Electronic medical records are becoming more and more prevalent in the hospital environment. Physicians meet this reality with mixed feelings; they do want the increased availability of patient history, but they also want a system that takes the same amount of time or less to complete their documentation. The electronic medical record also creates challenges for management of the records for the hospital system.
When the medical record is a voluminous pile of paper, the ownership of the record is fairly straightforward, he who possesses the pile of paper is the owner of that, and any data originated elsewhere is in the pile as a copy and not the original data set. Now with the electronic version, it becomes less clear, especially, if we consider the future of interfacing hospital records and physician office records. If we have a medical record showing the hospital visit information, and electronically linked to that is the history and physical from the surgeon’s office prior to admission, then who owns the history and physical?
If the patient presents at the hospital to obtain a copy of their medical record; then, you can only give them what you own. If the history and physical are required but obtained via electronic harvesting, then the system it was harvested from should be the legal owner and responsible for recordkeeping. What does this mean for the patient? They will have to go to multiple locations to obtain copies of the complete record that is available at the hospital but not owned by that facility.
(Veronesi, 1999) The next challenge is controlling access to medical records. When you have the pile of paper, it can be contained in the nursing station or locked in the medical records department, and access is very obvious. If an unknown person enters the nursing station, and retrieves your patient’s chart, the care team would challenge the access rights of that person. This would occur whether or not the person is an employee. Now, consider the same situation with an employee sitting at a computer terminal on the 2nd floor doing his job.
He can easily look up his neighbor’s record on 5th floor without anyone in that area knowing the record has been reviewed or that their patient’s rights have been violated. (Veronesi, 1999) The security of the medical record is a juggling act between access for appropriate and timely medical evaluation and treatment and protecting patient privacy and HIPAA compliance. All physicians on staff should have access to any medical record of any patient, not just their patient or patients they are treating in the facility. This is because they are a doctor first and provider second.
It does not matter if it is his patient or that of his competition. If the patient in room 15 is in crisis and the physician is present, he will treat and need access to all of the data to safely do so. A variety of tools are applied, such as, audit trail analysis, unique identifiers for each user, time-sensitive password systems, encryption, and access restrictions based on job type. This has also created a new profession of information technology security specialists in healthcare, which includes the security of hand held computer systems, whether hospital or physician owned, with access to the medical record.
(Ebell & Rovner, 2008) Security in the electronic media is less physical barrier and observation, such as locked doors and security cameras; while this is important, the new system can be accessed remotely without ever entering the physical building where the data is housed. Network monitoring and access control while reviewing audit trails are now required. Also, we need triggers, such as for an insurance clerk reviewing the radiology records for one patient who has not accessed that area of the medical record for any other patient in the last three months.
The other side of security is protection of the data by proper backup and off-site storage of backups to enable the data to be recovered in the event of a physical destruction of the equipment at the site by human or natural disaster. (Litwak, 2005) What are the benefits the electronic medical record provides to the facility in the delivery of patient care and record keeping? The facility receives major benefits in the ability to mine data from an electronic system, as tagged fields can be automatically extracted.
This can be anything from average reimbursement for patient with a certain DRG code, such as CHF patients and use of beta blocker on discharge to repeat hospitalization rates. (Anonymous, 2006) Other data such as door to balloon time for myocardial infarction patients to ensure maximizing patient care and compliance with the suggestions from the American College of Cardiology (American College of Cardiology [ACC], n. d. ) can be data mined or manually recorded and the data entered manually into a spreadsheet for analysis and reporting.
The other aspect of data mining is from external requests for information for research. The electronic medical record can provide an opportunity for this kind of data mining while stripping the patient identifying items off the record, such as patient name, medical record number, social security and basic demographics. Care must be taken in the level of access granted to these requests to prevent the inadvertent access to patient records in violation of the HIPAA rules. (Federal goverment, n. d.).
The inventory systems at hospitals have been computer managed for many years and are one way that the facilities try to save money based on utilization review and managing contracts that are favorable to the products and amounts used. With the medical record becoming electronic, the data mining options can now be expanded to see how much it costs for each procedure type. Such as, what is the average cost of a diagnostic only cardiac catheterization or a percutaneous coronary intervention with the placement of one, two, or three stents. The obvious next step is to see what the average cost per procedure is by physician. If Dr.
Jones consistently spends 25% less than Dr. Smith for the same procedure types, the cost savings can be increased by understanding what is different and guide Dr. Smith to those practices as long as they are safe for the patient. What the physician wants from the electronic medical record is twofold; first he wants to spend no more time and hopefully, less than they do with paper records and dictation, as well as consistent, dependable, and quick access to historical records. Physician structured reporting forms require the physician to use data entry skills to complete a record from a structured format, sometime called charting by exception.
The system puts forth a normal record for an echocardiogram, and the physician selects the mitral valve and changes it to mild regurgitation from the normal statement that was there as the only change. The rest of the normal statements are correct for this patient, and he then confirms the record. This is an example of a good report with minimal data entry by the physician and streamlining. However, the resistance from physicians is that it is cookie cutter medicine, and it takes away their individual intellect from the patient report they are doing.
It does require some computer skills which are common in the under-50 group but still a challenge for retirement age physicians. (GE Healthcare [GEHC], n. d. ) Quick access to medical records is a primary benefit for patient care delivery for the physician and the care team. Access must be consistent, quick, and easy for the clinician. We have experienced the pain of virus attack, worms, and denial of service attacks through either our home computers or at least through the media showing us the pain of losing all of your data or pictures of the family.
It seems that we don’t hear of the issues experienced by health care systems with these dangers. The biggest argument for keeping a microfilm or paper back up copy is when a hospital has to take the system off the network to purge a virus. We have to find a way to avoid ever having to take these records offline, regardless of the status of the network. Electronic medical records are of obvious benefit for rapid access to patient histories during a critical event in that patient’s life; however, that must be tendered with the security of the data and consistency of access.
Electronic medical records are here to stay and expanding rapidly. The next generation of information sharing will be the networking of hospital and community based records for the complete medical record, and the availabilty immediately and consistently.
References American College of Cardiology (n. d. ). PCI Registry. Retrieved May 1, 2009, from https://www. ncdr. com/webncdr/DefaultCathPCI. aspx Anonymous (2006). Beta-blockage in CHF: from contraindication to indication. European Heart Journal, 8(8), 19-27. Ebell, M. , & Rovner, D. (2008). Information in the palm of your hand. The Journal of Family Practice, 49(3), 243-251.
Federal goverment (n. d. ). The health insurance portability and accountability act of 1996 (HIPAA) privacy rule . Retrieved May 1, 2009, from The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule GE Healthcare (n. d. ). EMR physician reporting. Retrieved May 1, 2009, from http://www. gehealthcare. com/usen/img_info_systems/cvit_index. html Litwak, P. (2005). HIPAA requires limiting physical access to information. Alcoholism & Drug Weekly, 1(2), 27-29. Veronesi, J. F. (1999). Ethical issues in computerized medical records. Critical Care Nursing Quarterly, 3(22), 75-80.