by C. Peter Waegemann
For several decades, people have been promoting the implementation of EMRs, electronic medical records for a particular patient at a particular site. These would provide such integrated functionalities as e-prescribing, alerts, order/results management, workflow tasking, advance directives, communication, and messaging. Electronic health records (EHRs), by extension, would link a patient’s dispersed EMRs from multiple sites in order to have a complete picture of a patient’s health status and treatment.
The concept seems almost obvious. If we can have detailed records on buildings, cars, machines, household devices, etc., surely we can have comprehensive and detailed health records. And yet, uptake of EMRs has been anything but smooth. In 1991, the Institute of Medicine made EMRs a national priority, declaring it an essential part of medicine. At that point, everybody thought that every physician would have one in less than 10 years. President Clinton announced in 1994 that within 10 years such systems should be implemented and President Bush set the goal of 2014 for complete implementation in the US. Every Presidential candidate has stated that the creation of EHRs will save “hundreds of billions of dollars”.
And yet here we are, the year 2008 and fewer than 25% of physicians have an EMR. Emergency physicians frequently must act without knowing previous diagnoses, including allergies, and genetic dispositions, specific healthcare services provided, or medications used.
While many assume this low adoption rate is due to resistance from physicians, this is not so. In general physicians are more ready to adopt EMRs than the industry acknowledges—even the older population of physicians has integrated electronic communications into many aspects of their lives. Rather, the drawn-out adoption process is much more the result of the industry’s slow progress toward resolving the issues of interoperability (so that EMRs from multiple provider sites can be integrated), uniform documentation (using standardized terminology and codes), systems’ compatibility (allowing exchange between systems), and workflow issues (improving efficiency and reducing costs) regarding EMRs.
Many of the Regional Health Information Organizations (RHIOs) may not survive, other Health Information Exchange (HIE) projects are struggling. This process is slow and cumbersome and might take longer than 10 years as RHIOs are taking the same approach as Community Health Information Networks (CHINs) took some 8-10 years ago. More than 60 CHINs had been created on city, state, or regional level, and all imploded as the difficulties of interoperability and the lack of benefits for stakeholders became clear. Unfortunately, planners of RHIOs did not learn from this experience; some RHIOs have already collapsed and most others are struggling. Only a random few of the current RHIOs are expected to survive.
However, while we are waiting for these problems to be sorted out, a new approach is succeeding. It is based on the idea of not exchanging the bulk of medical record information because it is too voluminous and it is not sufficiently structured. Instead, one should focus on a distinct, manageable, and comprehensive basic dataset that provides a complete picture of the patient’s current health status. Several years ago, some 20 leading organizations joined together to create such a data set, based on input from practicing physicians. Within the standards organization ASTM International, the Continuity of Care Record dataset was created with the approval of such medical societies as the AMA, AAFP, and AAP, as well as health IT organizations. It has become the industry’s widely accepted standard for structured data content that provides a complete picture of a person’s health status. It includes data on the following:
This dataset can be sent by fax, email, as a message, or secure web communication. But who will fill out such information and who will maintain such information? These processes require additional costs and efforts.
Enter the patient revolution. Patients are tired of providers to whom they must give the same demographic information over and over. Consumers are tired and weary of healthcare providers who do not know their allergies and medications. So patients are saying, “If my doctor cannot get my information right, let me carry a personal health record (PHR) and I will provide the information myself.” If such a PHR is stored on a USB drive or other digital device, a provider can theoretically download such information. However, field tests have shown that providers may not allow the transfer of data because of fear of viruses. Also, patients find it quite cumbersome to load information onto a portable device. In the crucial moment when they would need it, they may not have it with them.
Now a new idea for transportability and interoperability has successfully emerged that integrates the CCR data set: the cell phone. People carry it with them all the time, information can be transferred with a simple phone call. And phones can be designed so that information is safe and secure even when the phone is lost or stolen. A wide range of scenarios are opening up for this application.
Imagine patients or their representative calling you before they enter the emergency department with their insurance information, their medications, previous diagnoses, even addresses of physicians who were involved in their care. This is not a utopia that may be 5 or 10 years away. No, this is being implemented today!
When you are transferring a patient, you can send their patient information to another department if your emergency department system is not interoperable or dependable.
This month, at the TEPR (Towards the Electronic Patient Record) conference in Florida, this will be demonstrated. Every participant will be able to download a mock dataset onto their own cell phone, test interoperability and security with various EMR vendors.
What does this mean for emergency physicians? Consider the following four questions:
- Will your department be ready if patients start calling in their data in a few weeks/months?
- How do you need to change the workflow to accommodate such an application?
- Can your information system import/implement the CCR data set?
- What does this mean to your department’s business model? What processes will be eliminated? How will payers react to this?
While the general development of EMRs is still slow, these core dataset and communication developments will rapidly change emergency health care. Add to these the changes that the new HIT industry players Microsoft and Google are stimulating, and you need to be ready for big changes. Such changes may be disruptive but they also provide an opportunity for success if you are open to them.
Alphabet Soup Understanding Acronyms
What’s an EMR and how is it different from an EHR, EPHR or RHIO?
EMR: Electronic Medical Record
An EMR is an electronically generated record of a patient encounter from a single facility. It generally includes all the demographic information about the patient as well. Technically, this definition does not include electronic (scanned) copies of paper charts. EMRs generally require direct input by the examining clinician, consultant, lab, etc... via free form dictation, an electronic template, or a combination of the two. Once the words are keyed in, the record becomes completely searchable. Resistance has come from some clinicians who find the current EMR programs to be expensive, inefficient, time consuming and difficult to adapt to unusual cases or findings. The benefits include clarity, retrievability, improved billing, and many other functions.
EHR: Electronic Health Record
An EHR is the compilation of all of a patient’s medical information from all locations and sources. Some current systems include scanned copies of paper charts, dictations, etc... but the ideal situation is to have these records electronically generated. The president and the IOM have made EHRs a priority, but it goes far beyond maintaining a patient’s tests and examinations for the benefit of the treating clinician. The IOM has stated that the key functions of an EHR are: 1. Health information and data (the patient’s compiled medical records)
2. Result management (records of the outcomes of treatment)
3. Order management (electronic tracking of tests and treatments)
4. Decision support (real time linkage to the latest pertinent research)
5. Electronic communication and connectivity (linkage of providers, patients, payors, etc...)
6. Patient support (providing access to records for the patient)
7. Administrative processes and reporting (tracking for efficiency and accounting)
8. Reporting and population health (tracking and reporting public health issues)
ePHR: Electronic Personal Health Record
Unlike an EHR, the ePHR is personal, maintained by the patient. Hence, the maintenance of accuracy is the responsibility of the patient. An ePHR typically contains demographic information, insurance, major illness, allergies, medications, and health directives.
HIE: Health Information Exchange
An HIE is the electronic movement of health information between interested parties, typically hospitals and providers, but it may include insurers, government, researchers, etc.
RHIO: Regional Health Information Organization
An RHIO is the governing organization that oversees the rules of exchange of health information between interested parties. The RHIO can direct the format in which information is gathered, stored, and retrieved. It can be hospital based, independent, or government.