Stepping into the digital era
Emma K. Whitney
BPharm, GradCertPharmPract | MSHP Foundational Resident Pharmacist, Canberra Health Services | emma.whitney@act.gov.au
[Pharmacy GRIT Article No: 20231393]
Approximately halfway through my residency program, the Digital Health Record (Epic Systems Corporation, Verona, WI, USA) was implemented at Canberra Health Services. This was not only a fundamental change in the way we cared for patients, but it was also a personal change in the plan for my research project. My project aimed to assess the safety, efficacy, and prescribing trends of extended post-operative tranexamic acid use in orthopaedic patients. It relied heavily on accurate and detailed medical record keeping as it was conducted retrospectively.
In previous retrospective projects that I had undertaken, the aspect of data collection was a slow and tedious process as it required reading handwritten notes which had been scanned page by page into each patient’s online record. This created the challenge of having to ‘interpret’ health professionals’ handwriting and reading numerous pages of notes to find relevant information.
The implementation of the Digital Health Record changed this. Suddenly, patient notes from any encounter with our healthcare system were easily accessible and most importantly, legible. We were even able to search relevant keywords to find specific information. I was fortunate to utilise the new system to conduct my data collection. It made my project more efficient as I was able to quickly locate the relevant information needed for my project, including patient characteristics and reasons for clinical decisions.
However, it would be remiss of me to say the Digital Health Record is a perfect system. I still encountered challenges in my project, the main one being documentation. Notes completed by healthcare professionals were often lacking detail or used unapproved acronyms, which increased the risk of human error during data collection. Another challenge was incomplete data, as it meant that patients had to be excluded from data analysis if the missing data was crucial for analysis. While these issues are not exclusive to an electronic health record, they presented a challenge in my project.
On reflection, I found that many studies have been conducted on the advantages and disadvantages of electronic medical records, including from Australian researchers. One study found that the details recorded in a patient care situation can be discordant and variable.1 This aspect of my project could perhaps have been improved if it were conducted as a prospective study, as this would require healthcare professionals to document specific clinical information according to study protocols.
Overall, I found the experience to be highly valuable as it provided me with exposure to the process of undertaking a research project. I was able to develop new skills with assistance from colleagues, including applying for ethics approval, and generating simple descriptive statistics on collected data. The experience will facilitate future research as I am now better equipped to complete research projects more independently due to a familiarity with the process.
References
- Allen-Graham J, Mitchell L, Heriot N, Armani R, Langton D, Levinson M, et al. Electronic health records and online medical records: an asset or a liability under current conditions? Aust Health Rev 2018; 42: 59–65.