CasesBlog - Medical and Health Blog: EMR

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What EMRs will be expected to do in stage 2, year 2014

Physicians would need to use their EMRs to meet 20 functionality objectives at minimum levels to earn bonuses and avoid penalties.

Core set (must meet all objectives listed below)

Use computerized physician order entry for medication, lab and radiology orders
Prescribe electronically
Record patient demographics
Record and chart vital signs
Record smoking status
Use clinical decision support
Incorporate clinical lab results into EMR
Generate lists of patients by specific condition
Set patient reminders for preventive and follow-up care
Provide patient portal access
Provide clinical summaries for patients
Identify education resources for patients
Use secure messaging with patients
Use medication reconciliation
Send summary of care records for referrals and care transitions
Send electronic data to immunization registries
Ensure EMR privacy and security

Menu set (must select and meet 3 objectives from the list below)

Access imaging results
Record patient family histories as structured data
Send electronic syndromic surveillance data to public health agencies
Have ability to report cancer cases to state registries
Have ability to report noncancer cases to state registries

Electronic medical record (EMR) - review of pros and cons in the Cleveland Clinic medical journal

Some negatives regarding the use of EMR:

- So far, electronic systems are not interconnectable
- Do electronic records improve or worsen the quality of care?
- Accuracy vs copying and pasting
- A third party in the examination room
- Devoid of real medical thought

A contrasting view:

- Connectivity will improve
- Staying focused on the patient, even with a computer in the room
- Doctor-doctor communication is enhanced

References:

Centers for Medicare & Medicaid Services, Electronic Health Record Incentive Program -- Stage 2, Feb. 23, 2012.
First look at the next stage of meaningful use - amednews.com

The electronic medical record: Diving into a shallow pool? CCJM.
The electronic medical record: Learning to swim. CCJM.
"The iPatient is getting wonderful care across America. The real patient wonders, "Where is everybody?" NYTimes, 2011.

Secure web messaging between patients and doctors: Not well received

Although e-mail may be an efficient clinician-patient communication tool, standard e-mail is not adequately secure to meet Health Insurance Portability and Accountability Act (HIPAA) guidelines. For this reason, firewall-secured electronic messaging systems have been developed for use in health care.

The Kryptiq messaging system was implemented at an academic center and messages were monitored continuously and tracked.

In the 8 months after implementation, only 5 messages were initiated by patients in contrast to 2,363 phone calls.

Patients/families expressed strong interest in e-mailing but secure Web messaging was:

- less convenient than using the phone

- too technically cumbersome

- lacked a personal touch

- only by a handful of patients

One pediatrician on Twitter wants a simpler solution:

@Doctor_V (Bryan Vartabedian): Gimme an integrated, secure Tw like tool for doc to doc/pt comm - part of record.

Comments from Twitter:

@davisliumd: No, Kaiser's data different: Use of Health Information Technology Leads to Improved Care Quality

@yejnes: My patients like it!

References:

Secure Web Messaging in a Pediatric Chronic Care Clinic: A Slow Takeoff of "Kids' Airmail". PEDIATRICS Vol. 127 No. 2 February 2011, pp. e406-e413 (doi:10.1542/peds.2010-1086)

Medical practices using email with patients see their voicemail volume drop - email replaces inefficient phone tag. "We in health care can no longer sit back and say, "I don't do email with patients" - a doctor in WSJ, 2012.

Image source: Wikipedia, public domain.

Electronic medical record (EMR) - review of pros and cons in Cleveland Clinic medical journal

Some negatives regarding the use of EMR:

- So far, electronic systems are not interconnectable
- Do electronic records improve or worsen the quality of care?
- Accuracy vs copying and pasting
- A third party in the examination room
- Devoid of real medical thought

A contrasting view:

- Connectivity will improve
- Staying focused on the patient, even with a computer in the room
- Doctor-doctor communication is enhanced

References:
The electronic medical record: Diving into a shallow pool? CCJM.
The electronic medical record: Learning to swim. CCJM.
"The iPatient is getting wonderful care across America. The real patient wonders, "Where is everybody?" NYTimes, 2011.

Electronic Prescribing Decreases Prescribing Errors Seven Fold

For e-prescribing adopters, error rates decreased nearly sevenfold, from 42.5 per 100 prescriptions at baseline to 6.6 per 100 prescriptions one year after adoption.

For non-adopters, error rates remained high at 37 per 100 prescriptions at baseline and 38 per 100 prescriptions at one year.

Illegibility errors were very high at baseline, and not surprisingly, were completely eliminated by e-prescribing (87.6 per 100 prescriptions at baseline for e-prescribing adopters, 0 at one year).

Prescribing errors may occur much more frequently in community-based practices than previously reported. This study findings suggest that stand-alone e-prescribing with clinical decision support may significantly improve ambulatory medication safety.

References:
Electronic Prescribing Improves Medication Safety in Community-Based Office Practices. Journal of General Internal Medicine, 2010.

EMR or "How Computers are Harming Doctor-Patient Relations" - Rick Payne

EMR or How Computers are Ruining the Doctor's Office and Harming Doctor-Patient Relations - a presentation by Rick Payne.

My experience with EMR has been mostly positive but it is certainly useful to be aware of other points of view.

Medical Malpractice Liability in the Age of Electronic Health Records - NEJM, 2010 http://goo.gl/cGZG9
"The iPatient is getting wonderful care across America. The real patient wonders, "Where is everybody?" NYTimes, 2011.

TED video: CIO of Cleveland Clinic talks about electronic medical records (EMR)

Video - TEDxCLE - Dr. C. Martin Harris, CIO of Cleveland Clinic talks about EMR. The Cleveland Clinic uses Epic Systems EMR and, although the system costs millions of dollars to purchase and maintain, it has been perceived as very useful by both physicians and patients.

Disclaimer: I was a Clinical Assistant Professor of Medicine at the Cleveland Clinic until 2008.

Medical Malpractice Liability in the Age of Electronic Health Records - NEJM, 2010 http://goo.gl/cGZG9

Turning medical residents away from copy-and-paste culture facilitated by EMR

From MedCityNews:

Cleveland VA is trying to cut out the burgeoning subculture of “copy-and-paste”: A phenomenon made possible by electronic medical records in which physicians copy old information about a patient and paste it into a new section of the chart.

The practice is seen by medical residents as a time-saver but the attendings consider it an “egregious problem” because the practice has the potential to perpetuate mistakes. For example, someone might copy and paste information from a patient’s medical history without verifying that the information is correct. Any errors that might exist will be repeated.

EMR can’t just disable the copy-and-paste function, since such a move would impact other programs.

References:

Turning medical residents away from copy-and-paste culture. MedCityNews.

NYT interviews Dr. Blumenthal, the President's EMR "czar"

From the NYTimes:

We found that about 17 percent of physicians in 2008 had adopted an electronic health record, and about ten percent of hospitals.

The Danes have virtually 100 percent of physicians using electronic health records. In Britain, virtually 100 percent of primary care physicians use them. In Australia, Sweden, Norway, virtually 100 percent. In many, many other Western countries, the electronic record is virtually ubiquitous.

From 2011 to 2015, there is a bonus (for adopting EMR). After 2015, if you have not adopted, and you see Medicare or Medicaid patients, you may experience a penalty.

On average, the cost is between $40,000 and $50,000, of which about a third is the software and the hardware, about a third is the cost of getting it set up in the office, and about a third is maintaining it.

References:
Computerized Health Records. NYT, 2009.

Medical Malpractice Liability in the Age of Electronic Health Records - NEJM, 2010 http://goo.gl/cGZG9

Video: How Does a Doctor Really Use EMR?

WSJ Video: How Does a Doc Really Use An Electronic Medical Record? A primary-care doctor in Ohio using an electronic system he bought about five years ago.

I have an extensive experience with Epic EMR, which is used system-wide at the Cleveland Clinic, and I have found it quite useful although the interface is far from intuitive. The Clinic has customized most of the Epic EMR applications and different templates have been created at department and section levels, and by individual physicians and residents. There are "super-user" courses available that teach you to how make your own templates and "smart phrases" to take a full advantage of the system. Epic EMR obviously can benefit from interface improvement but I find it more user friendly that VISTA EMR used at the VA hospitals and clinics.

References:
How Does a Doc Really Use An Electronic Medical Record? WSJ.
Why EMR may not be that helpful: health workers use "copy-paste" templates

Why EMR may not be that helpful: health workers use "copy-paste" templates

Deducting from my extensive experience with EMR (electronic medical records), I believe it has advantages and disadvantages, like any product.

For example, some users may become prone to copy-pasting and using templates that change very little with individual patients. See an example below:

All worksheets were followed as appropriate. Each diagnosis was stated precisely. There is no lack of a diagnosis justified. Functional impairment was mentioned. All remarks are addressed.

The onset of the skin condition was described, as was the course of the skin condition with any variation of symptoms over time, if any. Any treatment type and dosage, if found or used, was mentioned, if any. The frequency and duration of each treatment during the last 12 months, if any was found, was stated. The percentage of exposed areas, and entire body surface area percentage involved, were stated, if any. If any scarring or disfigurement was noted, this was stated, and if so, the scar examination worksheet was attached, if any disfigurement was noted - if none was found, the scar examination worksheet was not attached. If any acne or chloracne was present, this was stated, and whether it was superficial or deep, if found. Any diagnostic or clinical tests or photographs, if needed, were reported, if any.

However, there is little doubt that EMR is a much better solution than paper documentation overall.

References:

Obama proposing a massive effort to to make all health records standardized and electronic

Related reading:

Debate: Do Electronic Health Records Help or Hinder Medical Education? PLoS Medicine: http://is.gd/z9or

Obama proposing a massive effort to to make all health records standardized and electronic

From CNN:

- Obama proposing a massive effort to to make all health records standardized and electronic, to create 212,000 jobs

- Only 8% of the nation's 5,000 hospitals and 17% of its 800,000 physicians currently use EMR

- "Universal" EMR could cost at least $75 billion to $100 billion over the ten years

From Twitter:

dermdoc @AllergyNotes I use only electronic medical records in my practice. I love it. Medicine is the last luddite. 6 minutes ago from web in reply to AllergyNotes

dermdoc @AllergyNotes In my experience, docs who took good notes on paper take good notes electronically. Those who wrote worthless notes, still do. 4 minutes ago from web in reply to AllergyNotes

Deducting from my extensive experience with EMR (electronic medical records), I believe it has advantages and disadvantages like any product. For example, some users are prone to abusing the system by copy-pasting, using "canned" templates that change very little with individual patients, etc. However, overall the EMR is a much better solution than paper documentation.

References:
Obama's big idea: Digital health records. CNN.

Using Evernote as Electronic Medical Records Software

From EfficientMD:

Let me be clear: I'm not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work.

Evernote has confirmed by email that, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service."

Of course, if you're concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you'd still be able to use Evernote, but this means that you won't be able to access patient data from the web unless you use a program like GoToMyPc.com.

References:
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR). EfficientMD, 08/2008.

Google Health (Personal Health Record) Launches for Everybody Today

Screenshot of Google Health

Google Health is an online service which provides personal health record (PHR). The website is live and anybody can sign in, with a Google account, of course. It looks friendlier and easier to use than the competing offering by Microsoft called Health Vault. See the Google Health tour here.

A few excerpts from the "About Google Health" page are listed below:

Google Health allows you to store and manage all of your health information in one central place. And it's completely free. All you need to get started is a Google user name and password.

Why use Google Health:

- Keep your doctors up-to-date
- Stop filling out the same paperwork every time you see a new doctor
- Avoid getting the same lab tests done over and over again because your doctor cannot get copies of your latest results
- Don't lose your medical records because of a move, change in jobs or health insurance

With Google Health, you manage your health information — not your health insurance plan or your employer. You can access your information anywhere, at any time.

With Google Health, you can:

Create a health profile

- Build online health profiles: you can enter your health conditions, medications, allergies, and lab results into your Google Health profile

- Review trusted information on diseases and conditions

Search for doctors and hospitals

References:
Google Health launched. Google Blogoscoped.
Google Health: A View From the Inside. Wachter's World.
Image source: Google Health.

Related:
Would you like to see Dr. Google or Dr. Microsoft for your personal health records?
Adam Bosworth, Google Health Architect, Leaves Google
The Ultimate Guide to Google Health: 60+ Tips and Resources. NursingDegree.net.
Microsoft HealthVault and Google Health - The 'Coke and Pepsi' of Online Health (PHR). ReadWriteWeb, 10/2008.

Updated: 10/16/2008

Would you like to see Dr. Google or Dr. Microsoft for your personal health records?

According to the New York Times:

Microsoft’s software powers more than 90 percent of all personal computers, while Google is the default starting point for most health searches. People are increasingly turning to the Web for health information and advice. A Harris poll found that 52 percent of adults go to the Web for health information, up from 29 percent in 2001.

"Today, only about 20 percent of the nation’s patient population have computerized records. Under federal law, people can request and receive their personal health data within 90 days. But the process is complicated, and the replies typically come on paper, as photocopies or faxes."

Adam Bosworth talks about GoogleHealth. Image source: AlphachimpStudio, a Creative Commons license.

More or less, the current equation is as follows:

Microsoft = personal computer
Google = Internet

Both Google and Microsoft are reportedly preparing products aiming at the potentially huge market of personal health records.

A screenshot of Google Health. Image source: Philipp Lenssen, a Creative Commons license.

Microsoft’s offering is scheduled to be announced this fall, while Google’s will probably be introduced next year. The launch of new software products frequently faces multiple delays and missed deadlines -- Windows Vista is a good example. Most likely, "Dr. Google" or "Dr. Microsoft" will not be available to see you before 2008-2009.

Update 10/06/2007:
Microsoft launches an online personal health record portal called HealthVault.com.

References:
Dr. Google and Dr. Microsoft. NYTimes.
Google Health Prototype. Google Operating System.
First Google Health Screenshots. Philipp Lenssen.
Who's your patients' best friend? Google!
Google Finds Correct Diagnosis in 58 % of Cases Published in NEJM
Google, M.D. In Action
Google, M.D. In Action - Part II
"Google, M.D." at the Clinic
Image source: Doctors Using Google by Philipp Lenssen, used with permission.

Related:
Microsoft HealthVault and Google Health - The 'Coke and Pepsi' of Online Health (PHR). ReadWriteWeb, 10/2008.
Google now wants to diagnose your disease, offers differential diagnosis based on 10 sites and Wikipedia http://goo.gl/SD1qM

Better Information Technology Needed in Medicine - Blogger Opinions

Are medical records still in dark ages?

Medical Informatics Insider writes that hospitals are still in the dark ages when it comes to record keeping in paper format. This does not apply to all hospitals though. Martin C. Harris, who is a CIO (chief informatics officer) at the Cleveland Clinic, admitted that when the hurricanes hit Florida offices of the Clinic last summer, no medical records were lost. They had already been safely stored in electronic format on the servers in Cleveland, Ohio.

"Inefficient" electronic medical records (EMR)

Graham is a medical student who shares his frustration with the current use of IT in medicine in his post Health IT: This Is The Best We've Got?:

"My frustration continues to grow and grow the more I work and work. I find it extraordinarily hard to believe that with all the great minds in computers and medicine, we don'’t have a system that makes practicing medicine quicker and error proof. Even at the VA, a hospital system that has arguably the best computerized medical record, things are incredibly inefficient."

Electronic medical records can be very useful

In my comment to Graham's post, I noted that most of the fixes for the problems he listed are already available.

The Cleveland Clinic uses EpicCare which is popular software for EMR. Admission notes and progress notes can be done electronically and the system automatically pulls out vital signs, laboratory results, medications lists, etc. and puts them in the note.

I did my residency at Case/St. Vincent and the nurses there used to record their assessment (interval history, vitals, physical exam) in the computer system. When the residents round in the morning, they can see everything that happened since they left the hospital the previous day. The electronic assessment is so comprehensive that we used to joke that you do not actually have to see the patient because everything is recorded in the computer. Do not take this as advice though, of course, you HAVE to SEE the real patient.

Both hospitals given as examples have computer terminals in patients rooms (portable or stationary).

I also used to use a progress note template (printed on paper) that you just fill out and then put in the chart.

Check out these Sample Admission Notes for the Most Common Conditions. They can be used as paper templates or saved in the computer system and completed electronically.

References:
EMR, the new threat to your medical privacy. ConsumerReports.org
EHRs Fix Everything - and Nine Other Myths. Family Practice Management, 2007.
How Clinical IT is Transforming Hospital Care – For Better and Worse. Wachter's World, 01/2008.
An Introduction to Personal Health Records. American Academy of Family Physicians, 2006.
Image source: Wikipedia

Related:
EMR (Epic) primer: Our Most Expensive Typing Pool. Dr. Wes, 09/2008.

Updated: 09/04/2008

Cleveland Clinic Offers a Second Opinion Online for $565

From Washington Post:

A patient with mitral valve prolapse was prepared to fly to Cleveland to get a second opinion regarding the need for surgery until she realized that the consult can be done online.

"My Consult" is a secure web-based second opinion service offered by the Cleveland Clinic. For $565, a staff physician provides a consultation and treatment recommendation within a week.

Dr. Harris, who is the chief information officer of the Cleveland Clinic, says that the hospital has been working on the second opinion program for three years.

Limitations of the Online Second Opinion

Not all states are covered, the Clinic second opinion (or E-pinion, as The Washington Post calls it) is not available in Georgia, Kentucky, Louisiana, Nevada, North Dakota, South Dakota, Oklahoma and Wyoming.

Few insurance companies pay for the web-based second opinions.

What happened in the end?

The Cleveland Clinic specialist recommended surgery. After some time and a few more tests, the patient and her doctors agreed that, indeed, that was the best option.

Bloggers Matter

Washington Post has a new feature called "Who's Blogging?" with links to bloggers who posted about the article. KidneyNotes, who reported the story first, is listed in this Technorati-powered section.

The Clinical Cases and Images - Blog was a close second:

This type of blogs exposure gives the Washington Post readers a chance to get a broader view of what other people think about a particular article.

It is also a smart marketing move by the newspaper because it may stimulate bloggers to link more often to Washington Post articles.

References:
Second E-pinion. The Washington Post.
Second opinion counts for a lot. USA Today, 3/12/2006.
Image source: eClevelandClinic, The Washington Post.

Related:
Talk To a Doctor Now: Online! ScienceRoll.com, 03/2008.

Updated: 03/21/2008

Do It Yourself EMR (Electronic Medical Records)

The introduction of EMR is slow because of cost, lack of a common industry-wide standard and other issues.

Last week, the AMA launched the iHealthRecord website which lets patients save their medical history online for free. The physicians are charged $ 25 per month to access their patients' information.

(Via Wash Post)

Update 3/22/2007:
EHRs Fix Everything - and Nine Other Myths. Family Practice Management, 2007.

More resources:
Doctors Slowly Going Digital With Records - Wash Post 05/05
EMR, the new threat to your medical privacy. ConsumerReports.org
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR). EfficientMD, 08/2008.
Debate: Do Electronic Health Records Help or Hinder Medical Education? PLoS Medicine: http://is.gd/z9or

Medical Malpractice Liability in the Age of Electronic Health Records - NEJM, 2010 http://goo.gl/cGZG9

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