Impact of EPR Systems on Information Flow in Finnish Health Centers

Abstract

Introduction: We studied how well healthcare personnel in healthcare centers (HCs) in the South Ostrobothnia region of Finland are able to obtain patient information thorough electronic patient record (EPR) systems. This study followed the changes in availability of patient information during a 7-year period, from 2003 to the end of 2010. The patient group studied focused on those involved in anticoagulant (AC) treatment. Subjects and Methods: A structured questionnaire was sent in 2003 to the staff of 15 HCs. The questionnaire dealt with access and availability of patient information from the EPR. Respondents were asked to rate how often they obtain information concerning AC treatment from various sources. Results: In total, 1,114 questionnaires were sent, and 860 answers were received; the response rate was 77%. A repeat study was conducted in 2010, and 932 responses were obtained (response rate, 56%). Paper-based AC treatment cards carried by the patients were an important information source for 75.0% of the respondents in 2003 and 55.4% in 2010. For all new AC treatments, the EPR was a primary information source for 33.3% of respondents in 2003 and 60.2% in 2010. Conclusions: This study indicated that during the study period there was an improvement in access to EPR but that this did not always improve the overall availability of data. Results show that problems in information flow from secondary care to the HCs persist. Almost half of the patients dealt with in the HCs were affected by at least some problems. In the 7 years covered by this study, EPR systems have become more important as information sources for clinical data, but there is still room for improvement.

Introduction

Finland has a relatively long history of utilizing electronic patient record (EPR) systems in primary and secondary healthcare. Despite significant development efforts, physicians are still critical of EPR systems used in Finland.¹ Quick, effortless access to patient data is one of the key requirements in clinical work.²

It is very difficult to objectively determine how well EPR or information technology (IT) systems in general function. One of the earliest and still often quoted attempts was the model presented by DeLone and McLean³ in 1992, which defined the variables that could be used to measure the generic “quality” of any IT system. DeLone and McLean³ divided IT system concepts and indicators into separate categories, starting with generic “system quality” and “information quality” categories, which then eventually impacted on the use of the IT system and hence described its effect or impact on the user organization.

In a study published in 2005, we attempted to determine how well EPR systems meet the needs of general practitioners (GPs) and other healthcare professionals.⁴ We found that there was a significant difference between the type of EPR system and the percentage of patients for whom information was available through the EPR. However, differences in performance between EPR systems probably reflected differences in the way EPRs were used by different organizations.

In this project, we hoped to further improve our understanding of EPR systems as tools for GPs. More specifically, we wanted to determine what impact the adoption of EPR systems has had on availability and flow of patient-related information. To do this, we focused on how well healthcare personnel involved in anticoagulant (AC) treatment in healthcare centers (HCs) are able to obtain information related to the AC treatment through EPR systems.

Subjects and Methods

This study was conducted in the South Ostrobothnia region of Finland. The total population of the region is 196,000, and primary healthcare is provided by HCs. In 2003 there were 16 HCs in the region. Because of organizational changes, in 2010 there were seven HCs left. In some cases, social care services had been transferred to the HC organization, and in some cases home nursing had been transferred to social care services. These seven HCs still serve the same population, and the total number of care sites in itself was not reduced. HCs offer a wide range of services (e.g., health promotion, prevention of diseases, provision of medical treatment and rehabilitation services). Many HCs have a hospital of their own. In 2010 HC hospitals in the South Ostrobothnia region had 1,130 beds. Secondary care is provided by Seinäjoki Central Hospital (560 beds) and Ähtäri Hospital (28 beds).

Regional HCs used three different EPR systems in 2003. Seinäjoki Central Hospital had started implementation of an EPR system in 2002, but it was not yet functional in 2003. It was, however, in full use by 2010.^5,6

Data were collected from the staff of regional HCs involved in AC treatment. We focused on how well healthcare personnel at HCs were able to obtain information related to the AC treatment through EPR systems.

AC patients were chosen as the patient target group because patients receiving AC treatment form a significant patient pool in Finland and often receive treatment in different healthcare organizations.⁷ Although AC treatment is mostly restricted to the HC of the patients' primary residence or the local central hospital, the information pertaining to this AC treatment must be available for other medical purposes as well. Typically, three or four separate organizations will be involved in providing care for these patients for reasons other than the AC treatment itself. This is a significant issue for care, and for this reason the flow and access of information between different treatment locales should be as efficient as possible. The timely and efficient transfer and availability of information are very important for these patients also because of potential complications that can arise during treatment.

AC treatment effectiveness is measured by the international normalized ratio (INR) value. There is an individual INR target level that patients should reach. Since 2000, the INR has been used in the follow-up of AC treatment in Finland.⁷

Data were collected by a structured questionnaire sent in 2003 to the staff of 15 HCs involved in AC treatment. A reminder letter was sent some time after the initial questionnaire form. A repeat questionnaire study was conducted in 2010. Because of mergers of HCs, by 2010 seven separate HCs remained, with six using the same EPR as Seinäjoki Central Hospital. The Ethics Committee of the hospital district of South Ostrobothnia approved the study, and the local boards of health or executive committees of all participating HCs also gave permission for the study.

The approach taken in this study was to try and find suitable indicators for both the system and data “quality” for the EPR systems in use in regional HCs. As suitable “proxies” for system quality, a measure of how often data were retrieved from the EPR systems was used. Hence, the questionnaire respondents were asked to rate how often they obtained information concerning AC treatment from various sources, for instance, the EPR, patient AC treatment cards, telephone inquiries, relatives, etc. The scale used ranged from 1 to 5 (1=very rarely, 2=rarely, 3=sometimes, 4=often, and 5=very often).

As a “proxy” for data quality, a set of agreed-on data categories relevant to AC treatment was settled on. Respondents were asked to rate how often they were able to obtain patient information using a scale of 1 to 5 (1=very rarely, 2=rarely, 3=sometimes, 4=often, and 5=very often). The patient information in question consisted of information that was considered to be central to the treatment of this particular patient group: the patient's previous INR, warfarin dosage, duration of treatment, individual INR target level, and questions dealing with patient counseling.

It should be noted that the questionnaire choices were determined by GPs with extensive experience of AC patient work. Therefore the metrics chosen reflect the day-to-day work of GPs. Responses from personnel who dealt with AC treatment on a weekly basis in 2003 and 2010 were compared and analyzed (by chi-squared test).

Results

In total, 1,114 questionnaires were sent in 2003, and 860 answers were received, a response rate of 77%. In the repeat questionnaire study of 2010, 1,675 questionnaires were sent, and 932 responses were obtained, a response rate of 56%. The numbers of responses classified according to the respondent's profession are highlighted in Table 1.

Table 1.

The Number of Responses Classified According to the Respondents' Profession

	2003		2010
PROFESSION	N	%	N	%
Physician	84	9.8	52	5.6
Community health nurse	169	19.7	178	19.1
Nurse	253	29.4	278	29.8
Practical nurse or nursing assistant	271	31.5	340	36.5
Department secretary/assistant	75	8.7	59	6.5
Profession not indicated	8	0.9	25	2.7
Total	860	100	932	100

Information flow and access responses were analyzed from respondents who stated that they dealt with AC patients at least weekly because it was deemed that this indicated that the respondents were very familiar with the patient group in question. When these responses were analyzed as a proportion of each profession, in 2003 about 88% of the GPs responded that they dealt with AC patients on a weekly basis, and in 2010 this number was 83%. For nurses, the respective figures were 79% in 2003 and 76% in 2010 (Table 2).

Table 2.

Respondent's Profession Among Those Dealing with Anticoagulant Treatments Weekly as a Percentage of Their Profession

	%
PROFESSION OF RESPONDENT	2003	2010
Physician	87.8	82.7
Community health nurse	32.0	15.7
Nurse	79.3	75.7
Practical nurse or nursing assistant	48.9	50.8
Department secretary/assistant	50.7	11.9

Tables 3 and 4 show, respectively, the information flow and access data from the respondents involved in AC treatment on a weekly basis. The results indicate that the paper-based AC treatment cards carried by the patients were an important information source for 75.0% of the respondents in 2003. The importance of this card was reduced in 2010 so that 55.4% of respondents dealing with AC patients on a weekly basis indicated that they obtained information from this source often or very often for new AC patients (p<0.001).

Table 3.

Respondents' Answers to the Question Regarding Information Source: “The Patient Has Been Treated in Secondary Care and Anticoagulant Therapy with Warfarin Has Now Been Started. The Patient Arrives for an International Normalized Ratio-Control to the Health Center for the First Time. How Often Do You Obtain Information from the Following Sources?”

	%
INFORMATION SOURCE	2003 (N=404–459)	2010 (N=388–431)	P
Patients' AC treatment card	75.0%	55.4%	<0.001
Discharge summary received on paper	47.9%	51.1%	0.043
Nurse's referral letter	45.7%	46.6%	0.007
Patient's verbal communication	40.4%	37.6%	NS
HC EPR	33.3%	60.2%	<0.001
By telephone from previous treatment site	11.1%	19.3%	0.019
Relatives	8.2%	9.1%	NS
Electronic discharge summary	—	53.3%	—
Regional EPR database	—	30.6%	—

Respondents are staff at healthcare centers (HCs) dealing with anticoagulant (AC) patients at least on a weekly basis. Data are share of responses indicating “often” or “very often” in 2003 and 2010.

EPR, electronic patient record; NS, not significant.

Table 4.

Respondents' Answers to the Question Regarding Information Type: “The Patient Has Been Treated in Secondary Care and Anticoagulant Therapy with Warfarin Has Now Been Started. Now The Patient Arrives for the First Time for an International Normalized Ratio-Control to the Health Center. How Often Do You Obtain the Following Information from the Various Sources?”

	%
INFORMATION CONTENT OR TYPE	2003 (N=455–475)	2010 (N=422–447)	P
Previous INR	76.8	78.4	NS
Previous warfarin dosage	75.2	73.7	NS
Indication for AC treatment	65.4	70.4	NS
Planned duration of treatment	42.0	54.0	<0.001
Patient's individual INR-target level	29.0	46.7	<0.001
Has patient received basic AC treatment counseling?	16.3	19.3	0.013

Respondents are staff at healthcare centers dealing with anticoagulant (AC) patients at least on a weekly basis. Data are share of responses indicating “often” or “very often” in 2003 and 2010.

INR, international normalized ratio; NS, not significant.

For all new AC treatments, the EPR was a primary information source for 33.3% of respondents in 2003 and 60.2% in 2010 (p<0.001).

A great majority of respondents indicated that they had permission to access information from the EPR: 94.6% had permission in 2003, and 94.2% had permission in 2010.

As can be seen from the results given in Table 2, the great majority of GPs and nurses were involved on AC treatment on a weekly basis. On average, respondents estimated they dealt with 2.7 AC patients in 2003 and 2.6 patients in 2010 within a 4-week time frame. These were newly arrived patients from secondary care. Within this patient group, respondents estimated they experienced some type of problem in information flow from secondary care to the HC for on average 1.6 patients in 2003 and 1.4 patients in 2010. This corresponds to 59% of patients in 2003 and 54% in 2010. However, because the number of AC patients dealt with by the respondents within a 4-week period were only estimates, the responses can be judged to be indicative only. They do, however, show that at least some types of problems are experienced in handling or obtaining information for a clearly significant proportion of patients.

Discussion

The response rate to this study was relatively good. There was a small reduction in both the overall response rate and the response rate of GPs in particular from 2003 to 2010. This can most likely be attributed to “questionnaire fatigue” as there were many requests for healthcare professionals' opinions from mostly governmental sources during the study period.

The majority of the responses in this study are, not surprisingly, from nursing staff. Nurses are actively involved in AC treatment and deliver care within predetermined parameters and limits relatively independently. Hence, no treatment “teams” are involved in a typical AC treatment process. Therefore, the occurrence of multiple responses involving the same patient case is most probably not a significant issue.

To minimize possible response bias, the results were checked for consistency of answers. There were no significant indications of unanswered portions in the questionnaire that might indicate bias. The overall spread of answers also did not bring up any factors that indicated that possible bias was a significant issue. A pretrial pilot study was also conducted prior to the questionnaire study to alleviate bias. Because we concentrated on the answers from those who indicated that they were actively involved in AC treatment, on a weekly basis, the quality of the responses can be assumed to be good.

During the study period, there were changes in both the working practices and the organization structure. For instance, the active role of department secretaries in AC treatment was somewhat reduced by 2010. On the other hand, additional training was given to nurses after 2003 so that they were more actively involved in AC treatment. These factors are reflected in the reduction of GP numbers from 2003 to 2010.

When this study was commenced in 2003, there were three different EPR systems in use at the HC level. The regional central hospital had only started implementation of an EPR, which was not yet in use in 2003. It was assumed in 2003 that by 2010 at the latest all regional EPR systems would be interconnected and that all necessary patient information easily accessible by all regional healthcare organizations. By 2010, six of the seven HCs did have the same EPR as the central hospital, but this did not guarantee automatic interconnection between systems. There were, and still are, different versions of the software in use in different locations. Also, not all issues relating to permission and user access from different organizations to the shared EPR data had been solved by 2010.

Seinäjoki Central Hospital, responsible for the secondary care of AC patients, was also implementing an electronic form specifically for AC patients during the course of this study. However, the electronic form in use in secondary care was not initially visible in the regional HCs. During the duration of this study, partial access to this secondary care AC form was given to HCs, but even then HC GPs did not have automatic access to these forms.

Despite these issues, this study does indicate that EPR systems have become more important as information sources. However, they are still not the sole source of information. Only 60.2% indicated the HC EPR was the information source of greatest importance (indicated by respondents stating that the EPR is an information source “often” or “very often”) in 2010 for ongoing AC treatments, up from 33.3% in 2003. Hence, although in principle EPR systems and electronic treatment cards should include all relevant information, the results of this study indirectly indicate than in real life multiple sources of information will be used.

The role of paper-based AC cards was reduced during this study period. This is not thought to be a problem in emergency situations, as these cards might not be carried with the patients in emergencies anyway, but left at home, etc. In the future, smart integrated circuit cards might take the place of the present paper-based cards, but so far large-scale implementation of these in Finland has not taken place. Naturally, the same drawbacks for smart cards exist—they might not be always carried with the person, especially in cases of emergencies.

On a more positive note, though, a regional EPR database did start functioning during this study, so that 30.6% of respondents indicated this to be a significant information source in 2010 (“often” or “very often”). In 2003, this database did not yet exist, but it was operational in 2010. Initially, though, it was expected to be functional by 2005. In this respect also reality has proved to be more challenging than expectations.

Despite some progress made in EPR implementation, the proportion of patients impacted by information flow problems has not changed significantly during this study period. This is clearly something to be concerned about and a clear indication that a lot of work lies ahead in this regard.

Some of these problems appear to be due to the way electronic systems are implemented and used. According to user feedback, some of the issues include lack of interconnectivity between EPR systems and organizations, insufficient user training, and user interface problems.^5,6 For instance, some types of information have to be manually filled into multiple data fields in the EPR system, which is itself divided into different types of information “windows” or “forms.” AC patient information is collected in the HCs on a specific electronic form. Although laboratory results are automatically updated to this form, most other information, such as medication dosage, has to be filled in manually.

User experiences also indicate that that there are sometimes significant changes between software versions. This means that EPR system updates sometimes cause interconnectivity and incompatibility problems for users of nominally “identical” EPR systems. In one reported case, the implementation of a version update had to be delayed for a month because user tests indicated that the newest version did not handle physician dictations correctly.

Conclusions

Improvements in access to EPR data has not necessarily improved the overall availability of data. For instance, the central pieces of information for this patient group include previous warfarin dose and INR values. The previous INR value was available “very often” or “often” for only 76.8% of respondent in 2003, with this being only marginally improved to 78.4% in 2010. This should clearly be 100%. The situation is practically identical for the warfarin dose data; these were available “very often” or “often” in 79.7% of responses in 2003 and 75.8% in 2010, with the slight drop not being statistically significant. Therefore, although actual access to information might have improved, the “quality” of information has remained constant, insofar as the limits of this study permit us to draw such conclusions.

Perhaps because the requirements placed on EPR systems are so exhausting, additional types of records are and will be kept for specific purposes. One such record is the traditional paper-based AC treatment card carried by some patients.⁸ This research indicated that these traditional methods of recording information are still in use and apparently fulfill a clear need.

The study region is relatively typical in terms of healthcare delivery and population base; therefore, it can be assumed that the results of this study are valid in Finland more generally. The same EPR systems are used nationally, and treatment practices are also generally the same on a national scale.

National goals call for a centralized, national database. However, because there are clearly significant issues in developing compatible software for regional databases, even more problems can be expected to be in store for implementation of a national database.

One possible solution to the problems faced in EPR development is to involve users more intensely in the design of future solutions. Improvements in user training should also help—in some cases user attitudes seem to be due to simply not being aware of or being unable to use the systems to their fullest extent. More effort should also be put into user interface simplification, ergonomics, and streamlining.

In conclusion, it can be said that in the 7 years covered by this study, EPR systems have become more important as information sources for clinical data, but there is still room for improvement. Progress has clearly been slower than initially hoped for, and improvements in information flow during the 7 years of this study period have also been slower than expected. Problems in information flow and availability persist, unfortunately.

Footnotes

Acknowledgments

This study was supported by the research fund of South Ostrobothnia Hospital District.

Disclosure Statement

No competing financial interests exist.

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