Article

Health Informatics Journal

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Copyright © 2007 SAGE Publications (Los Angeles, London, New Delhi and Singapore) Vol 13(2): 155–160 [1460-4582(200701)13:2; 155–160; DOI: 10.1177/1460458207076470] www.sagepublications.com

The impact of electronic patient records on workflow in general practice Matthew Cauldwell, Caroline Beattie, Benita Cox, William Denby, Jessica Ede-Golightly and Fiona Linton The Patient Access to Electronic Healthcare Records System (PAERS) allows patients to register their arrival at a GP’s surgery and to view their healthcare record electronically whilst in the waiting area. The research reported in this short article was carried out to identify potential changes in clinical and administrative workflow resulting from the introduction of the system. The study considers workflow pre and post the implementation of PAERS. It also makes comparisons between two UK London-based surgeries, one with PAERS (Wells Park Practice) and one without such a system (South Lewisham Group Practice). The impact of PAERS on workflow and the potential benefits for GPs, administrative staff and patients are highlighted. Keywords administrative staff, electronic patient records, general practice, workflow

Introduction Recent legislation within the NHS [1] enabling patients to easily access their healthcare records and the ongoing drive towards digitization [2] has led to the development of specialized systems such as the Patients Access to Electronic Healthcare Records System (PAERS) [3]. PAERS was introduced at the Wells Park surgery in 2003 to facilitate patients’ electronic access to their records. Two separate terminals are sited in the surgery, one which allows patients to register on arrival by fingerprint recognition and the other which enables patients to explore their medical history and review details of previous consultations, results and referral letters.

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••••• Health Informatics Journal 13 (2) A plethora of published literature has described the potential clinical and efficiency benefits associated with electronic patient record (EPR) systems such as PAERS [4–6]. This literature highlights the fact that for electronic patient records to be effective and acceptable to the care team using them, there needs to be clear evidence of timesaving and improved service delivery [7]. However, few of these studies have specifically addressed the important issue of the potential impact of EPR on workflow [8], that is, the ‘cases, resources and triggers that relate to a particular process’ [9]. Amongst these studies is a report that clinicians are reluctant to adopt new ways of doing things that interfere with their workflow [10]. Further studies suggest that clinicians do not believe that the emergence of EPR will impact on patient waiting times [11], but acknowledge the potential for overall cost savings to be made through improved workflow [12]. The aim of this research was to identify the potential impact that PAERS might have on two aspects of workflow, namely, the impact of PAERS on patient registration time and its potential impact on clinical consultation time.

Method Two GP surgeries with similar patient demographics were selected for study, one with PAERS (Wells Park Practice) and one without such a system (South Lewisham Group Practice). The length of time taken for patients to register their arrival at the surgery was measured at both the Wells Park and the South Lewisham Practices. At South Lewisham a stopwatch was used to measure the lapsed time for 47 patients between their entering the surgery and seeing a receptionist. At Wells Park 38 patients who registered at the reception desk were similarly timed, whereas the 15 patients who used PAERS to register their arrival were timed from the point of arrival at the surgery until the point of electronic registration. A multimethod approach was used to assess the impact of PAERS on consultation time. Quantitative measures of the actual time of the consultation process were collected in addition to qualitative methods which were used to assess the perceptions of both clinicians and patients of potential impact [13]. Actual consultation length was timed at both surgeries from the time the patient was called from the waiting area by the GP to the time of their return. In order to improve the richness of the data collected and to further explore whether these groups perceived a change in workflow arising from the introduction of PAERS, structured interviews were conducted with GPs and patients at both sites. At Wells Park, interviews were conducted with 53 patients and five GPs. Inclusion and exclusion criteria were established prior to the interviewing process so as to ensure that only the views of those patients and GPs at Wells Park who had been registered or employed at the practice before the introduction of PAERS were captured. At the South Lewisham Group Practice, 47 patients were interviewed, as well as four general practitioners. The questions were matched to those at Wells Park so that comparisons could be made. Semi-structured interviews were conducted with administrative staff to explore whether these groups perceived a change in workflow arising from the introduction of PAERS. Eight administrative staff at the Wells Park Practice were interviewed and three staff members at South Lewisham. At Wells Park only those staff that had been employed both pre and post PAERS implementation were interviewed.

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In total, 120 questionnaires were completed at both sites. The data were analysed by the Statistical Program for the Social Sciences (SPSS) statistics programme [14]. Where Likert scales were used, responses were coded 1–5 (1 = strongly agree, 5 = strongly disagree). The data were summarized using the median and mode. Variability was expressed using the range and the interval size. Where appropriate, further statistical tests appropriate for Likert scales were employed [14]. Bar charts were constructed to clearly display Likert scale responses and quantitative data where appropriate, to aid analysis of results.

Results Impact of PAERS on time taken to register patient arrival Of the 47 patients timed at South Lewisham, only three had to wait beyond 1 minute to register on arrival. Of the 53 patients timed at Wells Park, 15 used PAERS to register their arrival and, of these, only one patient had to wait beyond 1 minute. This was as a result of their having to wait to use the system. The remaining 38 patients registered at the reception desk, and the mean time for these patients to register was 1 minute and 53 seconds.

Impact of PAERS on length of consultation time The average length of consultation time for patients at South Lewisham was 11.9 minutes. The average length of consultation time for patients at the Wells Park surgery who had not used the PAERS system was 11.5 minutes. The average length of consultation time for the nine patients who had used the PAERS system was 10.11 minutes. These patients were asked their opinion on whether viewing their e-notes prior to the consultation had any effect on the length of the consultation: 77.8 per cent of respondents believed that it had reduced the consultation length, whilst 11.1 per cent believed it had no impact. The remaining 44 patients at Wells Park who had not viewed their e-notes prior to consultation and all patients at South Lewisham were asked their opinion on whether viewing their e-notes prior to the consultation would impact on the length of the consultation. Here, 80.2 per cent of respondents believed that seeing their electronic notes before their consultation would reduce the overall consultation length. In order to focus these responses further in the light of views expressed by the GPs that PAERS had impacted on the length of time spent explaining results/letters, patients at both surgeries were asked whether the time spent explaining results/letters by the GP would be impacted as a result of viewing e-notes prior to consultation. In reply, 81 per cent of respondents expressed the view that there would be a reduction in consultation length. In response to whether PAERS would make the consultation process more efficient, 90 per cent concurred with 14 out of the 15 patients who had used the PAERS system in expressing the view that it had made the consultation more efficient. The GPs at Wells Park estimated that, where patients had viewed their electronic record prior to consultation, this had resulted in a reduction in the proportion of time spent during consultations explaining results/reports. Prior to the introduction of PAERS this proportion was estimated at 23.3 per cent of the total consultation time, compared with

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••••• Health Informatics Journal 13 (2) 19.3 per cent post implementation. In contrast, the GPs at South Lewisham expected to spend a greater proportion of consultation time explaining results if PAERS were to be introduced. They estimated that without the PAERS system they spent 24.2 per cent of the consultation time explaining results, but that this would rise to 36.3 per cent if PAERS were to be introduced. The GPs at Wells Park reported a fall in the proportion of time spent correcting inaccuracies in notes, with the proportion falling from 8.5 to 6.5 per cent of the consultation. At South Lewisham the GPs again expected to spend more time on this task, the proportion rising from 7.1 to 14.2 per cent. GPs at Wells Park also experienced a fall in the proportion of time spent explaining written notes to patients, from 16.1 to 11.5 per cent of the consultation. At South Lewisham the GPs again expected to spend more time on this task, the proportion rising from 7.1 to 16.7 per cent of the consultation. In response to the question as to whether PAERS had ‘improved the efficiency of the consultation’ and if this had ‘altered the length of the consultation’, four out of the five GPs at Wells Park felt it had improved the efficiency of the consultations, but not altered the length. At South Lewisham three out of four of the GPs expected PAERS to improve efficiency, but were unsure if it would alter the length of the consultation.

Impact of PAERS on administrative staff All nine of the administrative staff at Wells Park reported that the PAERS system had reduced the amount of time they spent registering patients, and 75 percent perceived a reduction in the overall time spent dealing with appointments. However, they estimated that it took on average 2 minutes to register a new patient to use PAERS and explain its use. At South Lewisham all staff were of the view that PAERS would reduce the length of time spent registering patients and that it would reduce the time they spend dealing with appointments.

Discussion Although patients at South Lewisham spent, on average, less time queueing to register than those at Wells Park, South Lewisham has a dedicated staff member assigned to this task whereas this is not the case for Wells Park. The 15 patients who used PAERS to register their arrival at the Wells Park Practice did not occupy any administrative staff time. Whilst this has obvious benefits for administrative staff workflow, these are somewhat ameliorated by the need to spend time demonstrating to patients how to use the system. When asked about reduction in consultation length, the GPs at Wells Park suggested that the time saving resulted from having to spend less time explaining written notes, results and reports to patients and less time correcting inaccuracies in the notes. Research has shown that GP consultation time is the most expensive commodity in a primary care setting, costing £2.09 per minute [16]. The average consultation length in the UK is 13.3 minutes [17]. The average consultation time at Wells Park for patients who had used PAERS was 10.11 minutes, costing £21.13. The average consultation time for patients who had not used PAERS was 12.4 minutes, costing £25.91. The average number of consultations per clinic per GP at Wells Park (i.e. one morning or afternoon session) is 14. The introduction of electronic records could therefore achieve a theoretical cost saving of £66.92 per GP per day. 158

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Whilst the potential exists for cost savings to be made, it is important to note that implementing these systems requires a large number of staff hours as GPs, administrative staff and patients all need to be trained to use the system. For example, there are currently 8103 patients registered at Wells Park Practice; given the estimate of 2 minutes of administrative staff time to explain PAERS to patients, this would represent 270.1 hours of work.

Conclusion Despite the limitations in the scale of this study, it provides early indications of the positive impact of electronic patient records on workflow in the general practice setting. An area of concern is the low uptake of PAERS by patients. Only 16.39 per cent of patients at Wells Park are registered to use the system, of which only 10.32 per cent use it regularly. There may be a number of explanatory factors for this which require further investigation. General practices will in the future have the option of purchasing one or other of the two components of PAERS: the fingerprint registration of patients on arrival and the booth for patients to view their e-notes. To enable this, facilities must be in place to provide continuous support for and encouragement of use amongst patients, alongside its implementation. On the basis of this study, we recommend adoption of PAERS as a means of improving efficiency only where the issue of acceptance amongst patients has been addressed.

Acknowledgements This study was approved by Lewisham Local Research Ethics Committee. We would like to take the opportunity to thank Dr Alasdair Honeyman for his support and guidance. We would also like to thank all the patients and staff who have generously given up their time to participate in the study, in particular Ms S. Evans, Dr B. Fisher, Ms P. Gaus, Mr R. Hutchinson, Dr K. Ismail and Dr S. Morris

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••••• Health Informatics Journal 13 (2) 12 Wang S J, Middleton B, Prosser L A, Bardon C G, Spurr C D, Carchidi P J, et al. A cost–benefit analysis of electronic medical records in primary care. American Journal of Medicine 2003; 114 (5); 397–403. 13 Bowling A. Research Methods in Health. Buckingham: Open University Press, 2002. 14 SPSS Data Editor Version 12 [computer program]. Chicago: SPSS Inc., 2005. 15 Mogey N. So you want to use a Likert scale. http://www.icbl.hw.ac.uk/ltdi/cookbook/info_likert_scale/, May 2005. 16 Netten A, Curtis L. Unit costs of health and social care. Personal Social Services Research Unit. http:// www.pssru.ac.uk/pdf/uc2003/uc2003.pdf 2003, February 2005. 17 Audit Commission. Transforming Primary Care: The Role of PCTs in Shaping and Supporting General Practice. London: Audit Commission, 2004.

Correspondence to: Matthew R. Cauldwell Matthew R. Cauldwell BSc(Hons), Medical Student Imperial College London Exhibition Road, South Kensington London SW7 2AZ, UK Tel: +44 (0)207 589 5111 Fax: +44 (0)207 594 8079 E-mail: [email protected]

Caroline E. Beattie BSc(Hons), Medical Student Imperial College London Exhibition Road, South Kensington London SW7 2AZ, UK Tel: +44 (0)207 589 5111 Fax: +44 (0)207 594 8079 E-mail: [email protected]

Benita M. Cox PhD, Reader of Operational Research Tanaka Business School Imperial College London Exhibition Road, South Kensington London SW7 2AZ, UK Tel: +44 (0)207 594 9164 Fax: +44 (0)207 594 9164 E-mail: [email protected]

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William J. Denby BSc(Hons), SurgS/Lt Medical Cadet (Royal Navy), Medical Student Imperial College London Exhibition Road, South Kensington London SW7 2AZ, UK Tel: +44 (0)207 589 5111 Fax: +44 (0)207 594 8079 E-mail: [email protected]

Jessica A. Ede-Golightly BSc(Hons), Medical Student Imperial College London Exhibition Road, South Kensington London SW7 2AZ, UK Tel: +44 (0)207 589 5111 Fax: +44 (0)207 594 8079 E-mail: [email protected]

Fiona L. Linton BSc(Hons), Medical Student Imperial College London Exhibition Road, South Kensington London SW7 2AZ, UK Tel: +44 (0)207 589 5111 Fax: +44 (0)207 594 8079 E-mail: fi[email protected]