Vol. 18 •Issue 26 • Page 8
Electronic Medical Records Eliminate the Paper Trail
We would expect Hurricane Katrina impacted and changed the health care systems in the southern Gulf Coast Region. And there are indeed some valuable lessons that have been learned the hard way from the tragedy.
Among them are the destruction of thousands of paper-based medical records coupled with the transport of patients to all corners of the nation, most of them without their records. This lack of documentation has fueled the debate for implementation of a national electronic medical record (EMR) system.
Eyewitness accounts of people volunteering in the disaster zone are rife with reports of patients who arrived at evacuation sites on oxygen but without any medical documents. Ocean swells churned up by Katrina swept away entire hospitals, outpatient clinics and physician offices in some coastal communities.
Few medical facilities in New Orleans escaped severe flooding, and medical records, often housed on lower levels, were inundated by muddy waters that saturated paper records for weeks, making them more suitable for papier-mache art projects than for patient care.
Proponents say EMRs are portable, more durable and more secure than paper-based systems. Even before Katrina hit, the federal government agreed. In July, President Bush signed the Patient Safety and Quality Improvement Act of 2005. This legislation is intended to deploy information technology assets to the user level to facilitate patient care and eliminate medical errors.
It works hand-in-hand with the E-Government Act of 2002 which intended to establish a framework of measures that require use of Internet-based information technology to enhance citizen access to government information and services.
In earlier legislation, the Medicare Prescription Drug and Modernization Act of 2003 recommended the use of health information technology to “manage the clinical care of beneficiaries.”
In the Hospital
This is all easier said than done. In the hospital environment, implementation of EMRs is problematic, because for it to work as envisioned, hospital computer systems must be integrated and compatible. Most hospitals have been moving in this direction for a few years now, at least in the E-prescribing and E-lab arenas.
Many were spurred on by the pressures to reduce medical errors. Others were spurred on early by Y2K fears (remember those?). Some facilities embraced electronic records in the hope of saving money in the long run; still others were attracted by the growing band of regulatory requirements for reimbursement and maintaining accreditation.
Regardless of their motivation for change, most hospitals are in the process of implementing some form of information technology to better manage their patients. Change is still stuck in slow gear, but it may be prodded into action soon. Two prime factors—reimbursement and accreditation—are, in fact, the carrots on sticks that are currently being held over the heads of many hospital administrators.
When the Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS) implemented public reporting of data this past year, hospitals were forced, at least on a minimal level, to use some form of electronic record reporting system or risk losing a percentage of their reimbursement.
Integration of the required quality measures to be reported to CMS along with Joint Commission for the Accreditation of Hospitals (JCAHO) measures has forced some facilities to expedite their electronic conversion.
In fact, experience has shown that a lot of modernization does occur in the six months prior to a JCAHO accreditation visit.
In Outpatient Settings
As we move from inpatient to outpatient settings, the terminology changes slightly, but the speed remains fairly slow paced. EMRs in this area are now referred to as electronic health records (EHR) rather than EMRs. Without the threat of lost reimbursement and accreditation, the challenge of influencing physician offices and stand-alone care providers has been tougher. An Agency for Healthcare Research and Quality study, released in September 2005, showed that only 14 percent of the more than 3,300 medical group practices surveyed nationally use EHRs.
Not surprisingly, the study found that the larger the practice, the more likely it was for the practice to have at least tried using an EHR. When stratified by size, researchers found fewer than 13 percent of practices with five or fewer full-time-equivalent (FTE) physicians had adopted an EHR. By contrast, almost 20 percent of practices with more than 20 FTE physicians had adopted the EHR.
At the same time, a whopping 42 percent of all practices had no immediate plans to implement an EHR at all.
There are reasons for such dismal showings. Although some practices have reported improvements in efficiency using an EHR, many remain dissatisfied with the design and performance of the EHR systems available. There has also not been a large volume of published data to show that the substantial investment that some of these practices would have to make to a adopt system, much less one that would integrate with their local hospitals, would benefit the practice.
To combat these shortcomings, CMS is investigating making the Veterans Administration’s EMR system (VistA) available as a low-cost EHR option for non-VA physicians. CMS has also initiated a Doctor’s Office Quality Information Technology (DOQ-IT) program. This program, currently being tested in several states, is intended to “promote the adoption of clinical information systems in physician practices with a vision of enhancing access to patient information, decision support and reference data, as well as improving patient-clinician communication,” according to CMS officials.
Clinical information system functions include:
• Registries or E-care management,
• Personal Health Record (PHR), and
• Electronic Health Record (EHR)
DOQ-IT will use quality measures that will be reported by the physician practices to the Quality Improvement Organization Clinical Warehouse via electronic media. This is identical to the process implemented in hospitals this year.
After the program was tested in that arena, reimbursement was tied to participation for hospitals. It is likely that the same will happen for individual physician offices down the line.
What does this all mean?
DOQ-IT, like its hospital predecessor, does not endorse any particular vendor, product or service. This is both good news and bad news. Physicians and managers of stand-alone clinics can tell you there are hundreds, perhaps thousands, of vendors out there vying for their time. This is definitely big business!
To get a handle on the fiscal numbers at stake, look at some of the data gathered to date. A report published in Health Affairs this fall, using data from the 2003 RAND Health Information Technology (HIT) Project team, noted that “effective EMR implementation and networking could eventually save more than $81 billion annually by improving health care efficiency and safety.”
From a clinical standpoint, the use of electronic medical records and eliminating the paper trail makes sense. Whether we adopt a central repository that health care providers can access or perhaps move to credit card-like records that patients can carry with them in an emergency remains to be seen.
What is clear is that we need some means to transfer patient information quickly, safely and securely. It would be a very sad state of affairs if we waited for another national disaster to stimulate us to action.
CMS Information Security Homepage: http://www.cms.hhs.gov/it/security/default.asp.
Doctor’s Office Quality–Information Technology (DOQ-IT): http://www.doqit.org/dcs/ContentServer?pagename=DOQIT/DOQITPage/PageTemplate.
News Release: Research Finds Low Electronic Health Record Adoption Rates for Physician Groups. Rockville, Md: Agency for Healthcare Research and Quality, Sept. 14, 2005): http://www.ahrq.gov/news/press/pr2005/lowehrpr.htm.
Hillestad R, Begelow J, Bower A, Girosi F, et al. Can electronic medical record systems transform health care? Potential Health benefits, savings and costs. Health Affairs. (2005; 24, 5: 1103-15).
Margaret Clark is a Georgia practitioner.