If you ask the question whether we need electronic medical records, the answer is going to be a resounding ‘Yes,’ said Bradley F. Marple, MD, Professor and Vice Chairman of the Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas. It’s the trend, it’s going to be at the forefront of pay for performance, and it’s one of those outcome measures that will be required of all of us.
D. Thomas Upchurch, MD, Co-Founder and Chief Medical Director of AllMeds, Inc., Oak Ridge, Tenn., which provides specialty-specific electronic medical record (EMR) and practice management systems to practicing physicians, noted that the general advantages of electronic medical records (EMR) include immediate, efficient, and documented communication. Dr. Upchurch, an otolaryngologist, used EMR in his office for seven years before ceasing his practice two years ago. It makes for much smoother and quieter office management operations, he said.
What are the advantages and disadvantages for implementing EMR, specifically as they relate to communicating directly with patients?
Advantages and Drawbacks of Electronic Communications
Valley ENT, PC, in Scottsdale, Ariz., uses a variety of forms of electronic communications, including instant messaging, standard e-mail, and a less stringent messaging component with their EMR, said George E. Smaistrla Jr., the practice’s Chief Executive Officer.
With each system and methodology, we have had to enforce protocols with the employees. Employees today are very proficient in instant messaging and the use of ‘slang’ or text abbreviations, especially given the common use of text messaging on phones, he said. Although the phrase CUL8R (i.e., See you later) or LOL (i.e., laugh out loud) makes sense when using a cell phone or instant messaging, any message that is ultimately transferred into a medical record must be coherent and easily read.
Second, said Mr. Smaistrla, staff members sometimes write fast, send fast-and read later. Responses are often not well thought out or well thought through (think ‘flaming emails’). This phenomenon has obliged Mr. Smaistrla and his colleagues to retrain their younger staff in proper messaging techniques. The good news is that a younger workforce quickly adapts and prefers these alternative means of communications, so they quickly adopt them.
Another positive outcome, said Mr. Smaistrla, is that our physicians like the idea of accessing issues and messages from anywhere, not just when they return to the office. Downtime between surgical cases means staff questions about patient issues can be addressed to simplify life and better manage time in the clinic.
Technology can also help staff communicate with each other. Most of the Valley ENT physicians use smart devices such as BlackBerrys and Palm Treos. This allows staff members to reach them more quickly, post updates, and even notify them of urgent messages or activities in the EMR. After-hours answering services appreciate this as well, said Mr. Smaistrla, because they can relay messages with call-back numbers easily and efficiently.
Dr. Marple thought there are many conveniences to using EMR with patients, including many kinds of routine monitoring of a medical problem or disease. Situations that come to mind, he said, might be that of monitoring hemoglobin A1Cs in patients with diabetes, or following coagulation profiles in patients who are being treated with Coumadin. In those cases, specific information regarding patient data are entered regularly into the EMR and patients can access that information for the purposes of monitoring their disease using a tool such as MyChart. (See https://mychart.utsouthwestern.edu/mychart .)
Other advantages include being able to address the questions patients may have later that are not wrapped up in the person-to-person medical encounter, and keeping track of tests and follow-up. This provides a nice, convenient way to close that loop-to provide the patient with all the information that was generated from an examination, said Dr. Marple. And in some cases, if used appropriately, it might even save the patient a second appointment.
Patients who are younger and Internet-savvy, especially, seek methods to communicate with Valley ENT via these alternative means, said Mr. Smaistrla. We have had countless patients and parents ask for the ability to request script refills, address problems, seek results from diagnostic tests, and make appointments without having to call the office, and we are attempting to address these needs too.
They are currently creating an Internet portal that allows them to do this. They have also chosen the technique of requiring the patient or other responsible party to create a login account, and then upon verification, assign a unique password that maintains HIPAA-required confidentiality. This means that patients will be able to make appointments in selected slots, retrieve test results, and route questions to nurses and doctors. This isn’t a cheap solution, Mr. Smaistrla pointed out. We will have to spend about $10,000 to design and implement this. We are also concerned that the questions posed in e-mails may become excessive, so this will have to be closely monitored. But we also see this is as a time-saver, which might ease staffing demands.
Confidentiality and Sensitive Information Release
Certainly the two biggest risk issues to watch for when using EMR with patients pertain to confidentiality and the appropriateness of information that is transmitted to patients. Confidentiality and HIPAA compliance just cannot be overemphasized, said Dr. Marple. It seems as if we are secure in e-mailing, but in fact, we’re not.
Many e-mail servers, he explained, especially those offsite from a practice, are not confidential. A physician communicating sensitive information to a patient may be exposing that patient to other onlookers. But among the many available EMR software systems, some have a feature that provides for competent, secure communication. We use a system called EPIC on our campus and a piece of that is a confidential way for physicians to communicate with their patients, which is called MyChart, said Dr. Marple. It gives patients access to their medical records in a confidential fashion. It also allows for release of reports and lab values to patients-for instance, a patient could have access to their hemoglobin A1C for diabetes so the patient could monitor that in real time, long-term. It also provides an opportunity communicate electronically with a patient.
Automatic settings may be particularly problematic. I order a radiologic procedure on the patient, said Dr. Marple, posing a hypothetical situation. The results that come to me frequently within the report include some normal variant that might appear alarming to the patient. In MyChart, I can affix a little note and forward it to the patient that says, ‘nothing to worry about; this is a normal examination.’
Physicians investigating EMR systems need to consider all the possible clinical scenarios through which they could be tripped up by premature release of information, Dr. Marple said. And that’s not to say we want to hold back information, but sometimes we need to be there in our supportive role as information is being relayed to patients.
Premature release of information to patients is especially troublesome in the case of delivering bad news. Particularly when a physician is in a rush, he said, if we’re not careful the way we relay information, patients may get the wrong impression. If I’m not careful in my explanations, that little aberrancy in a test that I think is relatively normal may be very worrisome to the patient.
Dr. Marple, who is on boards of the American Rhinologic Society and American Academy of Otolaryngic Allergy, and is active within the American Academy of Otolaryngology-Head and Neck Surgery and the AMA, among other organizations, said that physicians who are implementing these systems frequently voice concern that patients receiving these results electronically will be left to interpret their own medical results.
Now, with that being said, he added, we have to recall that the patient’s medical records belong to the patient, not to us, and the clinical interpretation is something that we, as health care professionals, provide for our patients. Sometimes these electronic communications are a little less personal.
He offered a classic example of communicating a bad outcome-a new cancer diagnosis-to a patient via this medium. One might ask, is it appropriate to release a biopsy result of a malignant melanoma to a patient via a confidential electronic means without having appropriate counseling in place? Although Dr. Marple would agree that no physician would think that it is appropriate, if you’re not very careful in how you set up your systems, there can be automatic release of information that is unintentional. And if for some reason?I’m at the AMA meeting, for instance?and that information becomes prematurely released to a patient, that could be quite a catastrophic blow emotionally.?
Decisions on what kind of system to implement involve a choice of interface, acquiring certification of confidentiality, cost, and addressing the specific needs of the practice.
Dr. Marple’s general observation has been that the more complex the medical system, the more complex the EMR interfaces with other electronic information systems. Integrated patient billing, procedural coding, automated prescriptions, and radiology are only a few of the systems that can be integrated into an EMR. Interfacing is a key consideration for the growth of EMR, he said. To answer that need, the American Health Information Community (AHIC) is a certification organization, endorsed by the US Department of Health and Human Services, which certifies EMRs based on their ability to interface with other information systems.
Because this technology is in its infancy, many systems don’t communicate with each other, said Dr. Marple, and if you are a small single-specialty clinic, say maybe a private practice with just one or maybe three practitioners, your requirements for EMR are going to be different than they would be if you are a large campus with several thousand physicians. The flexibility, versatility, and all the bells and whistles vary based upon the product.
For instance, he said, his practice is completely electronic with regard to the storage of radiographic information. If I get a CT scan of a patient’s paranasal sinuses, we don’t have hard films anymore; we look that up on the computer. And each time you have something separate or you have another hospital or clinic involved, there needs to be another interface to efficiently link all that information.
What are the costs of implementing an electronic system? It depends largely on the user base and the level of sophistication, said Mr. Smaistrla. Depending on one’s practice management system, EMR, or existing IT hardware, the costs may be extremely small. In our setting, we spent $15,000 for software and hardware improvements, which was quite affordable. This amounted to about $10,000 for the software and $5,000 for a hardware-based virtual private network (VPN) device. If you have to add a network server, costs will jump even more.
Advice for Newcomers to EMR
According to an analysis of the medical literature, as of 2005, only one in four medical practices were using EMR systems in the United States.1,2,3 What would our interviewees advise their colleagues about getting on the bandwagon with EMR? I would be very wary about just asking somebody else about it, said Dr. Marple, and I would certainly shop around and get several bids.
Perhaps the best and most cost-effective way to start up with EMR, and that which would be the best investment of time and resources, would be to consult an expert who can ask you about your needs and desires of the practice and the practitioners, and can begin to educate you about what to look for and the product variables from which to choose.
Go slowly is the best tip I can offer, said Mr. Smaistrla, and leverage existing systems to their capacity. When we had sufficient controls in place for less strict EMR messaging in place, we then added office email using an exchange server. We then extended remote access for a VPN and this stretched capacity even more.
If you are looking into implementing a system, examine the matter of checks and balances so no automatic default transmissions will oppose what you would want to happen, said Dr. Marple. You need to think of all the worst-case scenarios.
- Jha AK, Ferris TG, Donelan K, et al. How common are electronic health records in the United States? A summary of the evidence. Health Aff Web exclusive, October 11, 2006.
- Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc 1998;5:104-111.
- Waldren SE, Kibbe DC. Email in clinical care. BMJ 2004;329:E325-E326.
©2007 The Triological Society