Crashing e-records leave paramedics stricken

Ambulance staff say government-backed record system is sick

Paramedics are divided on the benefits of an electronic Patient Care Record (ePCR) system that is replacing old paper-based notes across Australia.

The ePCR system is the four-year brainchild of the former Metropolitan Ambulance Service, now Ambulance Victoria, and is dubbed the Victoria Ambulance Clinical Information System (VACIS) in that state.

The current paper-based Patient Care Records contain information from paramedics on a patient’s condition and are handed over to doctors and nurses when an ambulance arrives at a hospital.

Through moving them to digital records via the ePCR system paramedics will in theory cut down on the time filling out carbon-copy paper reports and create new lines of digital data which can be analysed to improve healthcare delivery.

However, irate paramedics using the system say records in the ePCR system take up to an hour to fill out, or four-times longer than with pen and paper, and claim it produces lax reports that do not adequately describe a patient’s condition. Worse, they say some doctors have been left stranded when overburdened paramedics have dumped patients at hospitals without PCRs.

“It frequently occurs that an [ePCR] is unfinished before we need to attend to a next case… this means [nurses receive] absolutely no record of events and patient’s condition and provisional diagnosis until we return sometimes hours later,” said one active Tasmanian paramedic on the condition of anonymity. “The paper [PCR] was at least filled in with the important bits and handed over to medical and nursing staff.”

Clive Wawn, an active Victorian paramedic of 23 years, said ambulance queues have bulged at hospitals because of the time taken to fill out ePCRs. His concerns were echoed by up to a dozen paramedics and ambulance union officials that described a situation where crucial PCR information is omitted due to technical problems or time shortages. Paramedics that fill out ePCRs say they do so either inside a speeding ambulance at personal risk, or while parked at hospital which wastes time and dumps the remaining workload on their partners.

All paramedics who spoke to Computerworld Australia said they struggle to locate the correct medical descriptions with the system’s pre-populated forms, with many choosing fields such as “animal-related injury” and then cramming patient details within comment boxes. One Triage nurse from a Queensland hospital acknowledged seeing poorly-completed ePCRs and said they are inferior to hand-written reports.

“Often reports are just not professional enough… [we] just put anything in [incomplete fields] to get rid of the bloody red dot,” said one Tasmanian paramedic.

Tech-savvy paramedics, one even an amateur software developer, said the system is rife with useability annoyances, such as unresponsive fields, and irksome trouble shooting and sign-on requirements.

A spike in fatigue and the near-cessation of some training and case discussion were some of the more serious outcomes blamed on the ePCR system by Victorian and Tasmanian paramedics speaking through the state ambulance union. One Tasmanian paramedic said he had gone into overtime on several occasions to catch-up on ePCRs.

One triage nurse from a Queensland hospital backed suggestions by paramedics in the state that ePCRs are inferior to hand-written reports.

A senior Victorian paramedic also said that the position of the laptops – on which the ePCR system runs - inside ambulances was also an issue, claiming that they would hit a user “straight between the eyes” in the event of a crash.

Spokespeople for Ambulance Victoria were unaware of the problem, but said it had moved the location of charging units to mitigate risk in some vehicles.

Victorian ambulance union spokesman, Steve McGee, said this risk is detailed in a report by Monash University’s accident research unit, and commissioned by then Victoria’s rural ambulance service, which found the laptops should not be used at speeds greater than 50 km/h.

Monash University would not supply Computerworld Australia with a copy of the confidential report, and requests to Ambulance Victorian for the report did not receive a response.

Other concerns include difficulty in re-charging the laptops, a scarcity of devices meaning paramedic crews have to “wait-in-line” to complete reports, and an “excessive” requirement to fill out dozens of text fields.

But some users reported positive experiences with the system. Queensland advanced care paramedic and state ambulance union official, Kroy Day, said the computer system is a success, but conceded there were teething problems. “It was a pain during the initial transition... but the electronic system is more accurate,” Day said.

The head of emergency for a prominent Victorian hospital said he has not experienced problems with ePCRs received from paramedics.

Ambulance Victoria CIO Cameron Crampton, while not aware of the paramedics’ concerns with the system, said it had acknowledged “teething problems” and difficulties in satisfying a large user-base.

“We can appreciate when individuals want things differently,” Crampton said. “We consulted paramedics and clinicians in the system design… there is always a trade-off between flexibility and obtaining good data.”

Crampton said VACIS data — which documents the process from the point of emergency call to the patient’s admission to hospital — has been used to improve the efficiency of the ambulance service and the delivery of healthcare.

As a result of the data analysis, he said Ambulance Victoria was able to dispatch 500,000 of the closest individual ambulances and paramedic-firefighters to emergency scenes last year, which replaced the common occurrence of multiple units arriving to one scene. Crampton said the changes free-up thousands of paramedics to attend other emergencies, and in further developments, some 3000 emergency calls, or 10 per cent of the total received each year in Melbourne, are now designated ‘non emergency’ and offloaded to a secondary call centre. Those changes are rolling out across the state this year.

He said Victorian paramedics now used better pain management techniques, following the analysis of 700,000 ePCRs last year which revealed inconsistencies in limb splints and a under-use of morphine.

Complaints and feedback for VACIS are categorised and fed into a joint-funded IT team which in updates the ePCR systems, according to Crampton. Noelle McCabe, head of the ePCR Victoria Ambulance Clinical Information System, meets with counterparts from health departments in each state and territory — excluding Western Australia — and interested officials in New Zealand throughout the year to review the system, and collaborate on what is considered the largest national health-standards platform in the world that will interlink all ePCR systems across the country. It is hoped that the ePCR systems will link into and provide critical data to the pending national e-health system.

Health officials through the Council of Ambulance Authorities walked New Zealand ambulance representatives through the ePCR system last December in an effort to expand the system.

Victoria, Tasmania and Queensland use the system, the ACT is set to go live in July, and NSW is in a phased deployment. South Australia and the Northern Territory are considering making the switch, while Western Australia has snubbed the idea.

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