The impact of a computerized care records service (CRS) on doctors’ work patterns in urological outpatient clinics

doi:10.4236/health.2011.311118

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Vol.3, No.11, 703-707 (2011)

doi:10.4236/health.2011.311118

Health

The impact of a computerized care records service

(CRS) on doctors’ work patterns in urological

outpatient clinics

Stefanos Kachrilas, Christian Bach, Pryia Kumar, Faruqz Zaman, Nicola Dickens,

Junaid Masood, Noor Buchholz*

Endourology & Stone Services, Department of Urology, Barts and The London NHS Trust, London, United Kingdom;

*Corresponding Author: [email protected]

Received 18 August 2011; revised 13 October 2011; accepted 21 October 2011.

ABSTRACT

Objective: Government targets to reduce wait-

ing times are putting enormous pressures on

outpatient services. The implementation of an

electronic care records service (CRS) at our

hospital in 2008 has led to widespread press

coverage of ensuing chaos in clinical admini-

stration. We wanted to know how this new elec-

tronic system impacted on our working patterns

in outpatient clinics and—more specifically—on

the time actually spent with the patients. Mate-

rial & methods: This study was performed 4 and

12 months after implementation of CRS to as-

sess its impact on the time distribution in clinic.

Senior doctors were monitored with a stop

clock during consultations. T imings for pre- and

post-consultation administration, and the actual

consultation with the patient were recorded. A

total of 170 consultations were evaluated in this

way. Results: The key findings were that the

total time needed to spend on a urological out-

patient of 16 minutes remains unchanged from

the pre-CRS era, but a majority (57%) of this

time is spent in administration on the computer

without the patient involved. Conclusion: No

more than 15 patients should be seen in a 4

hour outpatient clinic per doctor. This recom-

mendation drawn up by BAUS before CRS re-

mains still valid. Patient administration related

to the consultation that has previously been

done by administrative aides is now to be done

by the doctors on the computer in the same

consultation session. Intended to streamline

patient pathways, this does reduce the quality

interaction-time between doctor and patients

significantly.

Keywords: Working Pattern; Consultation Time;

care records service; Outpatient Clinic; N ational

Health System NHS

1. INTRODUCTION

Just before the end of the 20th century, an outlook on

the future of British Urology concluded that the urologi-

cal workload was set to increase. This was thought to be

mainly due to an increase in screening, investigations,

counselling and non-surgical treatments [1]. All these

activities concern the work in outpatient clinics. More

recently, government initiatives to improve patient care

and reduce waiting times have added even more pres-

sures on the effective use of outpatient resources [2].

Indeed, only around 20% of urologists are able to follow

recommendations of the British Association of Urologi-

cal Surgeons (BAUS) for outpatient workload “A Qual-

ity Urological Service for Patients in the new Mille-

nium” published in 2000 [3,4]. The average urology

consultant team in the United Kingdom (UK) “overper-

foms” in outpatient clinics by a factor of 1.4 [4]. Con-

sultants do spend more time with patients than in the

past. The list of medical investigations and surgical

treatments has increased dramatically, and patients are

better informed, more demanding and expect more ex-

planation, with doctors increasingly offering to share

their knowledge [1,5]. Therefore, it was thought that

perhaps an electronic system to access and record patient

information may be the best approach to ease these

pressures [6].

As one of a handful of sites, the Care Record Service

(CRS) by Cerner was implemented at Barts and The

London NHS Trust in April 2008 as part of a £ 12.7 bil-

lion National Program for Information Technology (IT)

in the National Health Service (NHS). Although initial

problems at implementation were and must be expected,

S. Kachrilas et al. / Health 3 (2011) 703-707

704

they went beyond what was anticipated [7-12]. As ex-

pected, clinicians were struggling with the new system.

Whereas the system held the promise of streamlining

patient pathways, administrative tasks that had been pre-

viously performed by clerks were now to be performed

by the doctor on the computer in the same patient ses-

sion (i.e. printing of results, ordering of investigations,

booking of surgeries etc.). In consequence, paper notes

holding pre-CRS information were left incomplete and

often in disorder. Finding information in these became

an additional time factor.

After we had waited four months thinking this to be

enough time to overcome teething problems, we wanted

to know how this new electronic system impacted on our

working patterns in outpatient clinics and—more spe-

cifically—on the time actually spent with the patients.

2. MATERIAL AND METHODS

Before April 2008, a senior urologist in our hospital

would see 20 patients in a typical clinic. As outlined

above, this was in line with a national average of “over-

performance” of a factor 1.4 [4] as compared to guide-

lines. This corresponds to 12 minutes consultation time

per patient which at that time was a mixture of conversa-

tion, viewing referral letters and results, and dictation.

Results were printed previously and readily sorted on top

of the file. Bookings of diagnostic tests and procedures

would be done by clerical staff. Because of the latter,

times were deemed appropriate although an average of

12 minutes per patient could be challenging depending

on the patient population. Therefore, BAUS issued its

guidelines recommending no more than 15 patients per

doctor per clinic [3,4] in 2003.

CRS was implemented at Barts and The London NHS

Trust in April 2008. Four months later, well after im-

plementation, urological outpatient clinics were moni-

tored as to time usage of the consulting doctors. During

August 2008, medical students shadowed three senior

urologists during outpatient clinics on a one-to-one basis.

New referrals and follow-up patients were booked and

seen at a ratio of 1:2 which corresponds to national

standards [3,4]. Consultations were broken up and sepa-

rately measured in seconds for:

1) pre-consultation computer and notes research dur-

ing which the patient was kept in the waiting area (re-

ferral letters and previous correspondence from different

departments for new patients, previously requested re-

sults for follow-up patients, and in case of patients suf-

fering from urinary stone disease also booking time for

an X-ray on arrival),

2) the actual consultation with the patient during

which no forms or computerized requests were filled in

or processed,

3) post-consultation computer and written administra-

tion (computerized bookings of investigations, admis-

sion forms etc.),

4) dictation of consultation letters.

Whenever there was a disturbance to the consultation

flow (i.e. phone calls), the clock was stopped. Booking

of follow-up appointments was done by the receptionists

and was not considered in this study.

To avoid bias through an initial learning curve in han-

dling CRS, the study was repeated one year after imple-

mentation of CRS in April 2009 in the same clinic, with

the same personnel, using identical methodology.

The timings measured were converted into minutes

(with seconds converted onto a decimal scale) and aver-

ages calculated. Results between the two study periods

were compared using a student’s t-test. A P-value ≤ 0.05

was considered statistically significant.

The timings measured were then extrapolated accord-

ing to a typical urologist’s working pattern of 2 outpa-

tient clinics a week [3,4] and 40 working weeks per year.

3. RESULTS

Before April 2008, a typical outpatient clinic would

see 20 patients per doctor per clinic. This meant 12 min-

utes total session time with each patient. The official

recommendation at the time [3,4] was 16 patients result-

ing in 15 minutes per patient. Usually, the patient would

be present and interactively involved in conversation

during most of this time.

In August 2008, four months after implementation of

CRS, a total of 83 consultations were monitored and

timed according to the criteria mentioned above. The

total average consultation time for a single patient was

12.97 ± 6.04 minutes (range 3.13 - 28.73 minutes). Time

spent with the patient was on average 5.11 ± 2.84 min-

utes (range 0.25 - 12.8 minutes) which corresponds to

39% of the total time. Consequently, 61% were spent by

the senior doctors on administrative work. 29% of pa-

tients needed an X-ray booked before seeing the doctor

adding to the pre-consultation administrative time.

Computer start-up with various log-in steps at the begin-

ning of each clinic counted for 8 (!) minutes pre-con-

sultation time for the first patient of the day.

In April 2009, one year after implementation of CRS,

the study was repeated in exactly the same fashion

measuring the same parameters in the same clinic. The

number of consultations was comparable (n = 87). 31%

of patients needed booking for a pre-consultation X-ray.

The total consultation time was 15.13 ± 8.52 minutes

(range 4 - 48.93 minutes). Of this, on average 6.94 ±

5.73 minutes (range 0.71 - 29 minutes) were actually

spent with the patient which corresponds to 45% of the

total time. In turn, 55% of senior doctors’ time was spent

S. Kachrilas et al. / Health 3 (2011) 703-707

705705

on various administrative tasks. Computer start-up times

were unchanged.

When comparing the two groups, the average total

time needed per patient was 14.05 minutes (range 3.13 -

48.93 minutes). This overall time is not much different

from the 12 (actual) to 15 (recommended) minutes pre-

CRS. Pre-consultation administrative time was stable at

4.49 ± 3.62 minutes (range 0 - 25.56 minutes). The con-

sultation time spent interacting with the patient had

slightly but significantly increased from ~ 5.11 to ~ 6.94

minutes (p < 0.05). For the whole group of 170 patients

it was 6.05 minutes equalling 43% of time spend on a

single patient. The average time for requesting investi-

gations had slightly but significantly decreased from ~

2.26 to ~ 1.48 minutes (p < 0.05). Dictation time had

remained stable and was for all patients ~ 1.66 minutes.

The total time spent on administration for a single pa-

tient seen in outpatients per senior urologist was ~ 8.03

minutes (range 0.88 - 26.27 minutes). Therewith, 57% of

time was spent on administration alone.

With the average time needed per patient of 14 min-

utes, a typical outpatient clinic of one programmed ac-

tivity (PA) of 4 hours can accommodate consequently no

more than 16 patient per senior doctor. This corresponds

with the recommendations of the British Association of

Urological Surgeons BAUS [3] issued well before the

arrival of any Computerized Record System.

Also, with an average of 8 minutes spent on admini-

stration, a typical senior urologist would spend 128 min-

utes per clinic on administration, that is 2 hours and 8

minutes, or more than half of the PA.

With on average 2 clinics per week [3] over 40 work-

ing weeks per year and 8 hours work per day, our typical

urologist spends 3.79 weeks = 21.3 working days =

170.66 working hours per year on administration of out-

patients in clinic.

4. DISCUSSION

To ease outpatient clinic pressures it was thought at

the start of this millennium that an electronic patient data

system might be the answer [6]. The Veteran Health

Administration (VHA) in the USA had successfully in-

troduced their Computerised Patient Record System

(CPRS) and introduced it as a patient-centred approach

to clinical computing rather than a department-centred

approach [13].

CRS was introduced at Barts and The London NHS

Trust in April 2008 as one of four sites in London, and

one in 12 in Southern England. British Telecom (BT)

had taken over the contract with Cerner who developed

the product and is due to implement 29 more sites until

2015 in England [14]. CRS means that all patient records

will exist within one central database, which can be ac-

cessed by the different medical bodies within the UK

[15]. After implementation, there were a lot of problems

in all places affected. The initial problems which would

be normally expected from a project of that magnitude

went well over the teething phase. Patients were lost in

the system [9], and government targets were not reached

[7,9], which led to a snowball effect onto the referring

primary care trusts [8]. Six months after implementation,

Barts and The London NHS Trust still faced significant

problems with data access, data recording and technical

issues, leading to a £3 million revenue shortfall [9]. An

independent external audit commission in another trust

using CRS reported that despite 2 years of extensive

remedial works since implementation they had little

confidence in the data generated, found the system

overly difficult and complicated and posing a significant

risk to the trust’s services, both in the ability to treat pa-

tients and in general administration [10].

In consequence, in February 2009 it was announced

that all further CRS implementations in England were

put on hold until the problems at Barts and The London

NHS Trust and one other major London Hospital are

fixed [11]. Following this and on the background of the

worldwide credit crunch, in May 2009 Cerner an-

nounced redundancies due to a sharply reduced expected

implementation rate which had been cut down from 70

to now 41 hospitals in total [14].

Whilst all this was making headlines, healthcare

workers were struggling as the end-users. Generally,

physicians seem to find electronic software more diffi-

cult than usual care with paperwork [16]. A one-to-one-

two-day learning curve was postulated for new users of

CRS [13]. Being based on the assumption of a glitch-

free system working user-friendly, this did not corre-

spond to reality. In particular doctors were expected to

research and find information that has been previously

presented to them in a ready-to-use manner (referral let-

ters, notes, printed results, X-rays), and they were also

given the additional tasks of booking many investiga-

tions and other things that previously had been in the

hands of nurses and clerks. They had to work with a

combination of both, paper records and CRS. Paper re-

cords were left incomplete as it was assumed that new

information is on CRS which could in many cases not or

only with difficulty be accessed.

It turned out that some administrative processes took

even longer with CRS and doctors found it impossible to

use CRS to its full potential due to time restrictions and

the untimely response of the system [12].

In the light of all this, we decided to look at the im-

pact CRS had on our working pattern and, in particular,

the time spent with the patients. In 1988, the time spent

with the patient in a urological outpatient clinic was 7.6

S. Kachrilas et al. / Health 3 (2011) 703-707

706

minutes on average. This decreased to 4.6 minutes in

2002 in spite of introducing time saving measures such

as nurse-led clinics and one-stop clinics 40% was spent

on administrative tasks [6]. In our own clinics before

CRS, an average of 12 minutes total time per patient was

scheduled. This on the background that most booking

and researching tasks were done by administrative aides.

This time was a mixture of administrative time and pa-

tient inter-action very much along the lines previously

described [6]. However, the patient was involved during

the whole time. We are glad to see that our study showed

that the patient’s time has not further reduced as com-

pared to 2002 [6] at ~ 6.05 minutes as might have been

expected with the additional administrative burden on

the doctors. However, whereas in 2002 40% of doctor’s

time in outpatient clinics was spent in administration [6],

this has now risen in our study to 57%.

Out of a total of 14 minutes spent per patient, 8 min-

utes are spent on administration. Apart from dictation of

letters, 45% of the urologist’s time is nowadays spent on

the computer and, more precisely, on CRS. In a similar

study in the pre-CRS era, an additional 15% disturbance

time rate was calculated [6] which has not been consid-

ered in our study. This was mainly due to interruptions

by phone, nurses, junior doctors and others. It also

means that the expected average consultation time per

patient as shown in our study would rise further by 15%

from 14 to 16 minutes, and the patient number to be seen

in clinic by a single doctor must therefore not exceed 15

(instead of 16). This is in accordance with the BAUS

guidelines mentioned earlier [3,4] drawn up for paper-

administered urological outpatient clinics in the pre-CRS

era. It is of note that these baselines have not changed

despite the introduction of CRS.

The time actually spend with the patient had a little

but significantly risen between the two study periods

from ~ 5.11 to ~ 6.94 minutes (p = 0.0097). Nevertheless,

the total administration time had not significantly

changed with ~ 8.03 minutes (p > 0.05) after 4 and 12

months post-CRS. The post-consultation administration

which mainly consists of booking of follow-up investi-

gations had significantly decreased from August 2008 to

April 2009 from ~2.26 to ~ 1.48 minutes, allowing for

the additional time spent with the patient. This may in-

dicate an increased familiarity of the doctors with CRS

in bookings, however it did not have a significant impact

on overall administrative time which remained increased

as compared to pre-CRS assessments in comparable

clinics [6].

Looking at the overall data 4 and 12 months post CRS

implementation, it appears that despite extensive reme-

dial works and increased familiarity of the users with the

system not much difference has been made to the doc-

tors although patients benefitted from a small increase in

time spent with them.

A key message of this study lies in the average time

required per patient. Data comparison with the pre-CRS

era shows that CRS is not the solution to outpatient

clinic overload. The BAUS recommendations from 2003

are still valid and, the clinic profile should not exceed 15

patients per doctor per clinic in urology whether working

with CRS or not. We believe however, that with CRS the

researching of referral data on new patients outweighs

the looking up of results in follow-up patients. Therefore,

at least in our clinic equal slots have been given to both

groups of patients of 15 minutes each.

Another key message of this study is that an addi-

tional administrative burden has been put on the shoul-

ders of the doctors in clinic. This does not mean admin-

istrative sessions in the office, reports, meetings and

academic activities. It means simple day-to-day tasks

without which an outpatient clinic and with it the doctor

cannot function. It is password protected, privileged and,

therefore, cannot be delegated. Extrapolating our data, a

senior medical doctor consequently spends 170.66 hours

or 3.7 weeks of his working life per year on administra-

tion within the outpatient clinic alone. With this price to

pay, it remains to hope that CRS will fulfil its promise of

a streamlined patient pathway in the long run.

5. ACKNOWLEDGEMENTS

We like to thank Ms. S Pararajasingam and Mr. A Ahmed for their

invaluable help with collecting the data from outpatient clinics.

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