaps expect, the GPs found improved access to patient medical information one of the main advantages of the practice EMR, including convenient access to the patient record, access to patient medical summaries, the ability to filter information based on a specific diagnosis or medication and access to immunisation data:
GP3:“... you can pull up things like summaries of results much easier [...] You can do searches and things a lot easier. So there’s a lot of advantages...”
GP9: “... The fact that it reads most things that you record. So everything is searchable. And the fact that you can search it, so you can search by keyword through the entire patient record which is very useful....”
GP23:“...It’s very easy to do searches: if you wanted to find someone who the last time they came up with – say: a sore elbow – you just put ‘elbow’ into the search bar and it will throw you up all the consultations where they mentioned elbow.”
Perceived Dis-benefits of information systems
n = 13 out of 25 GPs spontaneously reported some perceived flaws with their EMR, including the following features:
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the EMR is administratively cumbersome and/or not sufficiently flexible to support workflows, (n = 7/25)
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the electronic prescribing functionalities are not optimum to support existing work-practices, (n = 7/25)
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occasional system breakdown compromises work practices on the day of system failure, (n = 3/25)
System failures were reported as infrequent but caused substantial disruption to patient consultation when they did occur:
GP12:
“... It’s not a great feeling when you go down on a Monday morning and [...] the practice manager [...] says: ‘the computers aren’t working this morning and we haven’t got a clue who’s going to turn up’ [...] I remember one Monday morning we had about two patients that had come back to discuss results and I had... just had to say: ‘I’m sorry the computer’s down you have to go and make another appointment.’ ”
GP13:
“well, the main draw-back... [...] there were days when the system crashed... and in that case, what... because you’re so reliant on this, you would end-up seeing patients and saying ‘I’m sorry. Huh, but I don’t have access to your old record, so we will just have to, you know... huh, go by what you say and what you recall, humh...’ the dynamics of the GP consultation is – with most patients who are attending frequently – they would assume that the doctor would have access to their record and when they come in and, for a 10 minutes consultation, umh... you know, they wouldn’t expect that they would have to recall all their events and all their history so... if the system crash, you’re kind of, huh... you’ve got no back-up”
Both EMIS and INPS provide streaming solutions (EMIS Web[35] and Vision 360[36]) so that copies of clinical records held on local GP systems can be stored online on remote servers, thereby providing back-up access in the event of local system failure. However, while these additional online back-up solutions have been purchased and provided by a number of health-boards, they are not currently available to all GP practices across Scotland.
Information usage & user satisfaction
Perceived benefits covered four main areas
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the EMR provides useful information added value, include key-work based searches, information filtering, clinical summaries, and features for classification and categorisation, (n = 10/25)
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the EMR provides useful decision support features, (n = 5/25)
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training and experience allowed GPs to use the system with confidence, (n = 5/25)
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the EMR includes features which supports information sharing with patients, (n = 2/25)
Improved patient safety feature
Several GPs considered the fact that the practice EMR only allowed the user to have a single patient record opened at any one time as an improved and important embedded patient safety feature. The previous system allowed users to open multiple records concurrently, which increased the risk of mistakenly entering data in the wrong patient record. Also, the new systems include a number of decision support functionalities such as alerts and reminders. 5 GPs specifically mentioned decision support as a useful feature of the systems.
GP19:“... I think the sort of alerts, the clinical alerts, you know, it’s sort of got an in-built system where it will flash up pointers, you know: “this patient’s blood pressure needs taken”, or it links in with the Quality Outcomes Framework system for general practice... it gives you a reminder, instant reminders...”
Perceived dis-benefits
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the EMR has some information navigation issues and unnecessary steps (e.g. multiple clicks), (n = 9/25)
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a lack of training and understanding of the system prevents the GPs to use the system to its full potential, (n = 5/25)
Usability and navigation issues
Several GPs encountered usability issues when using the system :
GP7: “... it tends to be... to involve quite a lot of clicking and I’d quite like to have it simplified in using fewer steps. So... but that’s about all. I am really genuinely fairly happy with it”
“There are things that you could... you could do in one mouse click or one key-stroke that take 3 or 4. And by the time you’ve multiplied that by doing it a hundred times, it’s an awful lot of extra key-strokes. And that’s my main gripe about it, there seems to be a lot of unnecessary steps that if somebody just went to (see) how you use it, we’d be able to cut that down...”
GP10:“...I maybe don’t know the easiest ways of doing things. Or you do something for years and then you discover that there’s a much easier way of doing it that everybody else seems to know and you didn’t. For no good reason.”
GP18:“It’s a quite a busy front page and there’s many ways of accessing information... different routes into it which is quite complex”
GP22:“...personally, I am finding it difficult to teach myself exactly where everything is and how to transfer from one screen to another”
GP23:“...multiple clicks, it’s not very good, not user-friendly. Sometimes it’s a bit too much on the screen, it’s multiple screens, it’s hard to really see where’s the flow of the consultation [...] (an improvement would be)... if you could use the keyboard more than this multiple click thing”
Information and alerting overload
Several GPs raised information overload, particularly on the screen estate as a hindrance to the consultation:
GP1:“The acute stuff can be a bit tedious because of all the warnings it now comes up (with). And there’s so many warnings that one just... You can’t see the wood for the trees, but I suppose it could help there if there’s a bit more time (during the patient consultation)”
GP2:“... The main drawback is on the... we get our results direct... in the general screen, which is actually quite a useful screen, which is everything in chronological order. Since we’ve got the results direct into that screen, each result is on a separate line so there’s... that screen’s really kind of clogged up with stuff and you can’t see easily. And it’s also quite hard to because of the way the results are presented on the screen, it’s actually quite hard too to read.”
GP19:“the screen is very busy, you know the screen is extremely busy”
Difficulties in adapting to the new system
As previously suggested, several GPs had made a relatively recent switch to a new system based on NHS requirements. Several had become accustomed to the previous system and found it difficult to adjust to the new system:
GP22:“I don’t enjoy computer work [...] with me, it was a case of ‘better the devil you know’ [...] I am taking the responsibility that’s my inadequacy rather then the system inadequacy [...] there are things I have difficulties with but I don’t necessarily blame the system for that”
GP23:“There’s a lot of things you can do with it, but it’s also very, very time consuming.”
Individual & Organisational impact
Perceived positive impacts
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the EMR provides good support for record-keeping, access, retention and performance monitoring in the practice, (n = 11/25)
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the introduction of the EMR has positive impact on the office space, work environment (i.e. by reducing the use of paper records and forms across the office and reducing storage needs), (n = 7/25)
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the introduction of the EMR leads to individual and collective improvement in effectiveness and performance in the practice, (n = 6/25)
Improved audit
The GMS GP contract entails providing performance data to the health services and the practice EMR was perceived as indispensible for these tasks:
GP1: “general practice is driven by its contract and the contract is only operational because of the IT system... it relies on measuring, that’s what IT systems do so well and without that, we couldn’t do it”,
GP16:“you could not do the job of following the GP contract now without computer... it’s not as if you have a choice not to have computers... they are part of the job”,
GP22: “I think there are huge benefits, certainly from the point of view of auditing service provision, it makes a lot of sense...”,
GP23:“... It’s very good to search with and there are different ways of doing things with it so, audit-wise, it’s very good ”
Impact of EMR on record-keeping
In 2003, a study by Morris et al. found that a large majority of GPs (94%) routinely used computer systems in the course or their duties but only 3% of practices surveyed at the time reported being entirely paperless[37]. However, a more recent report by the British Medical Association reported that 90% of practices in Scotland were either paper-less or “paper-light”[9].
Using electronic patient records had a substantial impact on work processes within the practice, both in terms of a reduced burden on administrative staff, and the reduced physical area required for storage of legacy paper records. It also means that the nature of the work of administrative staff, and thus their skill requirements are evolving with the routine use (embedding) of computerised systems:
GP3: “it would be nice to completely get rid of the paper notes and have them all in... you know, have them all online in the patient’s (system)... but that would take so much time and effort (i.e. to scan paper documents in the system), it’s probably not worth it really. Because these notes... as every year passes, these notes become less and relevant... [...]
“The girls are losing their skills in finding them (the patient paper records). And some of them have never really used them much, so they find it more difficult. Some of the others were well used to it, so they have still got their skills [...] But we’re using them less and less as it goes further on, the more and more we have in the electronic (records) and the better that is.”
GP7: “I mean it’s very much less manpower intensive not using paper records”,
GP12: “I think generally being paperless is better, and all the information’s is on the computer, so you can get hold of stuff”, “...sometimes you can get hold of other records more quickly. I think it frees up receptionist time from filing and all that sort of stuff...” “...the receptionist staff [...] even like pulling all the notes for all the, you know, appointments and stuff, and then having to file them away, I mean I think that saves them probably a good hour, maybe two hours, a day [...] I think it certainly makes their job a bit better, it does.”,
GP14: “You don’t lose things so much now [...] It probably does reduce our receptionist time from hunting bits of paper, paper records and also now that all the blood results all just come through online, so we don’t have to fill in all these bits of papers as well...”,
GP17: “we started scanning in everything about 8 years ago and then we started... We kept paper records up until 3 years ago and then we’ve – you know, just as a back up – but we’ve now been able to shred. If we get paper records, we scan them and then we just shred the paper records...”,
GP22: “as far as staffing is concerned too, the fact that – physically – not having to find (paper) notes back and forward... their jobs’ description is going to change quite dramatically and... computer literacy for my staff obviously has to be... well... they’re ahead of me, I have to say...”
Facilitator of shared-care
Several GPs suggested that having an online patient record facilitated shared and continuity of care:
GP12: “ in the old days if you had, sort of like, one set of notes or something, sometimes like maybe the nurses want to look up something about a patient or something and if you had the notes, it was kind of awkward. Whereas now they could more or less look at the notes at the same time...”,
GP17:“it’s one clinical record that any, the staff that work in the practice can input information into, so we’ve got our district nurses put their information in and the practice nurses put their information in... so it’s a shared clinical record. You don’t... you can’t lose it and it means that more than one person access it at any time, so it’s not like, you know... one person’s got the notes and nobody else can see them”
Perceived negative impacts
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there is insufficient organisational support or resources (e.g. from the health-board) to support the training of staff and deployment of new ICT systems, (n = 3/25)
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the EMR is not sufficiently integrated with other electronic systems used in the practice, (n = 2/25)
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the introduction of ICT is having a negative impact on existing work practices, (n = 2/25)
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the introduction of ICT is having a negative impact on the clinical encounter, (n = 1/25)
Issues of interoperability of systems and systems integration
Several GPs found switching between several systems cumbersome :
GP9:“... Disadvantages are having to flick from one system to another, so you have to flick from Vision to Docman, to mail manager... it isn’t all there [...] So there are three separate systems that run that don’t automatically, I mean they do coordinate a bit, but they’re not perfect [...] it’s slow, you have to log in separately, it takes the computer some time.”
GP10:“... I’m afraid I have little understanding of it all, I do as I’m told. But you know if you have a patient record open and you’re looking for results that have been done at the hospital, you can’t access it from the patient record, you have to open the internet and then go into through the SCI (Scottish Care Information Gateway) and find out that way and type it all, it’s cumbersome.”
Interference in the patient consultation
One GP had very strong views about how ICT systems and performance-driven work practices compromised the patient-doctor relationship:
GP1:“it’s like having a third person in the room so it’s quite... It can be quite disruptive in consultation as well.”
“[...] Well both parties, both me and the patient can find their eyes drawn to the screen. That’s not really, I mean it’s a bit like having a conversation with somebody with the TV on in the background.”
“the IT revolution is destroying what was great about British general practice...” [...] “the stuff that we can’t measure – like the human compassion side of health – is being squeezed out by the need to record frequently meaningless data”
“ [...] nobody gives me any extra money for, you know, giving some patient a hug, the cuddle factor doesn’t attract QOF points”
This last comment echoes the concerns of a previous study which cautioned that financially incentivised performance targets strongly shaped the roles of primary care teams and the nature of activities, with less attention and efforts being allocated to non-incentivised activities[38]. This should also be seen in the light of a recent systematic review on the impact of the QOF in the UK which found modest improvements in quality of care for chronic diseases and an uncertain impact on costs, professional behaviour, and patients’ experiences[39].