The Beginning: Paper Trail SlumThe medical and healthcare field is characterized with the cumbersome practice of obtaining and maintaining extensive documentation of patient information. Medical staff, physicians and healthcare practitioners are legally responsible to maintain a comprehensive, efficient as well as effective way to collect, maintain and archive patient information. Traditionally, this process of information collection and maintenance was accomplished manually resulting in an endless paper trail of information. Everything from patient encounters to informational charts to billing was executed in a paper based environment and soon this record keeping method became too overbearing and tedious to manage. The integrity of this manual paper-based process continued to be compromised with issues surrounding the convenience, data mining ability, cost and safety of this method. The ability to effectively communicate among different personnel and patients and obtain on time information was rapidly decreasing when it came to this traditional method. With the advent of technological advances and its many application, players within the medical field like in any other field, were looking for ways to be more efficient in their health care processes.
A new lifeline was obtained when the introduction of the computer paved the way for more automation in this field.
The computer is considered a tool to promote communication. In the medical arena, a moment between life and death or sickness and health is contingent upon communication or the lack there of. Computers have been instrumental in facilitating many areas in the management of medical records, and with its introduction into the medical field about 30 years ago, experts believed its involvement would provide several advantages in the medical profession. With a strong push to integrate the computer and technology into the administration of services within the medical field, more executives are adopting Electronic Medical Report (EMR) systems to streamline the patient record maintenance process.
It's a normal trend for clinical departments to work for years with their own people, budget, and vendors to come up with a method of capturing their patient and billing data electronically, and that personalized method is one definition of an EMR. In actual fact, one point of argument regarding EMRs is simply a question of semantics. There are various definitions for an EMR. At one end of the scale, an EMR includes everything from patient's past medical history to diet and lifestyle preferences. At the other end, it can be as simple as an e-mail message to a fellow clinician. Our definition of an EMR is simply a repository of clinically important data that may be accessed and searched with relative ease and in a rapid manner. Most of us would be extremely content with something easily learned, easily understood, and relatively inexpensive.
The Future: Technology's PlaygroundToday, the use of EMR systems has revolutionized the medical field industry by facilitating a more efficient record keeping process and a more effective communication medium for medical personnel to exchange information. Many healthcare personnel now understand the importance and the impact these EMR systems are having on the overall delivery of customer service and the general administration of healthcare. Medical practitioners are constantly faced with challenges including the need to improve the quality of care, adhere to new clinical restrictions and processes, reduce waste and reduce errors. In recent times these challenges have been less of a burden as automated integrated systems help coordinate such process much better. Computerized systems like EMR systems help in reducing the amount of paperwork for medical offices, providing an easier way to access patient information, promoting more uniform delivery of processes and in some respects suggesting appropriate diagnosis and treatment for certain conditions.
The concept of an EMR system lies on the idea of a centralized informational power house that can provide orderliness in a once chaotic paper based environment. Its tangible value is evident in the opportunity to promote Data Mining or store data in one place and visibly extract or filter desired necessary information at a more expedient fashion. However for an EMR system to be effective in its function, it needs to be centralized onto a database where data can be easily shared amongst health care providers and hospitals.
In today's economic environments, costs and return on investment are just as important as the diagnostic process, moving to a more accessible and rapid electronic system has obvious benefits. Very few would argue the fact that an EMR has value over a printed chart when it comes to identifying practice patterns, assigning probabilities to diagnoses, locating inefficiencies in patient care, delivering reports to patients and consulting services rapidly, and achieving prompt billing. With digital form gaining traction in the medical industry, medical records can be automatically scanned for everything from potential drug interactions to gaps in clinical data that may affect reimbursement. In addition, a computer program can be used to automatically generate reminders for physicians and patients. Specific examples described below illustrate the potential benefit.
Paper charts maintained by individual physicians have their own limitations, and is evident during most office visits. At the beginning of a patients visit, they are required to provide a list of medical history, from family medical history, medication, prior and existing conditions. Due to medical charts rarely being shared by multiple providers, it is normal to see this information collected by each health care provider and often times collected on more than one occasion by the same provider. The amount of information required by each patient at the start of each office visit will depend upon the age or medical condition of the patients and can be a substantial amount. Patients not only resent having to recall this information on multiple occasions, but on occasion unintentionally omit critical pieces of information. The implementation of an EMR would reduce the need for redundant data collection and allow care providers to assess the same medical records. Care providers can quickly review the history and update the medical records where necessary. In some emergency cases where the patient or family is unable to provide medical history, having prior data available would be invaluable (e.g., patients with Alzheimer, unconscious patients).
Over a period of time patient charts usually contain considerable data regarding patient vitals from heart rate, blood pressure, and temperature to laboratory results such as, blood counts, blood sugars level. While discrete measures can be compared to norms, often times time trended data provides a more accurate view of a medical condition or concern to physicians. Physicians relying on paper charts are only able to create simple charts and would be impractical for them to create graphical displays for each clinical measure lending itself to a graphical representationWith EMR, generation and reviewing of graphical representations of one or more measures for a period of time would become a quick and easy task for physician. Graphical displays showing increasing blood pressure or blood sugar levels might alert care givers of an emerging problem and therefore help reinforce the severity with the patient.
When physicians determine the medication to prescribe to patients, they must consider both efficacy and cost. Prescribing medications that are beyond the economic means of patients is counter-productive. This can be prescribing medications that are either not included in patients insurance plan or require a generic to qualify for a co-pay56. Given the increase rate in medication options and variation, and the rate of change in health care insurance benefits it impossible for physicians to quickly compare the various options when using paper based systems. As a result, most patients do not learn the cost of medications nor the extent, if any, of insurance coverage until they present the prescription to a pharmacy. Patients, upon learning from the pharmacy that lower cost generics are available or that generics or other similar medications would be covered by insurance, frequently request that the physician prescribe an alternative medication. These requests are time consuming for the patient, provider and pharmacy. With an EMR system, a care provider can assess whether a medication is covered by a patient's insurance and discuss alternatives with them at the point of examination. EMRs can deliver this functionality by exploiting databases for both insurance plan formularies as well as on medications FDA approved. In an EMR setting the physician can discuss medication options, by assessing the level of insurance coverage during the examination itself.
Ultimately, EMR can help us to reduce cost. These are expenses associated to paper charts, poor documentation and high malpractice premiums, as well as new expenses as a result of support contracts, computer maintenance and product updates. Reducing paper chart costs including purchasing stationary, copying, printing, management and storage is the clearest benefit of EMR. Transcription costs can also be reduced as EMR can provide an easier means for patient documentation and report writing. EMR also avoid the cost of hiring new staff during peak time by becoming more efficient with the EMR system. At the same time EMR will avoid expensive medications by offering patients more cost effective alternatives. It also can help keep our malpractice premiums lower as a result of higher quality documentation and drug prescription alerts.
However, there have been some disadvantages to the use of computerized systems which has influenced the low adoption rate of EMR systems and their like. These disadvantages include high cost of implementation of such systems, failure to meet the firm's objective, security and confidentiality issues regarding patient information as well as an increase in malpractice lawsuits. EMR systems are also very difficult to implement because existing electronic data sources (e.g., laboratory, pharmacy and physician dictation systems) reside on many isolated islands with differing structures, levels of granularity and different code systems. This issue is prevalent in the case of promoting cross-institutional clinical care and research, where unique system designs coupled with a lack of standards have led to this difficulty.
Nevertheless, with the backing of the legislative and executive bodies, the use of EMR systems will soon be nationwide. President George W. Bush, in an attempt to encourage the push for incorporating American medicine into the information age, commented during a press release in Collinsville, January 5, 2005, "We need to apply 21st-Century information technology to the health care field. We need to have our medical records put onto IT." With three significant Federal mandates issued regarding the adoption of EMR, we will gradually see a more computerized approach to medical practice during the next coming years.
Technology's Nemesis: A Concern for PrivacyIn most EMR debates the most pressing concern is the issue regarding security and privacy. According to a Harris Interactive online media poll, 68% of respondents believe that the use of EMRs can improve the quality of care patients receive. However, most respondents also believe that EMRs make is more difficult to ensure privacy. As more provider groups, hospitals, and integrated health systems implement EMRs, concerns over patient privacy and ethical uses of data have also increased.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established strict guidelines for patient privacy. Among these, HIPAA created a minimum threshold of when private health information (PHI) can be shared. HIPAA also established standards for electronic health care transactions. Although the expectation is that electronic records can have better controls than paper charts, there are certain steps that health care organizations must take into account in order to reduce the risk of releasing privacy information:Ã¢ÂÂ¢Each office member must have a password in order to log into the EMR system. The password must never be shared with others and should be considered an electronic signature.
Ã¢ÂÂ¢Different levels of system access should be provided based on the user's job responsibilities. Some roles may only require the billing code and not the results of lab work.
Ã¢ÂÂ¢When not actively using the system, the user must log off to prevent anyone from accessing the information.
Ã¢ÂÂ¢The system must maintain an audit trail that can tie system use back to the username.
Ã¢ÂÂ¢If accessing the system remotely, the connection must be secure. The user must prevent those around them from viewing any information.
Ã¢ÂÂ¢Any information printed from the system must be filed within the appropriate location or shredded immediately.
EMRs integrate so many areas of the health care system under one basic heading. For example, Kaiser Permanente is an integrated health care delivery system. Kaiser serves as a pre-paid health insurance plan that maintains its own hospital facilities and ambulatory facilities, contracts with its own medical group (Permanente), operates its own pharmacy, and also contracts with separate existing hospitals. Kaiser recently developed an EMR system that can automatically track utilization for their members for all services, including outpatient, inpatient, and pharmacy. Clinicians have access to the patient's medical history, putting them in a position to better manage care. Privacy under this integrated model becomes a concern as there are so many parties with access to PHI. Instead of an individual office being required to uphold privacy standards, the entire model must work together. Not everyone at the hospital has the need to know about the physician's office visit from two years ago. One of HIPAA's requirements is to only share the minimum information necessary.
Although HIPAA was passed with the intent to assure privacy, many argue that this intent was reversed in 2002 when the HIPAA Privacy Rule was amended by the Department of Health and Human Services. The amendment limited how much control Americans would have over who could access their PHI. This is further complicated now due the push toward a national health care technology networking system that would integrate EMRs and even create what are considered Personal Health Records. The health information would be compiled by over 600,000 different sources. In addition to these sources having access to posting the record information, they would also have access to pulling PHI. Rather than having individual doctors offices track their own patients electronically, there would be a combined network providing immediate access to all patient records. The development of such a system creates significant privacy and ethical concerns over different segments:EmployersMany large employers self-insure their health care benefit programs. One of the advantages of the self-insured model is it allows employers to better manage the costs and risks of their population. The intent of HIPAA was to limit the level of detailed information the employer could receive. Through the integrated EMR system, there is the potential for sensitive data to become more readily available directly to the employer or through business relationships. Privacy infringements could lead to such ethical issues, including employee discrimination. Under the Kaiser Permanente example, the employer hired Kaiser to serve as the insurer, the physician's group, and the hospital. Once the physician's office enters medical information for a patient, it is possible that the pharmacy, the hospital, and the finance areas all might gain access to the patient's health record. There is the possibility this could somehow make it back to the employer. It is critical for employers to not only meet the minimum threshold established by HIPAA, but they also must have clear policies outline to mitigate any potential discrimination against employees.
GovernmentThere is the fear that a government established electronic health system would provide government agencies with immediate access to PHI. One of the original intents of HIPAA was to prevent the government from accessing specific health care information. Without a right of consent provision, Americans would not have an opportunity to prevent their medical records from being shared with the government. Similar to employer's discriminating against their employees; there is also the fear of the government discriminating against its citizens due to health care related issues. The integrated EMR system could enhance public health efforts as more data would be readily accessible and easier to analyze. This all leads to the ethical questions of how much information a government should have on its citizens and where to draw the line between overall public health and individual health rights.
Physicians/Health Care WorkersPhysicians and health care workers are looking for a system that provides them with clear information on a patient's medical history. The notion is that through more accurate and complete historical information, they can help improve the quality outcomes for the patient. In the process of receiving the historical medical information, physicians must also look forward to how their findings would be used in the future. Doctors must uphold an ethical standard required by the Hippocratic Oath. Physicians are not to disclose patient medical issues without the consent of the patient. EMRs that go beyond the limited basis of a physician's office or a hospital means that doctors could be providing information to other parties without the patient's approval. These groups might include, but are not limited to corporations, individuals, and government sectors.
As the push for technological integration in the medical field becomes more widespread, it is very pertinent that we consider both the pros as well as the cons of this application and implement the necessary checks and balances in order to reap substantial benefits and stay clear of any potential setbacks.
Pacing Forward: EMR Best Practices FrameworkIn order to sustain a well efficient EMR system guaranteed to support business processes and to maintain a streamlined process, documented below is an EMR setup framework, which when adopted could promote the best outcome in regards to system functionality and performance. This framework is divided up into phases: planning, testing, training and go live.
Planning PhaseÃ¢ÂÂ¢Identify goals and base planning strategies around these goals.
Ã¢ÂÂ¢Decide data required. It is common for practices to begin entering data into an EMR only to discover that the data is in a non-reportable format, not been consistently entered or not entered in any standardized manner by all providers.
Ã¢ÂÂ¢A phased implementation is highly recommended. Phased implementation work well for EMR because many of their functions are in discrete modules such as lab order entry, messaging, preventive health maintenance, patient tracking, e-prescribing etc.
Ã¢ÂÂ¢Create timelines, but be flexible. Constantly evaluate progress of the implementation process along the way, and ensure resource commitment in aligned to the timeline.
Ã¢ÂÂ¢Perform a workflow analysis. Analyze existing work processes while looking for opportunities for improved productivity and efficiency.
Ã¢ÂÂ¢Identify staff considerations and planning:Appoint a Physician Champion. This person should be motivating, enthusiastic, have a good working knowledge of the EMR.
Appoint an in-house Project Manager. Identify an in-house key person on staff to oversee the entire project.
Communicate to the staff the practice's desire to acquire an EMR before the purchase. Seek employee input and include them in the decision of which EMR vendor to choose.
Be aware that support staff may feel that they could be replaced by an EMR. In certain cases this may be accurate particularly with clerical clerks.
Have end-user staff be involved in the system set-up.
Map out Workflows utilizing current staff members: Map out current workflows on paper and bring in the end-users who perform the current workflows to help design new workflows for the EMR.
Establish access thresholds based on the different roles and responsibilities of each staff member.
Ensure sufficient time for learning curves. The learning curve for complete and successful adoption of the EMR is usually vastly underestimated.
Testing PhaseÃ¢ÂÂ¢Software/Hardware Testing:Test software extensively before implementation.
Perform Volume testing, if possible. Use a typical day and do a dry run in a test database.
Ask for a list of known bugs from the vendor. Create work-around and identify dates for patch fixes if required.
Ã¢ÂÂ¢Hardware Testing:Prepare InfrastructureÃ¢ÂÂ¢Staff and TestingPilot systems before implementation. Pilot workflows, procedures, modules, templates, documentation time etc. in a live environment utilizing a small group of staff long before go-live.
Training PhaseÃ¢ÂÂ¢Allocate sufficient time for training, including specific instructions on HIPAA and privacy requirements.
Ã¢ÂÂ¢Training should be performed outside of clinical work sessions.
Ã¢ÂÂ¢Set-up a training room for staff to practice.
Ã¢ÂÂ¢Appoint Super users.
Ã¢ÂÂ¢Evaluate staff's readiness for go-live.
Go-Live PhaseÃ¢ÂÂ¢Schedule the go-live in close proximity to the end of the training sessions.
Ã¢ÂÂ¢Reduce provider schedules: Reduce the number of patients a provider is required to see during the go-live phase.
Ã¢ÂÂ¢Provider Adequate Resources. Be certain to supply the staff with well trained individuals such as vendor trainers, super users, in-house project manager etc. during the go-live phase.
Post Go-LiveÃ¢ÂÂ¢Post Go-Live Assessment is necessaryÃ¢ÂÂ¢Evaluate the Go-Live with Staff: Query the staff regarding the go-live process. Get their feedback as to what was helpful and what was lacking.
Ã¢ÂÂ¢Provider on-Going training and support: Practice administrators should continue to offer training sessions well after the go-live for reinforcement and refreshment.
Ã¢ÂÂ¢Audit privacy procedures to ensure staff is adhering to requirements outlined.
References1.Agency for Healthcare Research and Qualityhttp://www.ahrq.gov/news/press/pr2005/lowehrpr.htm2.Clement J. McDonald, MD: The Barriers to EMR Systems and How to Overcome Themhttp://www.j-amia.org/cgi/content/abstract/4/3/2133.Centers for Medicare and Medicaid Serviceshttp://www.cms.hhs.gov/4.IS Kohane, P Greenspun, J Fackler, C Gruino, P Szolovis: Building National EMR Systems via World Wide Webhttp://intl.jamia.org/cgi/content/abstract/3/3/1915.Jaclyn Halpern: The Use of Computers in Healthcarehttp://ccat.sas.upenn.edu/~jaclynh2/presentation.html6.Cariaga, Vance. "Entering the Digital Age, A Baby Step at a Time." Investor's Business Daily. 22. Sept. 2006. http://www.investors.com/editorial/IBDArticles.asp?artsec=22&issue=200609227.Health News Digest. "Few Patients Use or Have Access to Online Services for Communicating with their Doctors." 25 Sept. 2006.
http://healthnewsdigest.com/news/article_4499.shtml8.Cosgrove, Meghan. "Special Report: Striking the Balance: HIPAA & the ED." American Health Consultants. 23 Sept. 2006.
http://www.e-topics.com/index.asp?layout=stdnewsdis&UserID=20040628063503766628&doc_id=NR200610013000.1_1d9601c7076bd9219.Thomas H. Davenport, John Glaser: Just-in-Time Delivery Comes to Knowledge Management. 1 Jul. 2002.
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