UCL study: electronic patient records are more than just data

The major literature review, published in the US journal The Milbank Quarterly this week, identifies fundamental and often overlooked tensions in the design and implementation of EPR programmes. The findings have implications for large-scale EPR programmes around the world.

Review co-author Dr Henry Potts from UCL's Centre for Health Informatics and Multi-professional Education (CHIME) here discusses the impact this review will have and whether technology and workplace practices can ever become symbiotic.

How did this research come about?

"It all started with a grant from the NHS Service Delivery and Organisation Programme in which I had said I would do a literature review of the relevant research on electronic patient records from an organisational perspective. However it soon became apparent that it was a much bigger project than I imagined so I linked up with colleagues in DoME (UCL Division of Medical Education) who were also interested in this area."

What surprised you the most when undertaking this review?

"One of the things that informed my research was understanding co-evolution: between what people do and the technology itself. When you give individuals a piece of technology, you have designed the technology to be used in a certain way, but people adapt the technology to do what they need within their working practices. For example, they might start entering data in different fields or share passwords because it makes their work more convenient - but this isn't intended by the design.

"The most surprising thing was the idea that an agreeable common record may not be achievable. Naively you might imagine that a medical record simply describes facts about an individual, so it seems sensible that everyone from an individual's GP, to their nurse and the hospital consultant, should have access to that same record. But when you look at how records are actually used, they are not simply a collection of facts that can be moved around from one healthcare worker to another.

We have to recognise that each of those people will interpret that information differently and that records require human interpretation. Healthcare professionals talk to each other a lot and while we may think that everyone accessing one record saves everyone's time, what some of the research shows is that the conversation between health professionals is a vital process of translation and negotiation about what will happen next to the patient."

Can technology account for human intuition?

"Yes, it is possible to achieve beneficial co-evolution. In the old days people would say that technology dictates how people behave, while others would say that the societal structure dictates how people use the technology but the idea of co-evolution is that there is a recursive relationship. The technology somewhat constrains what people can do but people then use the technology in a different way to how it was intended based on the context of the work they're doing and their imagination. Technology affects people and people affect technology. Co-evolution embodies the idea that as the technology evolves it incorporates what people can do with it, and so it evolves based on how people use it as a symbiotic process."

Is there still a place for paper?

"Anyone who works in an office knows that the paperless office has never really happened for most people. A lot of the proponents of technology have made the case for disparaging paper. But paper has a lot of advantages; it's portable, lightweight, you can interact with it. That's not to say that electronic records don't have advantages but how we integrate paper and electronic records is a different question. It's dangerous to make predictions about technology but it's possible that the new generation of mobile devices will help to bridge that gap between the portability and interactivity of paper and having a computer at your desk. This is part of our research; we need to make patient records more accessible across different platforms and networks."

How contentious is human error in the area of electronic data?

"It is very contentious because medicine is a high-reliability discipline where errors can cost lives. There has been a significant shift over the last few years in how we tackle patient safety in terms of taking a system approach. We have learned lessons from the airline industry and the nuclear industry but it's a slow process to get those messages across. One of the things we find is that risks are often linked to a failure of communications. We need to look at working practices rather than simply blame those mistakes on individuals. If we give people technology and tell them it's going to do something it's not fair to blame the individual when that technology goes wrong. We need to have a better understanding of that relationship between people and technology from the outset.

"It's easy to become cynical with the problems of the past but there are examples where electronic record systems have been used successfully such as the Veterans Administration in the US. Often people have naive and overly optimistic expectations but that doesn't mean we can't make some significant changes quickly."

How can we use this knowledge to improve patient records in the future?

"One of the points of doing a review is not just to find out what the existing research says but what it doesn't say. More research is needed but it needs to be targeted in the right way. One of the things I'm doing is looking at how we can better use this knowledge to make better systems. We need to stress the importance of talking and engaging with the users early on and throughout the lifetime of the technology as well as engaging with all the users. It's very easy to create a product that makes the doctor's and manager's life easier but makes the receptionist's life a lot harder. We need to recognise all of the users involved."

• UCL CHIME
• Dr Henry Potts
• The Milbank Quarterly

Images from top: Laptop and stethoscope; Doctor with patient discussing results; Doctor going through paper medical records.

UCL context

The Centre for Health Informatics and Multi professional Education (CHIME) was established in 1995, as a joint initiative of UCL and the Whittington Hospital NHS Trust. It undertakes research and provides undergraduate and postgraduate education in information and quality management, to support clinical practice and to benefit local communities - both patients and healthcare professionals.