What is all this business about electronic health records?
Traditionally, physicians and other health care providers have documented patient encounters by writing illegible notes in medical charts. If the patient encounter is is with a medical specialist or is an emergency room or urgent care clinic visit, and if the patient has a primary care doctor, a typed letter or report is typically written and sent to the primary care doctor , and maybe also to the patient. When patients are admitted to hospital, admission, progress notes, and discharge summaries are generally hand-written but typically the admission and discharge notes are also dictated and typed for the medical record and possibly for the referring physician. So, depending on a patient’s medical history (i.e., rare vs. frequent hospitalizations), traditional hospital charts range from small folders to giant multi-volume tomes of data, mostly unreadable (and often unliftable) except for the typed notes and printed forms with test results. Most physicians with office practices maintain so-called “shadow charts” on each of their patients which typically contain illegible clinic notes and correspondence, much of which does not appear in the hospital chart- this is complicated since some patients receive care at several different hospitals so that a complete record of their hospitalizations is not available in one location. Get the big picture? In the past (and in the present for many physicians) patient health care records, particularly those in physicians’ offices are not particularly useful when it comes to allowing communication among physicians and other health care providers about patients’ health history.
Welcome to the age of computers, databases, and the internet
Over the past 5-10 years there has been a slow but steady revolution in the way medical records are constructed and used. Electronic health records (EHRs) are being used increasingly in routine patient care. There are 2 main forms, the stand-alone personal health record (PHR) and the so-called integrated PHR. The former is typically an electronic record used within a single hospital or hospital/clinic system. For example, a group practice might have a system that allows generation of an electronic note for each patient encounter that becomes part of the institutional patient record database. The information is collected either from dictations that are transcribed and entered in to the database or keyed in directly by the health care provider. The institution might generate a typed note that can be placed in the clinic shadow chart, sent to a referring physician, etc., or not generate any paper unless there is a specific need; once the information is entered into the database it can be retrieved easily whenever needed.
The second form, the integrated PHR, allows access to the patients’ data by health care providers or other, including patients who are not part of the individual institution. Theoretically, this model would allow a physican in a Seattle emergency room treating a patient from St. Louis to have rapid access via the internet to the patient’s medical records.
These 2 forms of EHRs are discussed in an excellent article recently published in the New England Journal of Medicine (Pang PC, Lee TH. Your Doctors Office or the Internet? Two Paths to Personal Health Records. N Eng J Med 2009;360:1276-8). If this subject is of interest to you (it should be), I recommend that you check it out.
My experience with EHRs
The other day there was an excellent article in the New York Times about EHRs (NYT April 11, 2009). The article was entitled “A rural medical practice moves to digital records, and the doctor is pleased,” and written by Milt Freudenheim. The article describes the move to EHRs in a rural Kansas solo medical practice and how beneficial this has been in terms of improving patient care and also in terms of the physician’s satisfaction. The article alos discussed the “down” side of EHRs- the cost; it is difficult to set up even a simple system for less than $40,000-$50,000. Reading this article made me think about my own experience with EHRs.
My institution, the University of Missouri Health Sciences Center introduced EHRs 6 or 7 years ago. Prior to EHRs I maintained shadow charts on my patients and dictated clinic notes which were transcribed and typed copies were sent to the hospital chart, to me, and to whomever I indicated needed a copy of the note. Hospital admission and discharge notes were dictated, transcribed, and copies were placed in the hospital chart, and sent to me for my shadow chart, and to whomever was listed in the dictation (e.g., the primary care doctor). When we switched to EHRs, all dictated notes were transcribed, entered into the the institution database and typed copies distributed to whomever was listed in the dictation. I could dictate my clinic notes from any telephone, in town or out of town and I could also look up any dictated notes from any computer with internet access. All laboratory test results were also entered into the database. Recently, efforts are being made to have physicians and other health car providers at our institution type their own notes which are entered directly into the database with no paper copies unless distribution is requested for another physician, or perhaps, the patient. Thus, the institution has made major efforts to more or less eliminate the transcription process and all paper records, including shadow charts. Obviously, this approach requires that computers be available throughout the hospital and clinics and within the clinics, in examination rooms.
So, am I on board with the revolution?
First, in general, I love EHRs. I love being able to tap into the database whenever I want to and from wherever I might be as long as I have access to the internet. This greatly simplifies patient care ,and I think, improves it appreciably. During a patient’s clinic visit, I can quickly look up a laboratory test result that I had not seen earlier. If I can’t find the patient’s shadow chart, not to worry, as I can quickly get at whatever information I need such as the last clinic visit note. I can also communicate more easily with other health care providers regarding the patient. For example, I recently received an e-mail from a former patient who was requesting medical records for an upcoming clinic visit with a new doctor in another city. The visit was to be in 2 days. I was out of town. So, I went on the internet, got into our patient database, reviewed the patient’s medical records, typed a summary for the new physician (an old friend of mine as it turned out) , including pertinent laboratory test results and sent the information by e-mail to the physician and to the patient. I also had my office fax copies of the medical records from my shadow chart. Who wouldn’t love EHRs?
Now, it would have been even nicer if we had in place an integrated EHR (or PHR as it is usually called) so that the new physician could just tap into the database himself and get whatever information he needed, but what we have in place now is the next best thing. The big problem at the moment with integrated PHRs is the issue of confidentiality; how does one prevent unauthorized access to patient health data? Even within my institution there is concern about use of e-mails with patients as being “insecure” communications, which is a legitimate concern.
Yes, I truly love the electronic revolution with e-mails and EHRs except for one small thing. I am still not sold on the idea of paperless offices and the use of computers WHILE interacting with patients. It will take some doing to persuade me that shadow charts are not still useful. I can’t actually remember when I last looked at a hospital chart, but I still rely on my shadow charts. When I see a patient I want to talk to them, look them in the eyes, and not have my eyes focused on the computer. I think my opposition to this new approach to patient care is legitimate if not less expensive for the institution (if one does not need to transcribe a note and if one doesn’t need to generate “paper,” it definitely saves money. Maybe I’m just old fashioned?
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