Introduction Evidence of written clinical documentation exists from pre-historic times. An early example of written medical records for didactic purposes can be traced back to 1600 BC, more precisely to the Edwin Smith papyrus, which originated during the reign of the 18th dynasty in ancient Egypt3,4. However, with the advent of the revolution in computers and associated technologies, the adoption of Electronic Medical Records in the Ambulatory settings has been widely recommended by notable and influential groups such as the Institute of Medicine as a way to reduce errors and improve the quality of healthcare provided1,2.

Pervasive clinical e-documentation and casenotes-less state of clinical care are possible, but some considerations need to be met – (i) physician-patient relationship and continuity of care shouldn’t be adversely affected, (ii) progress expectations should be realistic, (iii) big data analysis perspective should be adopted, (iv) capture of behavioural health and social determinants information through e-documentation means that there are bound to be structural and privacy standards related changes3,5, and (v) changes in processes to accommodate established practices, such as patient recall and critical results’ alerts. At SGH, the future of clinical e-documentation seems promising. Followed by the successes at DMC, efforts are ongoing to make the upcoming Ambulatory Endoscopy Centre paperless. By mid-2017, approximately 50% of SGH’s outpatient visits would be electronically documented.

Better legibility

Increased availability

More reliability

Figure 1 : Expected benefits when clinical documentation goes from being paper-based to electronic

The Diabetes and Metabolism Centre (DMC) is a one-stop patient centric multi-disciplinary set-up that started operations in May 2015. The clinical departments operating out of DMC include Renal Medicine, Endocrinology, Internal Medicine and Vascular Surgery. Around 500 patients visit the centre everyday, making it one of the busiest centres within SGH. As compared to a majority of the other outpatient clinics and centres, the DMC is located significantly away from the medical records office (> 0.5km), thus making any unplanned(ad-hoc) request for casenotes time consuming and manpower intensive. Hence, there was a need to achieve the following -:

• Electronic documentation by clinicians for all DMC patient visits

• Physical casenotes not required for any DMC patient visits

• Electronic availability of clinical information for all DMC patient visits

Why are casenotes essential and can’t be done away with?

Because clinical doc. and correspondence doc. are stored in casenotes.

Why are they stored in casenotes?

Because care providers need to access them for continuity of care.

Why do care providers need to access them only from casenotes?

Because there is no electronic availability of past casenotes.

Why is there no electronic availability?

Because there is no dedicated e-platform.

Why is there no dedicated platform?

Because such a platform is manpower and resource intensive.

Why doctors continue to write on paper when electronic doc. options are available?

Because doctors feel that e-doc. systems don’t fulfil their requirements.

Why do they find the e-doc. system to be inadequate?

Because doctors can’t easily navigate their way in the system.

Why can’t doctors navigate easily?

Because doctors have not been adequately trained.

Why have doctors not been adequately trained?

Because there are insufficient actual cases to practice.

Why are there insufficient ‘live’ training opportunities?

Because departments and clinics have not embarked on ClinDoc & rely on MR.

0%

5%

10%

15%

20%

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

Internal Medicine Endocrinology Renal Medicine Vascular Surgery

0

200

400

600

800

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

Internal Medicine Endocrinology Renal Medicine Vascular Surgery Required Tracing Actual Traced

Clinic Counter

Consult Room

Listing Room

Inpatient

• Patient arrives and Registers • No casenotes provided for NC

•Doctor documents on ClinDoc •Patient Signs Consent form

• Nurse lists patient • Financial Counselling • Procedure prep advice given

1. Referral letter 2. AAF forms

3.Consent forms

1.AAF forms 2.Consent forms

3.Listing checklist 4.eFC acknowledgement

5.Referral Letter 6.Other essential documents

• Patient is admitted • Clinical documentation

done electronically

Consult Room •Doctor views inpatient report via SCM

•Other documents are viewed in SMR

HIMS • Scans referral letter and other

essential documents into SMR

1.Report 2.Consent forms 3.eFC acknowledgement 4.Images 5.Referral Letter 6.Other essential documents

Patient arrives

for consult

Past Med Records

available online ?

Doctor documents online

Consultation episode over

Stop

Doctor provided with casenotes

Doctor uses HIDS to doc for

current visit?

Doctor documents online HIDS Summary

and the notes are printed

Loose sheet scanned and stored in SMR folder;

SMR & STG record filed in library

No

Yes

No

Yes

Yes

No

• All Adhoc requests (walk-in, special request from doctors) are to be entertained. Reason for request to be clearly specified.

• If requested notes are already available online, then MRO will advice clinic that doctors can view prior medical records in SMR.

• During initial transition period, even if patient casenotes have been scanned and are available online in SMR, but physical casenotes are requested for by the clinics for any reason, MRO will facilitate the provision of the notes.

Aim

Methodology – 5 WHYs and Ishikawa

Process Changes

Outcomes – Strategy and Success Story

Conclusion – Replicability and Future State

0%

20%

40%

60%

80%

100%

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

Endocrinology Internal Medicine Renal Medicine Vascular Surgery

Clinic sends records and paper to MRO

Doctor documents on paper

Doctor uses ClinDoc

to doc?

Strategy

Essential documents to be scanned into SMR (Scanned Medical Records)

SMR to be accessible through SCM without need for context switching

Scanned essential documents (paper based) stored in separate MR

Actual Scanned notes not provided to care areas (medico-legal)

Stringent quality control to reassure doctors about document integrity

Past MR to be provided to care areas on an adhoc as-needed basis

Improve upon the uptake of ClinDoc by clinicians

Address the challenges related to ClincDoc such as porting of Images

Figure 4 : Increasing trend of patient consultation related ClinDoc (electronic documentation) adoption

Percentage of patient visits

Figure 5 : Increasing trend of ClinDoc (electronic documentation) adoption during patient consultation

Figure 6 : Reducing trend of the physical casenotes being traced for patient visits

Figure 2 : Ishikawa diagram showing the reasons for unavailability of patientcare information (and the needed to be addressed as a standard part of change management of

clinical documentation from paper to electronic)

Figure 3 : Electronic clinical documentation and associated processes from the perspective of the DMC clinics

Table 1: 5 WHYs technique to answer two fundamental questions – (a) Why is it difficult to do away with physical casenotes? and (b) Why do care providers continue to use paper documentation when electronic options are available?

No system

to track

People Method

Equipment

Unavailability of patient care information when needed

forms never

reach HIMS

requestor

fax but

HIMS never

receive

manual form

misplaced by

porter

manual

form easily

misplaced

porter has many

destination to visit

before HIMS

manual form

misplaced by

requestor

manual form

not sent by

requestor

personally

manual

form easily

misplaced

requestor has

many requests &

tasks to track

work

requirement

doesn’t allow

requestor to

leave workplace

for long

long time

taken to walk

to HIMS just

to submit

form long time

taken to wait

for request to

be processed

Inherent problem

with fax machine

forms reach,

but

misplaced at

HIMS

form

misplaced

at counter

form

misplaced

by tracer

many

things

happening

at counter

Long time taken

to retrieve

medical records

many requestor

crowding at

counter

staff have

many requests

to follow up

manual

form easily

misplaced

Borrower takes time

to response

Difficulty

locating

hardcopy

Filing shelves

too tight

Folders too

many and thick

Patient’s with

chronic

problems

Many active patients

Incompatibility

of systems

Lack of stdization

in organization of

scanned medical

records

e-documentation

system doesn’t

match doctors’

expectations

No online system

of viewing past MR

to support

e-documentation

Too many legacy

systems that need

to ‘talk’

Reports are not

completely ported

over

Information is not

available in the

format doctors

desire

Difficult for staff to

organize scanned

documents

Doctors are

reluctant to use

e-documentation Time consuming to

type consultation

notes on e-platform

Difficult to learn

and navigate

through systems

No easy guide

available to refer to

Doctors can’t use

SMR for viewing

past MR

Doctors can’t find

patients’ past

records scanned

into SMR

Difficult to scan all

documents into the

SMR

Licensing issues

Network Bandwidth is not

suitable for SMR

Unavailability of the

scanned medical records

(SMR) system

new porter

Hardcopy not

at filing

shelves

Staff careless

Staff careless

Borrower

cannot locate

file

Records

misfiled

Inherent

problem

with

hardcopy

Images are not

ported over

Some doctors are

not well versed

with computer

systems

No system

to track

form

No system

to track &

reprint

Software system

too complex for e-

documentation

Context

switching

needed

Hardcopy

records

leaves not

trail

Inherent

problem

with

hardcopy

Borrower

not around

and other

staff have

no idea

Inherent

problem

with

hardcopy

Records with

another borrower

Resource

intensive to

trace back

Environment

Many forms and

supporting

documents still

manual

Electronic Input

systems don’t mimic

paper based input

Confusion about

what is available

online and what

needs paper

Doctors and other

care-providers more

comfortable in using

paper documentation

This provided SGH with the ideal opportunity to use DMC as a test-bed for rolling out the electronic documentation of medical records, making healthcare safe and of high quality.

Figure 7 : Generic workflow to support clinical e-documentation efforts at SGH

• AT DMC ClinDoc adoption has increased to more than 80% of all patient visits.

• Although initially only for NewCases, ClinDoc was soon adopted for FollowUp cases. Departments such as Vascular Surgery are now close to 100% on ClinDoc.

Increase in ClinDoc adoption by doctors (Figure 4)

• Creation of SMR w.r.t to patient visits have gone up from o% to almost 15%.

• Increase in scanning of physical notes and documents (as evident from increasing no. of SMR folders) correlates with increase in e-documentation.

Increase in Scanned Medical Records generation (Figure 5)

• Consistent & continuous decrease in use of physical medical records at DMC.

• Increasing gap between number of casenotes folders required (without e-documentation) and numbers actually delivered for TCU post e-documentation.

Decrease in paper Medical Record usage (Figure 6)

Percentage of patient visits

Number of casenotes folders

Koh Guat Cheng, HIMS, SGH Siddhartha Sanyal, HIMS, SGH

Loh Li See, HIMS, SGH Asiah Bte Abd Latif, HIMS, SGH

Chia Koh Hua, HIMS, SGH Anne Goh, HIMS, SGH

Stephen Wong, SOC, SGH Yvonne Chan, SOC, SGH

Puspalatah D/O Satasivan, SOC, SGH Yeo Shuan Khiag, SOC, SGH

Dr. Chong Tze Tec, Department of Vascular Surgery, SGH

1. Berner, Eta S., at al. "Will the wave finally break? A brief view of the adoption of electronic medical records in the United States." Journal of the American Medical Informatics Association 12.1 (2005): 3-7. 2. Hahn, Karissa A., et al. "Electronic medical records are not associated with improved documentation in community primary care practices." American Journal of Medical Quality (2011). 3. Gillum, Richard F. "From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age." The American journal of medicine 126.10 (2013): 853-857. 4. Al-Awqati, Qais. "How to write a case report: lessons from 1600 BC." Kidney international 69.12 (2006): 2113-2114. 5. Lau, Francis, et al. "Impact of electronic medical record on physician practice in office settings: a systematic review." BMC medical informatics and decision making 12.1 (2012): 1.

References

Findings -: Slow adoption due to perceived system limitations and unawareness of system functionalities have been contributing to the challenges associated with electronic documentation. Clinical practitioners rightfully want access to prior medical records of patients in a timely and seamless manner. These issues need addressing in a structured and systemic manner if e-documentation is to succeed.