Comparisons of the pre-and post-implementation surveys highlights interesting trends in different users’ experience with eClinician. Figure 2 shows that users found navigating to the PFT tab of the EMR more difficult four years later. This suggests that with prolonged use, users came to realize that an unsorted media tab with multiple PFTs was getting more challenging to use. Figure 3 supported this as individuals found navigating to PFTs was taking more time than in a paper chart four years after implementation. However, the option of the physiology flowsheet did increase user satisfaction with the process of accessing PFT data in Figure 4. Figure 5 shows that overall there is still strong support for the trending physiology data function, although manual entry continues to be a barrier to wide-scale implementation.
As AHS considers processes in healthcare delivery in Alberta, Connect Care, a proprietary EMR also created by Epic, will be the new system for sharing records. This quality assurance project on implementation of a physiology flowsheet was conducted with consideration towards this new EMR. The dynamic nature of lung function over one’s lifetime requires that pulmonary function laboratories convey data to an EMR with a trending function to ensure EMRs appropriately capture this information for individuals from birth to death within one electronic health repository. For decades, various studies have highlighted the importance of longitudinal numeric pulmonary physiology laboratory data for patient management both to identify those individuals more susceptible to rapid rates of lung function decline early on (5–9) and assessment of changes to therapeutic agents added to a patient’s care. Longitudinal data in the form of pulmonary physiology flowsheets is critical in management of chronic respiratory diseases like asthma and COPD, and the varied forms of ILDs. In addition, it is also useful in related patient education and research. Although there is significant variability in the natural decline of parameters like the forced expiratory volume within the first second (FEV1), disease patterns emerge over several clinic visits that reveal changes due to underlying pathophysiology within disease groups such as asthma, COPD, ILD and normal patients. Longitudinal monitoring of pulmonary physiology is also an essential tool in the management of several other chronic conditions, including connective tissue disorders (i.e. rheumatoid arthritis, lupus) with pulmonary sequelae (4), neuromuscular disorders (i.e. multiple sclerosis, myasthenia gravis), and other conditions. From a public health perspective, longitudinal spirometry and PFT flowsheets allows particular insults to be identified and provide preventive care (i.e. removing an individual from a workplace with an agent to which that person is sensitized as in occupational asthma).
One strength of this report is the relative novelty of this work. It is the first of this nature in Canada, but we are aware of at least two large academic health centers in the United States (Cleveland Clinic, University of Wisconsin) are currently utilizing Epic along with a physiology flowsheet in one (University of Wisconsin) (17, 18). This pilot highlights a provincial priority that is of national importance as well. Since 1992, the Canadian federal government has discussed the importance of electronic records and the transferability of data between health jurisdictions. National guidance surrounding the development of digital health care is provided by Canada Health Infoway (“Infoway”). This crown corporation, which reports to a board of directors composed of all ten provincial deputy health ministers, has also recently prioritized integration of interoperable EMR’s into all aspects of clinical practice (11,12). A 2011 study on the Canadian experience on implementing the Canada Health Infoway plan, a $1.6 billion government funded initiative, identified “the retrieval of laboratory test results and graphing results over time” as a distinct benefit of developing electronic records (12). Similar motivations were echoed by the Pan-Canadian Respiratory Standards Initiative for Electronic Health Records (PRESTINE) working group (10). In the modern clinical environment electronically available data is becoming an expectation.
In this pilot project to implement pulmonary physiology discreet data elements into our health region-wide EMR, we found the potential for clinical utility, patient education and research to be significant; however, the logistics are still problematic. Utilization of a pulmonary physiology flowsheet is feasible and useful in selected ambulatory respiratory clinics. The majority of end users found it useful in their clinical practice. Our pre-implementation process review highlighted the biggest area of concern, lack of time in a busy clinical practice for manual entry needed to generate flowsheets for trending. PFT incorporation into the EMR as physiology flow sheet data within this dedicated area should be prioritized. It is an important tool for both clinical assessments and patient education and compliance. However, this pilot implementation demonstrated that raw data from the PFT software must be incorporated directly into the EMR to allow EMR-generated flow sheets for PFTs so busy clinicians can use the flowsheets efficiently without manual data entry into flowsheets. Otherwise this process improvement is hindered by the limitations on efficiency of the end-users of this software. As well, PFTs should have a dedicated area in the EMR (instead of being buried under a menu one of various types of media files) as toggling between screens increases the time required to assess a patient.
Clinicians must have the ability to usefully trend available data to utilize it effectively for treatment decisions, patient education and research. Our current EMR does not automate PFT data entry and instead a PDF copy is uploaded into the media section. While it provides access to current data, clinicians cannot trend data easily to understand the trajectory of lung disease. The current inability to acquire, trend and share pulmonary function physiology data de-emphasizes the importance of lung function to the detriment of quality patient care, education and safety (9). As such physicians maintaining health records have a duty to ensure the record is as complete as possible and this includes effective documentation of changes in data trends (13).
Through this process we learned of several limitations of our study. One factor is the restricted generalizability of the study findings to other health systems or other EMR departments as we only studied a relatively limited setting—single site, pediatric and adult departments and only ambulatory care settings. As well, this study ran over a relatively short period of time of only one week, which may bias respondents if they were experiencing unusually higher clinic volumes during that time of the year. The response rate was approximately 50% for this survey-based study, which is relatively high. Part of what may have increased the response rate was increased awareness of EMR related changes and spending in the health region at that time with the roll out of a new inpatient EMR in the near future. Lastly, our study ran using a methodology that would not be supported under usual clinical care conditions in that an external individual was hired for data entry. Although manual numeric data entry from individual spirometry / PFT tests is currently being done, the Epic EMR system has the ability to have data integration with the PFT laboratory equipment software to allow automatic data integration through a specialized proprietary software’s (“V-Link”). This software provides translation of data point into the existing physiology flowsheet structure (using the HL–7 standard computer language). This V-Link software has already purchased and is in use within certain areas of AHS. However, this software was not in use at the time within the pulmonary EMR department because at the time of this pilot study, there was no mechanism within the EMR to accept data from V-link. Thus manual entry of PFT data was utilized to create flowsheets to gauge user support for incorporation of this software.
Despite these limitations, the concept of the physiology flowsheet was well received. This would still require manual data entry, which is a major barrier to this tool in the clinical setting where time is limited. Data from the physiology flowsheet tool can be helpful in formulating clinical decisions and documenting results of care in patients with any pulmonary disease. The flowsheets illustrate that longitudinal pulmonary function results may be regarded as quantitative data, analogous to laboratory tests or vital signs, that reveal a larger clinical picture than single point in time assessments alone. If the clinician can access this longitudinal physiology data before seeing the patient, particularly comparative data from previous visits on a flowsheet, he or she can formulate a clinical plan more accurately as improvement or regression from baseline can be visually confirmed and measured (i.e. “airways obstruction is improved 30% this year as compared to last year on medication x”).
While care providers are considering interoperability between PFT and spirometry device software and EMR or EHR software, device manufacturers have been producing products geared towards this transition. Such technical statements on specifications of devices, central servers and network requirements are appearing in publications geared at the respiratory equipment sales community (15). It behoves governments and other publicly funded institutions to know how to best utilize taxpayer dollars to optimally purchase and use these new technologies for improved access and patient care.