EMR Jasis 95 Emr

EMR Jasis 95 Emr
EMR Jasis 95 Emr
EMR Jasis 95 Emr
EMR Jasis 95 Emr
EMR Jasis 95 Emr
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Transcript of EMR Jasis 95 Emr

  • 8/13/2019 EMR Jasis 95 Emr


    The Electronic Medical Record: Promises and Problems

    William R. HershBiomedical Information Communication Center, Oregon Health Sciences University, BICC, 3 18 1 S. W. Sam JacksonPark Rd., Portland, OR 97201. Phone: 503-494-4563; Fax: 503-494-4551; E-mail: hersh@ohsu.edu

    Despite the growth of computer technology in medicine,most medical encounters are still documented on papermedical records. The electronic medical record has nu-merous documented benefits, yet its use is still sparse.This article describes the state of electronic medical re-cords, their advantage over existing paper records, theproblems impeding their implementation, and concernsover their security and confidentiality.

    As noted in the introduction to this issue, the provi-sion of medical care is an information-intensive activity.Yet in an era when most commercial transactions areautomated for reasons of efficiency and accuracy, it issomewhat ironic that most recording of medical eventsis still done on paper. Despite a wealth of evidence thatthe electronic medical record (EMR) can save time andcost as well as lead to improved clinical outcomes anddata security, most patient-related information is still re-corded manually. This article describes efforts to com-puterize the medical record.Purpose of the Medical Record

    The major goal of the medical record is to serve as arepository of the clinicians observations and analysis ofthe patient. Any clinicians recorded interactions with apatient usually begin with the history and physical exam-ination. The history typically contains the patients chiefcomplaint (i.e., chest pain, skin rash), history of thepresent illness (other pertinent symptoms related to thechief complaint), past medical history, social history,family history, and review of systems (other symptomsunrelated to the present illness). The physical examina-tion contains an inventory of physical findings, such asabdominal tenderness or an enlarged lymph node. Thehistory and physical are usually followed by an assess-ment which usually adheres to the problem-oriented ap-proach advocated by Weed ( 1969), with each problemanalyzed and given a plan for diagnosis and/or treat-ment. Subsequent records by the clinician are usually in

    G 1995 John Wiley & Sons. Inc.

    the form of progress notes, which are written for eachencounter with the patient, whether done daily in thehospital setting or intermittently as an outpatient. Inter-spersed among the records of one clinician are those ofother clinicians. such as consultants and covering col-leagues, as well as test results (i.e., laboratory or x-rayreports) and administrative data.These various components of the records are oftenmaintained in different locations. For example, each

    physicians private office is likely to contain its own re-cords of notes and test results ordered from that office.Likewise, all of a patients hospital records are likely tobe kept in a chart at the hospital(s) where care is ren-dered. Only at large health centers, where both hospitaland ambulatory care is provided (i.e., public or univer-sity hospitals), will the complete medical record for apatient exist in one location-and perhaps not eventhere.The medical record serves a number of otherpurposes. For example, it is used to provide documenta-tion that a patient was seen or a test was performed inorder that the clinician can obtain reimbursement by aninsurance company or government agency. It is also usedas a medium of communication among different clini-cians as well as ancillary professionals (i.e., nurses, phys-ical therapists, and respiratory therapists) who see thepatient. In addition, the medical record serves as a legalrecord in the event of claims due to malpractice or occu-pational injury. Finally, it also is used to abstract data formedical research.In recent years, the medical record has taken on new

    purposes. With the growing concern over the cost andquality of medical care, it serves as the basis for qualityassurance by health care organizations, insurance com-panies and other payors, and the federal government.This activity has taken on increasing importance withthe growth of managed care, which requires that clinicaldecisions be scientifically justified as well as cost-effective. Another more recent area of use has been indecision support, where clinicians are reminded aboutthe efficacy of or need for tests, or are warned about po-

  • 8/13/2019 EMR Jasis 95 Emr


    tential drug interactions. All of these newer purposes aregreatly enhanced by the EMR.The Paper-Based Medical Record

    Despite the documented benefits of the EMR, mostclinical encounters are still recorded by hand in a paperrecord. This is not without reason. Dick and Steen( 199 1) note that the traditional paper record is still useddue to its familiarity to users, portability, ease of record-ing soft or subjective findings, and its browsabilityfor non-complex patients. There is also a sense of owner-ship of paper records, due to their being only one copy,which increases the sense of their security (although itwill be noted below that this may be a false sense ofsecurity).Nonetheless, there are many problems with paper-based medical records. The first is that the record canonly be used in one place at one time. This is a problemfor patients with complex medical problems, who in-teract with numerous specialists, nurses, physical thera-pists, etc. Another problem is that paper records can bevery disorganized. Not only can they be fragmentedacross different physician offices and hospitals, as notedabove, but the record at each location itself can often bedisorganized, with little overall summary. In most paperrecords, pages are added to the record as they are gener-ated chronologically, making the viewing of summarizeddata over time quite difficult.Another problem with the paper record is incomplete-ness. In an analysis of U.S. Army outpatient clinics, Tufoand Speidel ( 197 1) found as many as 20% of charts hadmissing information, such as laboratory data and radiol-ogy reports, a finding consistent with more recent obser-vations ( Korpman & Lincoln, 1988; Romm & Putnam,1981).A final problem with the paper-based record is secu-rity and confidentiality. Although usually ascribed as aproblem of the EMR, there are attributes of the paperrecord that increase its vulnerability to access by non-privileged outsiders. Its difficulty in duplication leads toa great deal of photocopying and faxing among providersand institutions. Furthermore, abstractions of the paperrecord are stored in large databases, such as those of theMedical Information Bureau, which are maintained byhealth insurance companies to prevent fraud but containmedical information of more than 12 million Americans( Rothfeder, 1992).Additional Challenges for the New Health Care Era

    The problems of the paper-based record listed aboveare magnified in this new era of health care fueled bymanaged care. Managed care systems, typified by healthmaintenance organizations ( HMOs), act as both healthcare insurer and provider. The traditional indemnity in-surer operates in a fee-for-service environment where the

    providers are reimbursed based on charges billed. Themanaged care organization, on the other hand, is pro-vided a fixed fee per patient, which gives it the incentiveto keep patients healthy and provide care cost-effectively. The benefits and drawbacks of managed careare beyond the scope of this article, but suffice it to saythat managed care will play an increasingly larger rolein the provision of American health care, and successfulmanaged care organizations require cost efficiency,which in turn requires effective management of informa-tion.There are many areas where improved informationmanagement can aid managed care organizations. Forexample, because many of these organizations providecomprehensive health care for their subscribers, theyneed effective communication between different provid-ers, ancillary staff, and/or hospitals. Likewise, they needto determine whether those groups are providing cost-effective care and not ordering excessive laboratory tests,x-rays, etc. Finally, these organizations often try to con-trol the use of expensive medications and substitute theiruse with cheaper but equally effective ones.Even outside the context of managed care, the effi-ciencies in communication and cost will be desired bysociety in general as the cost of health care continues toconsume larger proportions of the gross domestic prod-uct. All payors, even traditional fee-for-service insurancecompanies, are beginning to require it.Implementations of the Electronic Medical Record

    Although the complete EMR does not currently exist,portions of the medical record have been computerizedfor many years. The most heavily computerized aspectsare the administrative and financial portions. On theclinical side, the most common computerized functionhas been the reporting of laboratory results, usuallymade easier with the installation of automated equip-ment for laboratory specimen testing. As more informa-tion recording functions become computerized (i.e., cli-nician dictations transcribed into word processingsystems), i ncreasing proporti ons of the record are com-puterized as well.Dick and Steen note that all comprehensive EMRsshare several common traits ( Dick & Steen, 199 1). First,they all contain large data dictionaries that define theircontents. Second, all data are stamped wi th time anddate so that the record becomes a permanent chronolog-ical history of the patients care. Third, the systems havethe capability to display data in flexible ways, such asflowsheets and graphical views. Finally, they have aquery tool for research and other purposes.A number of successful EMR implementations havebeen in place for decades. One of the earliest ambulatoryc