0100101101011001: Kentucky goes binary.

An electronic medical record (EMR) is a computer-based system designed to capture and display patient-specific clinical information. First described in the 1960s by Lawrence L. Weed, such digital systems are increasingly used by physicians and hospitals across the country and boost a number of advantages when compared with traditional paper medical charts. In particular, electronic records offer readily accessible, easy-to-read medical information that reduces the likelihood of error and misinterpretation. Most systems allow users to access information both within the office and at remote locations, which enhances clinical decision-making for on-call providers. Having such information readily available can be lifesaving in critical clinical situations in which time is of the utmost importance.

In March 2005, the medical division of the Kentucky Department of Corrections was directed to select an EMR that would meet the unique needs of a correctional medical environment and implement that system in all 13 state facilities within 15 months. Using a memorandum of agreement already in place with the University of Kentucky, the DOC invited several vendors to demonstrate and discuss their EMR systems. Vendors were provided with the expectations and flexibility requirements of the DOC and within one month, a vendor was selected and the process of primary platform implementation was initiated. After 15 months, all 13 state facilities were equipped with a functioning EMR.

Selecting an EMR

The two most pertinent attributes of the selected system were Web-based applicability and feature flexibility. Web-based applications offer decreased demand for manpower and server maintenance in addition to ease of access from remote locations. Furthermore, most users are already familiar with the user interface and menus inherent in Internet connectivity.

With the increasing number of EMR vendors entering the market, system options also are rapidly expanding. Most vendors offer a number of modules that are included in or can be added to the basic platform--some at extra cost, others not. Although systems vary widely in what is included in their EMR and options are abundantly available, many of the features and options offered are not capable of being "flexed" in order to meet specific requests by the consumer. Many of those that do offer such flexibility offer it at a substantial additional cost. Customers should be specific about their requirements and obtain detailed fee-for-service information on modifying features or adding capabilities to a potential EMR. Basic systems may only offer organized storage and display of clinical information. Others will provide clinical information, electronic consultation and prescribing, data-mining, scheduling, laboratory interface, and disease-specific decision support. Other elements that should be addressed during the selection process include ownership of the data, security protocols, redundancy of backup information, HIPAA compliance, and any hidden costs such as customer support, maintenance and staff training.

The Institute of Medicine listed eight key capabilities that should be inherent to any EMR:

* Health information and data;

* Results management;

* Order entry/management;

* Decision support management;

* Electronic communication and connectivity;

* Patient support;

* Administrative processes; and

* Reporting and population health. (1)

Although components such as health information and order entry are obvious necessities, it was critical to the DOC mission that reporting and population health be available. In essence, the ability to mine data and determine the epidemiology of diseases that represent major cost centers is imperative to improving disease management and implementing wellness programs that can enhance primary care and subsequently reduce secondary care expenditures. It was also assumed that administrative efficiency would be greatly improved because special report functions of the EMR would obviate the need to contact individual institutions for information requests from the paper medical record. Decreased administrative response time has been experienced with regard to medical grievances, transfer requests, peer review, nonformulary management, and investigations of morbidity and mortality.

Implementing the System

Determining the technical components of the system, although essential, is only the first hurdle to overcome. Staff acceptance of the procedural change is also critical. The mere mention of change is enough to induce anxiety in most people. But telling medical staff that the record-keeping system will be converted to an electronic format, eliminating paper, is enough to prompt an outright revolt. Although all providers in the DOC agreed that the paper record system was inefficient, usually incomplete and occasionally required hours to even locate a file, there was considerable hesitancy in evolving to a higher-order system. Fears ranged from decreased clinic efficiency to full-scale technophobia. However, at the end of the day, nearly all providers agree that clinical information is now readily available, thorough and obtainable from any location that provides Internet access. The peer-review process is accomplished within an hour or two, instead of a day. Nonformulary requests are not lost to the fax machine's occasional data diet. The quality of clinical services has improved as a result of necessary information being available to the provider during times of critical decision-making. And clinic efficiency, which initially declined, is now on the upswing, as demonstrated in Figure 1. It has also been the DOC's anecdotal experience that prescription errors due to illegibility have decreased. This is significant from a quality-improvement perspective when one considers that prescription errors are the number-one cause of adverse medication death and injury. (2)

[FIGURE 1 OMITTED]

One of the largest operational benefits of the DOC EMR is the eContact function, which is also in operation in Oklahoma. The eContact allows for asynchronous (not real time) consultation to be provided to the primary care provider in the facility by a group of offsite specialists at the University of Kentucky Medical Center. For example, the primary care provider completes an electronic form that was created in coordination with the specialist. The primary care provider may attach various notes, images and test results from the EMR and then send it electronically to the participating specialist. The specialist reviews the information and makes a formal recommendation, which ranges from a simple medication adjustment to an office visit request. In many instances, an office visit is not necessary. Thus, public safety is increased (because the inmate never leaves the institution), security transportation costs are decreased, and clinical consultation has occurred at a reduced rate with a faster turnaround time. Furthermore, the primary care provider is educated through this process, which leads to better clinical decision-making in the future. As detailed in Table 1, the eContact feature has allowed for more than 400 specialty consultations to occur without the inmate ever leaving the prison grounds. Subsequent to the consultation, several inmates need to be seen in the office or sent to an outpatient center for diagnostics. However, for many inmates the eContact is the final step in the consultative process, allowing the primary care provider to continue treatment inside the fence, which is where significant savings occur.

Working Out the Kinks

Even though the process has not been as painful as most expected, there are several complications yet to be resolved. One unanticipated problem being investigated appears to involve a bandwidth issue resulting in increased loading time of clinic notes and templates. Other operational inefficiencies relate to clinic note organization and display formats that are not as easy to use as the providers would like. Fortunately, the DOC's EMR vendor has been very responsive to requests for customization of the basic platform. On the lighter side: It has been interesting for administrators to witness the provider complaints of "not having a specific lab report available when needed in the paper record" transform into complaints regarding the number of mouse clicks it takes to open the lab report in the EMR.

The decision to implement an EMR is one that should not be taken lightly. Although the benefits of electronic data maintenance are clear, there are a number of issues that must be examined, understood and discussed within the department before entertaining vendors who will be all too willing to sell their product. The number of variables, available features and pitfalls is beyond the scope of this article. Consultation with correctional administrators from other states who have undergone the process is strongly advised, with the intent of understanding the advantages and disadvantages of their experience. Expect the process to take at least 12 to 18 months from conception to implementation and understand that, at least temporarily, clinical productivity will decrease. Keep in mind that providers will be fearful of the change and anxious that the product will not deliver what they need. However, once all has been put into place, the agency will have a record-keeping system that provides accessibility to all pertinent patient data, improved clinical decision-making, decreased errors related to legibility and transcription, increased medical administrative efficiency, and a number of other clinical attributes that will assist the providers in delivering the highest quality care possible to an agency's inmate population.

ENDNOTES

(1) Committee on Data Standards for Patient Safety. Board of Health Care Services. Institution of Medicine of the National Academies. 2003. Key capabilities of an electronic health record system. Washington, D.C.: The National Academies Press. (July).

(2) Koppel, Ross, Joshua Metlay, Abigail Cohen, Bryan Abaluck, Russell Localio, Stephen Kimmel and Brian Storm. 2005. Role of computerized physician order entry systems in facilitating medication errors. Journal of the American Medical Association, 293(10):1,197-1,203.

Scott A. Haas, M.D., is medical director for the Kentucky Department of Corrections.

Table 1. eContacts by Specialty Group

                      Jul06  Aug06  Sep06  Oct06  Nov06

Physical Medicine     24     41     31     42     41
  and Rehabilitation
Cardiology             4      1      3      5     10
Dermatology           *      *       2      7      2
Oncology               0      1      1      1      0
Ophthamology           2      0      0      0      0
Total                 30     43     37     55     53

                      Dec06  Jan07  Feb07  Mar07  Total

Physical Medicine     38     51     38     25     331
  and Rehabilitation
Cardiology             6      3      2      5      39
Dermatology            1      5      6      2      25
Oncology               2      2      1      5      13
Ophthamology           1      0      1      0       4
Total                 48     61     48     37     412

* Specialty was not available at that time.