Enviat per: Grup d'ètica CAMFiC | Novembre 14, 2018

Statement on hyper-registration (“registritis”) in the clinical professional-patient encounter in Primary Care (PC)

CAMFiC Ethics Group

Introduction
Patients complain more and more that professionals do not pay attention to them, that they look at the computer more than at them. A complaint that reveals a feeling of depersonalization which according to the Dictionary Merriam- Webster means ” to deprive of the sense of personal identity”.
Professionals also complain because they understand that institutions and companies are prompting them to register more and more data, and linking such registration of data to economic incentives. It is necessary to spend a lot of time attending the computer to record everything that is demanded. Twenty years ago, a clinical encounter consisted of an interview of two people in which the professional took some notes in the paper clinical record. Now we can say instead that the clinical act has become a situation where the professional, in addition to doing what he/she did before, it has to attend a screen that asks much more than it returns. We could even think that it can act as a distracting factor, because it is easier to press keys than listen to someone who suffers, or to make a good anamnesis of a common symptom, or a good differential diagnosis, or even a negotiation with the patient to make shared health decisions.

Complaints from one and the other side are supported by scientific studies that say that primary care doctors spend more than half of their daily work time doing tasks on the computer, both in the presence of patients and when they are not visiting patients. What is more worrying, when the doctor-computer-patient relationships are analyzed at the clinical encounters, it is verified that the professional looks more at the computer than at the person.

The presence of the computer is a fact, and it currently occupies a preponderant place in the daily health consultations. It is evident that its use, in addition of being a reality, has introduced important gains in health care, such as in communication and coordination between professionals of different care levels, in the evaluation of the quality of care, or in patient safety, among others.

It must be remembered, however, that the purpose of the professional-patient clinical encounter is to create a trust relationship useful for the patient and for the professional in the task of “sometimes cure, relieve often, listen, understand and always accompany”[1]. Clinical records and registrations should be a tool to help the professional to care for patients, and technology should be used for clinical purposes and to enhance clinical relationship.
Nowadays the clinical record is a data collection tool that apparently improves health care, but it is clear that our profession is much more than collecting data and that it cannot be focused on the data collection. Clinical records should be available and at the service of the professional, the patient and the relationship among them, and not, as it is happening, that professionals, patients and clinical records are at the service of data collection.
What changes are happening in the consultations and in the professional-patient relationship?
1. The computerization of clinical records has led to a great proliferation of checklists, structured templates, computer lists, etc., which introduces “a third element” in the medical consultation. This fact has consequences in the dynamic and interaction between people and technology, constituting a new social phenomenon[2].

  1. The first consequence is that the demands for registrations have increased exponentially, something in the professional slang already referred to as “registritis”.
  2. These structured computerized records have forced to standardize even more the clinical terminology, the reasons for consultation, and the demands of the patients.
  3. Many of these records don’t have welfare objectives, rather they are generated for management or for epidemiological purposes, even if it is known that the reliability of many of the data for these non-clinical uses is doubtful.

What are some of the main risks of the current situation?

What gives life to work in the field of PC are soft technologies: the relationship, the word, the trust…, which enable the professional to act based on reality and the particular context of each person they attend.

The uniformity of the attention provoked by the registers gives rise to a bureaucratized clinical practice.

The records have become an objective in itself displacing the main objective of the PC and subtracting quality and time for care.

The numerical and standardized “registritis” makes difficult to listen to narratives, it makes it difficult to think narratively, and it directs us towards the codes and the disease, instead of the person, making us less interested in human and relational factors.

If the registration is not useful for the clinical evaluation it causes a conflict of loyalties between our first allegiance with the patient and other loyalties (such as Health Department, the company, the mutual insurances, etc.).

It affects the humane relation, “the presence” and the trust relationship, and the ethical commitment we have with the person we are attending.

Some authors point out that one of the most important problems of the current work is the division of labor that has motivated a long chain of responsibilities where those who decide must not face the consequences of their decisions, because they are separated from the objects of these decisions. And those who execute do not have the responsibility to decide, but only to carry out the orders. It is necessary that decision makers and executors both reflect on the work globally, take actions and assume responsibilities.

Recommendations and proposals

Recommendations to professionals

Communication, empathy, compassion and soft technologies continue to be the central value of a humanized clinical relationship in primary care. It´s important for us to constantly remember it.

Let’s always ask ourselves the objective of each data record. Is it the patient’s health? If it´s not, what is the objective?

If the aim is not the health and the clinical relationship, and it takes us time for care, we must inform the management and the team about the convenience of dispensing a register. Can we consider not making the register?

We must not be dazzled by novelty and innovation. Let’s be clear and demand that every new program and registration must be evaluated before its implementation.

In the case of records with clinical application, let us evaluate if the load of “clicks” is justified. Is it logical that we have to make so many clicks to register the flu vaccine? Would it be possible to robotize this record? If the number de “clicks” is not justified, let us question it.

Let us work with full attention, listening and feeling words, gestures and emotions from both sides of the table. During the interview, let’s focus on looking and listening to the patient and, whenever possible, register after the consultation.

If it is not possible and we have to consult and / or make records during the visit, we can share what we are doing with the patient, working with an open screen.
Requests to the managers and people responsible of clinical software design

They must understand that any new program and record must be evaluated before its implementation.

They should review the burden of the records they request from each professional if this compromises clinical work and reduces patient care time. They should be aware that the basic technology of the PC is time to build a relationship.

It is essential that they robotize the incorporation into the clinical history of the data that we obtain with devices that can be automatically downloaded (analysis, spirometry, blood pressure…).

They must review the clinical usefulness of the different software and registers and be clear that the first loyalty of the clinician is with the consulting person, who, in case of dilemma, passes in front of the other loyalties.

They should consider taking the records of the consultations for non-clinical purposes (management or epidemiological purposes), and they should reflect whether these records are essential. If they are not essential, they must look for other ways to obtain the data.

They should adhere to the evidence that shows that linking the registration of data to economic incentives, to teaching and to the professional career can have perverse incentives and lead to maleficence for the health of patients.

In conclusion, electronic records and hyperegistration are profoundly modifying the nature of clinical work and contributing to bureaucratization of care. Putting technology at the service of people care and the clinical relationship is necessary to avoid prioritizing “institution-centered” care instead of “patient-centered” care, as Trisha Greenhalgh points out very aptly.
In order to change the current situation of “registritis” and the bureaucratization of consultations, decisive actions are required, not only individuals, but mainly collective actions of the professionals involved, especially because many registers are linked to economic gain, professional career or stability at work.
If you wish, you can download the document here

[1] Sentence attributed to French doctors on the last years from XIX century Bérard and Gubler

[2] Deborah Swinglehurst, Trisha Greenhalgh, Celia Roberts. Computer templates in chronic disease management: ethnographic case study in general practice. BMJ Open 2012;2:e001754. doi:10.1136/bmjopen-2012-001754. http://bmjopen.bmj.com/content/2/6/e001754.full

 

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