Substitute teacher here today. I'm scheduled to provide 3 essays on local govt, but thought I'd jump in with a riff on electronic medical records.
Hope Crissie is enjoying her vacation, and that she packed the SPF 30.
One of my last projects before sailing into retirement sunset was to lead the effort to implement the inpatient pharmacy component of our electronic medical record (EMR). I worked for the North Brooklyn Health Network and inpatient pharmacy was the third module incorporated into our EMR. Labs and radiology (diagnostic radiology, nuclear medicine, cat scan, ultrasound) were the first components implemented in our EMR. That is, lab ordering and results posting were done electronically, same for radiology.
This commitment to an EMR made us one of the 10% of hospitals in the country implementing an EMR.
The North Brooklyn Health Network consists of a 370 bed acute care facility, 15 offsite (adult and pediatric primary care) clinics, and a diagnostic and treatment center (110,000 patient visits). 90,000 patients used our emergency room annually and our onsite clinics recorded about 250,000 visits per year.
We were motivated to add an inpatient pharmacy component to our EMR by a 1999 Institute of Medicine study finding that between 44,000 and 98,000 deaths occur annually as a result of medical error, a large portion of which was related to prescriptiion drugs.
I've read with great interest the healthcare reform diaries on DKos (chalk me up as a single payer advocate) and have have noted that remarks about EMRs will find their way into diary comment. My guess is that the pro/con electronic medical record split is about even.
From what I understand the arguments against an EMR relate to the threat it poses to (1) patient privacy and the threat that an insurance company or employer might obtain personal healthcare data, (2) it's not user friendly to the physician, (3) downtime, rendering the system inefficient.
Other concerns about an EMR have to do with interoperability
In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged.
I think they are all valid concerns. Taking these concerns one at a time.
PRIVACY
I am not a security or privacy expert. Our system at the NBHN was password protected and to launch the EMR a physical key needed to be inserted into the computer. We did the best to secure patient information. I know of no security or privacy breakdown. It can happen, security and privacy are paramount.
Congress has passed laws to prevent third parties from misusing our healthcare data. The Genetic Information Nondiscrimnation Act (GINA) makes it illegal for employers or insurers to deny anyone healthcare coverage on the basis of genetic data.
And, there is the Health Insurance Portability and Accountability Act (HIPAA) which establishes guidelines for patient data use and disclosure (e.g., billing departments). You sign the HIPAA statement when you first use a doctor's office. It's a good thing that we have HIPAA. The Los Angeles Times conducted a study that found that for each hospital admission the possibility exists that 150 people may see some part of, or add to your medical record.
Is HIPAA a deterrent to patient data hacking? It would seem that cases could be brought against hackers by applying the HIPAA law.
John Hammergren is the CEO of McKesson the largest private healthcare company in the world and the 18th largest corporation. Hammergren envisions a day when all our healthcare data will reside in an integrated delivery network. From an article in Harper's:
When my oldest daughter has her first child, I believe that baby will get a genomic profile for roughly $800. The data obtained through that profile will be stored in a central information system, called an Integrated Delivery Network (IDN), to which primary care physicians and specialists will have access throughout the course of my grandchild's life.
Electronic medical record today, smart medical chip tomorrow. Clearly, we need protection.
We're relying on President Obama for a lot. cybersecurity is on his radar and his June announcement met with high praise. Legislation is pending in congress. Let's hope a first rate cybersecurity plan can be developed and that we can stop the bad guys.
PHYSICIAN USE
Many physicians are less than enamored of a healthcare information technology system. At Cedar Sinai Hospital in Los Angeles physicians revolted against a Computerized Physician Order entry system which resulted in the loss of $34 million.
Here is the gist of the matter as stated by Wikipedia:
According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EMR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself. Such organizational and social issues include restructuring workflows, dealing with physicians' resistance to change (or, alternatively, software engineers' evolving research in deep modeling of the physician's knowledge and workflow domains), as well as IT personnels' resistance to design and implementation flexibility needed in the complex healthcare environment, and creating a collaborative environment that fosters communication between physicians and information technology project managers.
This was our project implementation plan:
* Ergonomic considerations at inpatient workstations, arrange computers to accommodate user
* Upgrade hardware
* Create comfortable training area
* Involve all stakeholders from the beginning and planning stages
* Train, train, train
* Hire temporary IT staff as needed during early phases of implementation
* Vet and hire trustworthy vendor
Still, with all this, we could have done better. Our implementation was OK, not great. I learned that a lot more people are computerphobic than I would have thought. The good news is that the inpatient pharmacy module was implemented and the benefits we sought were realized.
DOWNTIME
We hoped to greatly reduce or minimize downtime. If you don't upgrade your equipment at the right time it becomes noticeably slower, perhaps obsolete. Older hardware may not be able to load new software programs. To help with this we hired staff who were expert in hardware issues. And, we spent a lot of money on new hardware.
WHY AM I A FAN OF AN EMR
The North Brooklyn Health Network is large and generates a lot of paper from treating many patients.
Our medical record physical plant was huge and the staff was large. What happens in a large facility is that medical records proliferate, as you could probably guess. At any one time many departments or providers may need the patient's medical record.
- The physician and or other provider
- The Medical Director or Department Heads Office
- Utilization Review Department
- Quality Assurance Department
- Risk Management Department
- Reiimbursement Department
- Patient Accounts Department
- Social Service Department
- Infection Control department
Tracking and controlling records is a large task. I would be lying if I said that all the paper that was constantly created could be filed expeditiously and available on demand for every user. To do this efficiently, you need an electronic medical record.
A SCENARIO
The state Medicaid office submits a notice for audit to the Patient Accounts Department. The state wants to confirm that the outpatient claims they paid for actually occurred and the diagnosis and procedure listed was documented in the chart. The state asks for a sampling of 100 charts and the Patient Accounts Department submits requests for these 100 charts to the Medical Records Department (Health Information Management). The MR department complies and sends the patient accounts department 88 charts. Where are the other 12 charts? One is in clinic with the patient, 5 are out to risk management, and others scattered to other departments. One may have been archived offsite and needs to be retrieved from the vendor who does archival management. Medicaid will give us time to locate the charts and validate the payment claim, but for any unvalidated claim, Medicaid will extrapolate the denial percentage over the 10,000 visits they paid for and for which the audit pertains.
Can this be done any easier? With an electronic medical record, the 100 charts and the pertinent visit data is available at a keystroke. Does this add to the hospital's efficiency? Will this reduce expenses? I believe so.
THE DOCTOR/PATIENT RELATIONSHIP
As mentioned above we launched our inpatient pharmacy module after a 1999 Institute of Medicine report indicating that between 44,000 and 98,000 errors occur annually from medical errors. What our system sought to do was to minimize dosing errors and the medication dispensing confusion surrounding look alike/sound alike drugs. Some drugs are just that: they sound alike but are different or they look alike. The most publicized drug dispensing error (look alike) that occurred happened to the actorDennis Quaid's twins His newborn babies were almost killed by a dispensing error.
Our system would flash risk alerts on the screen if any ordering or dispensing anomaly occurred (based on the systems logic). Through this system, we endeavored to minimize medication dispensing errors, improve patient safety and patient care.
VALUE OVER TIME
The value of an electronic medical record will increase over time. As providers more efficiently access and use the system, a body of record will accrue that makes it easier to use and more efficient to render care. All matter of your record will be available physicians at a few keystrokes, in a readable format, transferable to other providers as needed depending on healthcare needs.
Above I mentioned that we had 15 offsite clinics. Imagine this scenario: a pediatric patient is referred to our pediatric cardiology subspecialty clinic. The Peds Cardiology department conducts their examination and orders tests for the patient. The patient is given a few follow up visits and then referred back to the offsite clinic. With an EMR, the referring clinic now has, at the exertion of a few keystrokes, the results of all of the examinations and tests. Without an EMR, the physical chart would flow back and forth between the clinic with charting would occur where? Offsite or onsite? Would the staff at the offsite clinic coordinate the paperwork, or would the onsite staff do it? Would the medical record staff be responsible for transporting the paper record back and forth between the onsite and offsite clinic? These are issues that we had to resolve, any hospital has to resolve. The EMR replaces all this bureaucratic back and forth with a streamlined process of patient information.
These kinds of examples abound.
THE FUTURE
I would like to see the integration of the EMR and the billing system. What the healthcare industry does not possess is a workable cost accounting system. It has a cost finding system, but not a cost accounting system. Developing a cost accounting system should be strongly considered if reduction in healthcare expenses is to occur. Maybe another diary about that at a later date.
The $20 billion that President Obama earmarked for healthcare IT just scratches the surface. I hope that more funds will be made available and I hope that many good paying permanent jobs will be created to implement the EMR.
Will the electronic medical record reduce costs as President Obama hopes? I know medical record staffs and patient accounts staffs won’t need to be as large, and, if there is a backend interface to post to the billing system, other staff could be reduced. This staff reduction would be offset with a larger IT staff. Probably malpractice costs would be reduced. Reducing test redundancy would translate into more savings.
It is not a panacea for reducing healthcare costs and should not be sold that way (eliminate wall street medicine is the answer for that) but it should be an arrow in the quiver.