This AM, I heard part of an NPR report on a survey conducted about patients’ attitudes about EHRs.  I didn’t catch all of the report but I gathered that people were more or less skeptical that EHRs would save much money.  Frankly, I was surprised that anyone asked the general public what it thought about EHRs since few people have had any real experience with EHRs.  I would consider the results of the study more or less useless.  EHRs are fabulous (as I have discussed earlier) but are not often used in the U.S.  Who cares of they save any money, if they markedly improve patient care?  No question- setting up and using EHRs cost more than the traditional approach to medical records- mostly illegible physician notes and reams of nicely typed hospital record sheets with illegible notes and nicely typed laboratory test results.

How to use EHRs effectively

It’s nearly driving me crazy that we (physicians and patients) have not figured out how to use EHRs effectively.  Let me suggest the following: assign every person to a “medical home” or MH .  The MH could be a large hospital/clinic system with outlying clinics or whatever.  Anyway, if every person in the U.S. had a primary care doctor or nurse or whatever, who was affiliated with the MH, the primary care provider and the patient could jointly take  responsibility to update the EHR which is maintained by the MH.  Thus. at least within the MH each patient’s EHR would be easily accessed by authorized providers or the patient.

How do I know we can do this?

Most of us already have electronic records maintained at our local banks, national investiment banks (e.g., Vangard), and utility providers.  These providers have a databases that we can access if we have user names and passwords.  We can do the same with EHRs.  Finding a way for all providers to have access to all EHRs is a bit trickier but that’s far less important than the first step- a medical home for every person.  I assure all of you that we can do it.  It will be a wondrous thing.

The subject of EHRs must be a really “hot” topic these days since in almost any medical journal or newspaper I pick up there is something about EHRs.  For example, yesterday’s New York Times (Saturday, April 18, 2009) had an article in the “Patient Money” section entitled “Some caveats about keeping your own electronic health records,” written by Walecia Konrad.  The article was a well written general discussion about  patient-controlled EHRs (these are often called personal EHRs).  It was clear from the article that just as U.S. hospitals are a long way from wide-spread use of EHRs, the same is true for personal EHRs.  In fact, the article contained an interview with Dr. Ashish Jha, who was the lead author of the New England Journal of Medicine article I wrote about yesterday.  That study surveyed U.S. acute care hospitals and found that fewer than 10% were using EHRs in any meaningful way and fewer than 2% that switched over entirely to EHRs.  In the newspaper article, there was even a photo of Dr. Jha (it’s always nice to put a face with a name), as well as a quote: “we’ve got a long way to go before we get there,” referring to universal use of patient-controlled online health records that can be shared with physicians.

Anyway, I am yet to be convinced that patients should bother just yet with trying to put together a detailed EHR.  It would be much easier if we had a real health care system and in that system every patient had a primary care provider (physician or nurse practitioner or whomever) who had a comprehensive EHR on every patient in the practice.  Of course that EHR would need to have data from specialists the patient might have seen, results of all laboratory tests performed, and so forth.  In this way, all the patient would need is easy access to his or her EHR, which eliminates the need for the patient to do much of anything to have a personal EHR.  I believe that in the long run, that’s how EMRs will work.  In the short run, everything is up in the air, largely blown about by the $17 billion the U.S. Congress just budgeted to stimulate the development of EHRs.

A few days ago (April 15, 2009), I posted an entry about EHRs.  I should have waited because that very afternoon what should appear in my mailbox but  the most recent issue of the New England Journal of Medicine with an article about U.S. hospitals and EMRs.  The article was written by A.K Jha and others and entitled “Use of electronic health records in U.S. hospitals.”  The authors all of whom are from either Boston or Washington, D.C., surveyed use of EHRs in all acute care  general medical and surgical hospitals in the U.S. that are members of the American Hospital Association (AHA).  The survey was conducted between March and September 2008 and included almost 5000 hospitals.  The investigators received responses from 3049 hospitals or about 63% of those sent surveys.  They found that only 1.5% of the hospitals had  comprehensive electronic-records systems (comprehensive meant that all of the hospital’s clinical units were using EHRs).  Another 7.6% of hospitals had  basic systems, meaning that at least one clinical unit was using EHRs.  Even a greater percentage of reporting hospitals had in place at least parts of  EHR systems such as use of EHRs for results of laboratory and radiological reports.  Surprisingly, the perceived barriers to adoption of comprehensive EHRs were similar in those hospitals that had implemented at least some EHRs and those that had not: initial costs; maintenance costs; uncertain return on investment; inadequate IT staff; and physician resistance.  By far the greatest perceived barrier was inadequate capital to purchase an EHR system.  The investigators concluded that among the hospitals that participated in the study, although few hospitals had even  basic EHR systems in place, many hospitals had parts of  systems in place and that governmental policymakers hoping to promote wider use of EHRs should focus on financial support, interoperability, and training of IT support staff.

What is the U.S. government doing to promote widespread use of EHRs?

The U.S. government has taken big steps to “push” the medical community into the use of EHRs.  If you are interested in the subject, I strongly recommend you check out 2 recent articles in the New England Journal of Medicine.  The first, written by Kenneth Mandl and Isaac Kohane was entitled “No small change for the health information economy.”  The second, written by David Blumenthal was entitled “Stimulating the adoption of health information technology.”  Both articles discuss the recent measures taken by the U.S. government to promote use of EHRs through the American Recovery and Reinvestment Act of 2009.  The Act uses both carrots and sticks by offering both rewards in the way of cash payments and punishments in the way of lower reimbursements for patient care services depending on whether institutions and medical practitioners get with it (i.e., implement or do not implement EHR systems).

I must say that I think the U.S. government has perhaps taken on too much now in terms of the rapidity with which the “required” changes must be implemented.  I am particularly concerned that we (i.e, health care administrators, physicians, the general public) don’t yet have a medical care system in the U.S. that could be reasonably considered anything close to a real system and that we haven’t really figured out exactly what we want our EHR system to be as part of the overll not yet existent health care system.  It will be very interesting to see if the “money on the table” helps to sort these things out or if we end up with a bigger mess than we have already.

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?