Myths and realities of electronic medical records: 9 vital functions combine to create comprehensive EMR. (Medical Records).

IS THE ELECTRONIC medical record (EMR) a myth?

A myth, according to the dictionary, is a traditional story of historical events that helps people understand their world or understand a practice, belief or natural phenomenon.

A mythical story is what I often hear when physicians talk about their EMR. They explain the history of their EMR and justify why it meets, or fails to meet, their needs.

Rather than describing the functionality of their EMR, all too often physicians say the system was purchased in the past, some applications were added and it doesn't work well.

Major problems that physicians often experience with the EMR are:

* Lack of sufficient functionality

* Poor performance

* Lack of access to the computer

* Lack of training (typing and computer skills)

Functionality is key

Although the global purpose of EMR is to improve patient care, the myth is perpetrated when functions are added without an overall focus on patient care.

Computers are supposed to make our lives easier, but many clinicians may doubt that as they struggle to use their EMR system.

How can a physician executive sort through the myth to assess what type of EMR the organization currently has and plan how to make it useful for clinicians?

Let's examine a model to assess the functionality of the EMR. We'll focus mainly on the clinician's use of the EMR in direct patient care, keeping in mind that physicians from specialties such as pathology and radiology demand a much different type of functionality.

One way to appreciate the multi-functionality of the EMR is to focus on a concept developed at the University of Missouri Health Care called the Patient Care Cycle. The cycle lists what a patient experiences from start to finish for a clinical encounter.

A patient in the outpatient clinic takes 12 steps to receive care:

1. Awareness of services available

2. Request for service

3. Registration

4. Creation of visit

5. Patient arrival

6. Interaction with nursing/clinical support

7. Interaction with provider

8. Formulation of impression/plan

9. Documentation of services provided

10. Implementation of plan

11. Ancillaries/follow-up

12. Billing

Look how some of these steps play out for a patient going to a facility with a fully functional EMR.

The patient:

* Learns about the services provided from the organization's Web site.

* Makes an appointment on the secure site.

* Submits the necessary registration information on the site.

* Arrives at the clinic and has the appointment confirmed at the front desk.

* Is seen by a nurse who accesses the patient record and updates the patient's medications, allergies and other data elements stored in the EMR. In addition, the patient's vital signs are entered directly into the record.

* Is examined by the provider who looks at the record to view previous clinical notes, and consult reports and laboratory results.

After the patient is assessed, the provider:

* Formulates the impression and plan.

* Implements the plan that includes prescribing medications and ordering therapies, laboratory tests and X-rays.

* Enters the E/M and ICD9 codes for billing.

* Enters the information directly into the EMR with a choice of typing, clicking with a mouse or using voice recognition software.

Other functions of the EMR may also come into play.

After updating the record, the provider may send a copy of the report to the referring physician. Also, while prescribing a medication, a warning may appear in the EMR of a possible drug interaction. While coding, a notification may let the provider know that some documentation is missing to justify that level of care.

The EMR is not just an electronic copy of the paper record. Added functionality can make it a very useful tool.

Evaluating EMR systems

To evaluate an EMR system or prioritize future development of the EMR, it's helpful to categorize the functions. The nine functions of an EMR are:

1. View

2. Manage

3. Document

4. Share

5. Bill

6. Remind

7. Comply

8. Gather

9. Educate

View

This is the electronic version of the paper chart and the first priority for getting clinicians to use the computer to find information. Unless 95 percent of data is available to view, the EMR will languish as an added burden rather than as a useful patient care tool.

The major challenge for this function is getting the data systems to talk to each other to exchange information. This is done by setting up interfaces and can take much effort and time.

Examples of viewable types of data include:

* Demographic information

* Clinical documents including notes, operative procedures, nursing notes and problem lists

* Laboratory information including chemistry, hematology and pathology

* Radiological reports including X-rays, MRIs and CAT scans 

* Other lab information on arterial blood gases, pulmonary function tests, EEG's and endoscopies

* Scheduling information

* Billing data (although, sometimes this is contained in a separate system with an interface needed to exchange information)

The EMR should provide choices to display the data in different ways such as graphs or tables. This allows quick identification of trends such as blood sugars and blood pressures. Images are especially important for radiology, catheterization and endoscopy.

Manage

The next level of functionality allows clinicians to directly interact with the EMR to place orders and to perform other management functions.

The importance of this is underscored by The Leapfrog Group -- corporate leaders who joined together to improve health care quality for their employees -- that included computerized physician order entry (CPOE) as one of the three essential criteria for health care plans.

The Leapfrog Group notes that when CPOE systems with intercept capability based on protocols specified by the Institute for Safe Medication Practices were used in hospitals, they reduced serious prescribing errors by more than 50 percent.

CPOE requires a high degree of user friendliness. It must be fast and easy to navigate and use look-up features for data such as codes. In addition, it is useful if CPOE systems display relevant laboratory data to assist clinicians in making decisions.

For example, being able to view the patient's potassium levels when ordering IV fluids can prove very beneficial, saving time and reducing errors.

Document

The ability to create a clinical note within the EMR can be accomplished in several ways.

Currently, uploading the transcribed document from a dictation system or scanning in the document are most common. While these methods enable the documents to be viewed in the EMR, they do not represent a major breakthrough in time or cost savings.

Voice recognition is growing more popular but is not quite ready for widespread use. Human speech is complex and with variations in speaking patterns it is challenging to create a system where all users' speech is recognized with a minimum of errors.

Even if voice recognition is perfected, the problem of how to store text for retrieval for quality assurance and other purposes remains.

There are at least two ways to store the data for later use.

1. Dictated notes can stored using natural language processing techniques (NLP), which look at every term and store them in separate places in the database. This is called parsing. Providers do not have to have special training; they just keep on dictating. The problem is that the physicians use different terms to mean the same thing and it is difficult for NLP to resolve the ambiguity. For example, the terms colon cancer and carcinoma of the large intestine may mean the same thing, but unless NLP has both terms programmed, they will not match up when a search is performed to look at all patients with this diagnosis.

2. Structured clinical documentation (SCD) is designed to overcome this problem with clinicians selecting terms from a fixed list or vocabulary. While the database is much better organized, physicians have to change their work process and create their notes differently. This may require training and draw resistance. Some EMR vendors attempt to facilitate this process through the use of point and click or drop down menus to select terms.

Along with retrieving quality assurance data, EMR notes can yield significant savings. These savings include costs for transcription that can run up to $.14 a line and costs for medical records personnel to process the documents. EMR notes also can speed up billing because the sooner the note gets in the chart, the sooner the bill can be submitted.

Share

Exchanging information is key to EMR success.

Although the EMR allows multiple accesses at once, it is useful to send or call attention to specific pieces of information. For example, a provider might want to send the referring physician a discharge summary by directly faxing it from the EMR. Or, a nurse might want to have the provider be aware of an abnormal laboratory value. Many EMR's provide e-mail links within the record to send messages to personnel within the system and outside.

A sharing feature also allows providers to co-sign notes. This is very useful in teaching hospitals where a resident may compose the note and need to have the attending physicians review it, add documentation that they were present and sign it. This can save many trips to medical records to sign the hard copy.

Bill

A billing function within the medical record truly makes it possible for clinicians to do "one-stop shopping" in caring for patients. They can view the chart, record their impression, order tests and consults and then code the visit for reimbursement.

As with the manage function (physician order entry), look-up features for codes and other billing information are essential. Another useful feature is the ability to view a patient billing history to select codes used on repeated visits for chronic diseases such as diabetes.

Remind

Another strength of the EMR is the ability to compare data and produce reminders or alerts when the data does not comply with an established rule or guideline.

A common example is abnormal laboratory values. Often, EMRs flag these values (such as (H) for abnormally high) or highlight the value in different color to attract attention.

If the share function is available, an alert might be sent to the provider as an urgent e-mail or through a page.

In the Primer on Physician Order Entry published by the California HealthCare Foundation, reminders for basic error checks include:

* Duplicate therapies

* Drug-drug interaction

* Drug-allergy interaction

* Drug-lab interaction

* Hospital formulary 

* Expiring orders

* Exception documentation for alert overrides

Reminders can also help manage medical conditions.

For example, Maviglia uses data from an electronic medical record to show that compliance with cholesterol treatment guidelines was poor. They plan to use this information to develop a sophisticated reminder system to help address deficiencies.

The remind function is where the EMR can make a real difference by improving patient care through comprehensive coordination and data assessment.

Comply

Compliance with regulations like documentation for Medicare reimbursement is an essential but time-consuming task for the clinician.

As with the remind function, the comply function can alert clinicians to deficiencies in documentation.

Applications such as E/M coding wizards are commonly used to scan the electronic documentation to determine if the requirements for the level of care selected are met.

If not, the clinician has the choice of entering the appropriate documentation if the service was performed or selecting another level of service.

Another important comply function is keeping track of chart completion and signatures. This is much easier than keeping track of the paper flow. Physician deficiencies can be noted sooner and handled for billing and compliance purposes.

Gather

Over time, the EMR becomes the storage repository for a large amount of data. These data are very valuable, particularly for quality assurance and research. It's crucial that the data be stored so they can be easily retrieved and examined.

For quality assurance, routine reports can be generated and simple set-up screen forms can be created to perform simple queries of the data. In some organizations, establishing a separate data warehouse is a useful way to allow QA and research personnel to work with the data.

Educate

Physicians learn best when their learning:

* Is in the context of patient care

* Answers their questions

* Is directly applicable to their work

* Does not take too much time (2)

Including a learning opportunity within the EMR accomplishes a number of these objectives and can potentially improve patient care.

The learn function could be as simple as providing a link to external resources such as PubMed, UpToDate, OVID or other Web sites.

More advanced functionality can allow the user to click on a term such as a drug name in the EMR and have relevant information about dosage and side effects appear.

Another education function is for patients. Clinicians are more prone to provide materials to patients if they can obtain them at point of care and distribute them by print or e-mail. There are a variety of services that can be accessed as long as the appropriate links are in the EMR.

Other issues affect EMR

Functionality is just one of the issues that clinicians have with the EMR. Others include:

* Poor performance

* Lack of access to computers

* Inadequate training

Poor performance usually falls into two categories: downtime and lack of speed.

If the system is frequently down or if the clinician has to wait for information to appear, usage drops dramatically.

The trend is to use central servers to provide data to client computers rather than relying on individual networked workstations. The use of secure Internet connections for transmitting the EMR is gaining widespread use.

Providing more computers at the point of care can solve access problems, but there are often space considerations and workflow issues. Physicians are nomadic by nature in making rounds.

Sitting down at a terminal and logging on each time is inconvenient. Wireless technology to allow the use of portable devices is being used in a number of institutions. But major issues to address include secure transmission (encryption) and devices that can display enough information yet be lightweight and durable and have a long battery life.

Palm sized units suffer from small screen size yet can be used for specialized applications such as prescription writing or coding. However, to achieve one-stop shopping with full functionality, a full-sized screen is necessary.

Lack of training in entry skills such as typing and in learning how to use a computer and the application cannot be underestimated.

An institution must make a resource commitment to provide training. Computer-savvy physicians can be recruited to motivate and teach other clinicians who find computers intimidating. (3)

A comprehensive EMR program includes all nine of the functions and adequate training and hardware to support the system. Use the function list to compare EMR systems or determine what needs to be added to existing systems to make them more useful for clinicians.

Acknowledgements:

Integrated Technology Services, University of Missouri-Columbia, and Johnny E. Bates, MD, for his review and additional comments.

Robert Hodge, MD, FACP, FACPE, CPE, is on the faculty of the School of Medicine of the University of Missouri-Columbia as professor of clinical medicine in the department of medicine and clinical professor in the department of health management and informatics.

References:

(1.) Maviglia, SM, Teich, JM., Fiskio, J and Bates, DW. "Using an Electronic Medical Record to Identity Opportunities to Improve Compliance with Cholesterol Guidelines." SGIM 2001 August, Vol. 16(8):531-37.

(3.) Ebell, M. "Information at the Point of Care: Answering Clinical Questions." J. Am Board Fam Prac. 1999, 12(3):225-35.

(4.) Carter, J.H., MD. Physician Adoption Strategies in Electronic Medical Records, A Guide for Clinicians and Administrators. American College of Physicians-American Society of Internal Medicine, Philadelphia, Pa., 2000.

Examine why some electronic medical record systems are flawed and discover step-by-step ways to evaluate new EMR systems and fix existing ones.

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Scrapping Paper for Pixels

A close-up look at two organizations leading the charge for EMR

University of Michigan Health Systems, Ann Arbor, Mich.

When surveyors for the Joint Commission on Accreditation of Healthcare Organizations arrive to review patient records at the University of Michigan Health Systems in Ann Arbor this year, "they're going to sit down at a computer terminal," says William Bria, MD, medical director of clinical information systems, "and they're going to pull up the chart online."

Since 1998, the four hospitals, 27 outpatient clinics and 2,000 physicians who admit patients to UMHS have been linked by a single Web-based clinical information system, called CareWeb.

Authorized care providers from any of 10,000 desktop, laptop or wireless handheld computers can access CareWeb. It integrates more than 40 previously non-communicating digital data "siloes" and it virtually eliminates paper.

Health care organizations throughout the United States are busy planning and budgeting implementation of electronic medical record systems. Only a few have actually crossed the digital divide. But, asserts UMHS associate chief of clinical affairs Aileen Sedman, MD, the odyssey is well worth the effort.

A pediatric nephrologist, Sedman simply taps out her password on her keyboard when she arrives at her clinic office each morning, logs on to CareWeb, brings up her day's schedule, clicks on a hyperlink and views each patient's chart.

Sedman can also view:

* A problem summary list to which she can add data by dictation or direct entry

* A demographics section that includes patient profile information, referring physician and insurance coverage

* Each patient's past and future appointment history

* Dictated medical documents, which can be catalogued by service and time period

* All lab results, which can be organized in a flowchart

* Radiology and nuclear medicine results

* Scanned images of paper documents including referrals

* An immunization section that can be updated by clinicians

* Pulmonary function tests and electrocardiograms

* An inpatient medication profile, showing the drugs presently ordered by clinicians as recorded in the pharmacy system

Occupancy at UMHS hospitals soared and lengths of stay decreased in the five years since CareWeb was introduced, Bria says.

Shuttling paper charts around the organization used to add more than $10 per patient to the cost of care, he says, not counting delays and frustrations, Now the need for the paper record is uncommon.

Because physicians can sign records electronically, more than 90 percent of all documentation requiring a signature now has one within 30 days versus 55 percent three years ago.

Patient medication records, printed out by pharmacy once a day in the pre-CareWeb era, are now updated hourly.

A computer physician order entry (CPOE) system is now being created as the next enhancement to CareWeb. It will include standard order sets offering comprehensive pick-lists and clinical decision support to help physicians adhere to evidence-based best care practices in diagnosing, treating and prescribing. UMHS expects it to be fully functional by late 2003.

Cedars-Sinai Medical Center Los Angeles, Calif.

Paper records are already as antiquated as papyrus scrolls in nine intensive care units at Cedars-Sinai Medical Center in Los Angeles, according to surgical ICU director Michael Shabot, MD, who also serves as Cedars-Sinai's medical director of enterprise information services.

A paperless charting system is also being piloted in six Cedars-Sinai outpatient clinics, as part of a plan to co puterize all 117 clinics at the facility.

And by April, says Shabot, a Web-based order entry system will eliminate paper orders altogether throughout the 1,000-bed facility, "unless the patient is being transferred somewhere else, in which case the orders will be printed out. You won't even be able to admit a patient to this hospital without a computer."

Not only has Cedars-Sinai digitized information management, its internet-based medical data viewing system, called Web/VS, lets doctors keep tabs from anywhere in the world on a patient's condition. All lab test results (with abnormal readings flagged by an asterisk) and an array of diagnostic reports and flow sheets can be displayed. Heart rate, bloodpressure, ventilator settings and blood gases are uploaded hourly from allICUs.

"All our docs can get all their records electronically, and the medical center no longer prints lab and imaging reports," Shabot says. "Even X-ray images are available electronically, and unless you're planning a detailed neurosurgical operation, you've got enough information to care for the patient -- the image and the report are in your hand."

He means that literally. Many Cedars physicians now use handheld Palm Pilot computers programmed with Web/VS applets that enable them to beam information from Cedars-Sinai around the clock via a wide-area wireless network covering Los Angeles and most metropolitan cities in the United States. "All patient information available remotely is securely encrypted, including the wireless links, and requires strong sign-on authentication."

University of Michigan hospitals also will add wireless within the year, says Sedman. "It's less expensive than having a lot of fixed terminals," she explains.

But Bria says existing technology still has a structural snag: the requirement that users enter data by keyboard.

"Physicians don't type," declares Miller Orthopedic Clinic CEO Marty Rosenberg. "Any technology that requires a significant amount of manual entry by physicians won't cut it."

Bria agrees. "The next breakthrough we're waiting for," he says, "is a truly user-independent, multi-capability, voice-to-text medical translator."

David Weber