ELECTRONIC MEDICAL RECORDS - PUTTING MEDICAL RECORDS ONLINE

ELECTRONIC MEDICAL RECORDS - PLACING MEDICAL RECORDS ONLINE

Just about every time that the topic of trying to stem the tide of rising healthcare costs comes up,
the idea of "putting records online" arises, and the assertion is that digitizing medical records and
putting them on a secure server, will be a tremendous cost saving benefit.

I have been in healthcare for 19 years, and longer than that, in the field of computers. I was an
early adopter to the use of scanning and scanners, when these devices became affordable
as consumer peripherals, and well remember the early days when the early versions of Windows
had trouble with TWAIN drivers.

I said that to indicate I am not a newbie when it comes to digitization of records, online
storage, or things like OCR technology, PDFs, etc. Now, I will NOT argue that digitization
highly increases the ability to access documents, increases searchability, and decreases
the physical space to store the records. Nowadays, I try to scan in and store those documents
I believe are important and which I may need to transmit via email or by way of a server storage.

So, you will not get an argument from me on issues such as the advantages of digitization
of records with regard to portability, searchability, access, etc.

Digital records though, whether stored on optical drives, RAID drives, thumb drives,
DVDs, or any other removed or non-removable drive or media, can necessitate access
to a computer (using the term broadly, including devices like PDAs / Blackberry) at the minimum
and perhaps access to broadband.

The CONS though include things such as the fact that the original , ANALOG, physical
media (read here, "paper") is ALWAYS superior to a scanned image in that it contains
more data, because, by definition, it is a three dimensional object, a real
world holographic entity . The untrained eye may not detect significant differences,
and one may be able easily enough to extract the
form and basic content / data needed (i.e., you can read the document or view the pictures
well enough to get what you need), but, the physical document contains far more data
than the digital image (for example, there is the tactile dimension of the stock and
type of paper used that does not come through in two dimensional viewing).

Next, a digital image of a document is extremely vulnerable to alteration. There are plenty
of sophisticated and even entry level graphics programs, that allow anyone to alter
the document, without trace of the alteration.

After that, there is the issue of lifespan of the media. Anyone who has worked in computers
for twenty years, KNOWS that hard drives can crash suddenly and without warning whether
you obtained a backup or not. Someone with a bulk eraser can quickly and effectively,
destroy millions of medical records. In these days of terrorism and hacking, we need
to be aware of this. Furthermore, although makers would like you to believe that DVDs have a
great lifespan, I wouldn't bet the farm on the notion that the DVD you make today, will be
readable in ten years.

Another issue is viruses and worms. Nowadays, all it takes is an infected laptop hooking
up to your network to infect it. Some worms and spyware automatically connect with distant
ports and can upload everything on your drives. Some viruses wipe drives or make them
unreadable, but the more sophisticated ones, can just change small things here and there,
changes which may in fact go undetected. And, if you think your network is protected because
you are using a super secret "secure" virtual tunneling protocol or VPN (virtual private network)
, with encrypted medical records, think again ! It is often said that in theory,
ANY NETWORK CAN BE HACKED!
From http://www.ciscopress.com/articles/article.asp?p=341484
"In a recent survey conducted by the Computer Security Institute
(CSI, http://www.gocsi.com), 70 percent of the organizations polled
stated that their network security defenses had been breached
and that 60 percent of the incidents came from within the organizations themselves."

Another consideration is that papers and documents do not scan themselves, Some might
counter this by saying that if they have a high dollar, high output scanner with a document feeder,
the need for a human to feed documents is very reduced, These document feeders can fail,
the rubber guide rollers can accumulate shiny deposits so papers are not grabbed properly,
and look, they are mechanical devices. Mechanical devices break down.

So, the question is, where are these tremendous savings from medical records digitization
coming from ? One obvious answer is that it saves time that would be spent by some office
worker retrieving the records and bringing them to you. Yes, this may be a negligible benefit
but does that mean you get to save money by letting employees go and increasing the already
mounting unemployment rate ?

The next question is what file format are you using. In order to preserve form as well as content
you need something like Adobe PDF (portable document format), but of course, this means
that usually, there is an intermediary step in which the physical document becomes an image
and then is converted. Now, this is not that big a deal, but it does mean if you are sharing
documents online, you need to keep your Adobe Acrobat Reader up to date.

Back to the lifespan of digital records. Acid free paper / papyrus, etc., has a proven track record
of being able to withstand power outages, electromagnetic pulses, the infamous "DEL" (delete)
button, and is not prone to depending on whether or not the platter on your drive has developed
bad sectors, or if the drive itself is going to tank. We have paper / paper like records, from the time
of Jesus that can still be read, But, perhaps, clinicians only care about maintaining the records for
the seven year period mandated by law. The progeny at some date MAY want to see the medical
records of their Mom or date, and though paper, properly stored will survive, as storage becomes
a premium, the files may not survive the edict to "purge the files".

But, let's get another perspective besides mine.
http://goliath.ecnext.com/coms2/gi_0199-1399500/Myths-and-realities-of-electronic.html
(Note "EMR" stands for "Electronic Medical Records")

"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."
(READ MORE AT THIS LINK)

I notice that the people who are screaming about saving money in health care usually do not
quantify how much money they say they will save, nor do they outline exactly how this saving
will be brought about or realized. Some politicians may even spout that they can save "billions"
by bringing medical records online. How would one prove that. I say they cannot.

The last issue, one which may seem conspiratorial at first glance, is that digitization and online
storage of records leads to databases, and databases can lead to monitoring by the government,
establishment of mega-databases accessed by insurance companies, etc. In fact, digitizing and
putting medical records with social security numbers online, is a giant informational leak nightmare
waiting to happen, no matter how encrypted, no matter how secure you think your servers or network
are...all it takes is a little effort and technical expertise, and perhaps a functionary on the inside to suddenly
find millions of personally identifiable health information files on the net in a hundred websites,
on servers in a hundred foreign countries.

So, think more concretely about this "monetary savings" notion before putting healthcare records online.

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