Electronic documentation for Health and Social Care Professionals: The patient perspective

Abstract

Introduction & Practice Change : The Health and Social Care professions (HSCPs) comprising of physiotherapy (PT), occupational therapy (OT), medical social work MSW), clinical nutrition (CN) and speech and language therapy (SLT) in St. James’s hospital together with the IT department, have designed and implemented an electronic clinical documentation system aimed at replacing paper-based documentation for these professions. This is in line with national and organizational strategic aims towards a complete electronic patient record. Aim : To examine the patient’s perspective on electronic documentation, to proactively address their concerns and expectations of the system. Targeted population : Patients from inpatient and outpatient settings across a variety of clinical areas were surveyed. The questionnaire included demographics, patients views on the security and efficiency of electronic vs paper based documentation, their preferred method of documentation and open questions for comments or suggestions they had regarding the use of electronic documentation. The inclusion criteria were; actively being treated by a therapist, the ability to understand questions and verbalise responses. The results were then entered into Microsoft Excel for analyses and performance of simple descriptive statistics. Timeline : August 2016 Highlights : 94 participants completed the survey (PT=20; OT=16; MSW=17; CN=21; SLT=20), comprising 44 inpatients and 50 outpatients. 32% (n=33) were over 65years of age. 41% (n=39) were male. 86% of participants (n=81) felt that electronic documentation was as secure or more secure than paper notes, while 95% (n=89) felt that electronic documentation was efficient or more efficient than paper notes. 45% (n=42) preferred electronic documentation, 25% (n=24) preferred paper while 30% (n=28) had no preference. Themes emerging from patients comments were mainly positive. Many remarked on efficiency and convenience. However patients expressed concerns over potential hacking and access to their documents. Sustainability & Transferability : The use of electronic documentation has been perceived positively by patients surveyed. 94% of patients identified efficiency as an advantage to this style of documentation. Their concerns regarding the security should be addressed by disclosing this information in an open manner. The information gained will be fed back through the hospital's information governance committee and a list of FAQs will be gvien to patients.