As Records Go Digital, How Physicians Preserve the Full Story

By Amy Fletcher

The electronic medical-record revolution is upon us

The United States is on the verge of a technological evolution—if not revolution—when it comes to health care. But the extent to which electronic medical records will improve patient care and tell patients’ full stories depends in part on the types of systems providers implement and how they are used.

Prompted largely by the availability of federal funds from an incentive program and the reality of lower reimbursements in coming years if new standards aren’t met, the health-care industry is moving—albeit slowly in some cases—toward implementing electronic medical records. In the eyes of critics, the current way of recording and using clinical information is downright primitive, with important information stored in file folders and papers, with no way to analyze or search the information systematically.

Patient information is often divided among several doctors’ offices and hospitals, with no office or facility having access to the full story. Even a patient’s own doctor may have to thumb through a paper file to find out, for example, whether a patient has recently had a tetanus shot. This manual and tedious process takes time and can lead to oversight and error. The use of paper records—or even of electronic ones that aren’t shared—can lead to different physicians ordering the same tests, or prescribing the same or conflicting medications, as well as to incomplete information about patients’ medical histories. Duplication results in unnecessary bills, and incomplete information leads to lower-quality care.

In this period of transformation,
it’s important that no elements
of the patient record are lost.

This kind of data isolation is often the norm in health care, and a far cry from the progress that other industries have made in terms of using integrated networks to deliver powerful results.

The federal government—and even certain parties within the health-care sector itself—is hoping to change this. As for the government’s part, it has developed an incentive program designed to offset the cost of implementing electronic health records and the systems needed to make this change. However, there are some strings attached. Providers must meet a “meaningful use” standard to receive the federal funding. That’s because the goal is not merely to get technology in place and scan in existing health records, but to have useful data points that are well organized and can be shared across secure networks. The idea is that information that is more useful, manageable, and accessible will help doctors and others make better decisions.

The Challenge

While excitement builds around a better way of collecting and sharing patient information, there are also concerns about what could be lost—namely large amounts of vital information that patients share with doctors and nurses that don’t fit easily into an electronic medical record. And physicians and other providers are also concerned about identifying software and hardware that can talk to each other, meet the meaningful use standard, and aren’t too expensive or difficult to master.

That’s where Health Story, a nonprofit alliance of health-care vendors, providers, and associations, comes in. Over the past three years, Health Story members have pooled resources to produce common data standards for the flow of information between traditional types of health-care documents and electronic health records. They’ve also developed scanners, software, and systems that accommodate the way that doctors, nurses, and others are used to working.

In this period of transformation, it’s important that no elements of the patient record are lost. Existing medical records are goldmines of information, containing important private data about patients, including their medical histories, medications, and lab results. Some of this data is relatively straightforward—such as height, age, weight, and temperature—and easily correlates with fields in a database that might form an electronic medical record.

What’s more difficult is capturing the more nuanced information that comes from patient observation and interaction, namely lifestyle factors and other events that provide valuable information but are generally recorded through long-hand narratives. This information may include observations made by surgeons during a procedure that are later transcribed, or written reports that are not easily transferred into the fields of a database. For example, there is no code to indicate that stress at home or work may be contributing to a heart condition, or that a hospital patient didn’t sleep well because he or she got a bit tangled in an IV line.

Many providers are used to jotting down notes that are later entered into a computer. But merely putting this information into a word processing file or scanning a paper document doesn’t go far enough, especially when considering the new meaningful use standards. However, new technology allows even observations about how a patient slept to be recorded in a way that makes the information recognizable, usable, and universally available, even across different systems. And these systems can be used without extending providers’ workdays or negatively impacting interactions with patients.

Any professional will tell you that in order to do his or her job well, they must have the proper tools. Health-care professionals have been operating for far too long without always having the very tool they need the most: the right information. Electronic health records, and the “smart” documents to accompany them, provide instant access to a patient’s full medical history. Having the right information in the right place at the right time is a prescription for success.

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Amy Fletcher is a freelance writer based in Denver. She specializes in writing about health care, health-care policy and education.

Source: Theatlantic