EMRs – Electronic Medical Records

    EMRs

    Remember the days before email and internet?  A chat group was a group of people sitting in the same room talking about something.  A bite was something we went for when it was lunch time.  MySpace was something you weren’t welcomed in, and we had to buy a whole CD just to get the 2 songs we liked on it.  Greeting cards were signed and delivered by the mail man, and stamps were less than the cost of a Coke.  Times have changed, and computers are everywhere.  They are in our grocery stores, our homes, the libraries, our elementary schools, police cars, and our children are proficient at using them.  We have come to accept that at some point, our personal information will be stored somewhere in an undefined location, and we’ve become rather complacent by the idea.  So why not computerize the health care industry at the point of service, and not just for insurance claims and billing?

    EMR is the latest and greatest breakthrough promising to change the way we administer health care to patients all over our nation, and our world.  It has taken what nurses and doctors used to do by hand and transferred it into electronic form.  “Advances in electronic medical record (EMR) technology have made it possible for the EMR to replace many functions of the traditional paper chart, and use of EMR systems promises significant advances in patient care” (Makoul, Curry, & Tang, 2001).  Just like most anything else, when computers become the operating source of data, actions become expedited resulting in saved time and ease.  Additional bonuses in the medical world can include the relieved burden of reading the notoriously bad handwriting of doctors, misreading medications, and the ability to perform a more thorough assessment of each individual patient.

    Doctors Makoul, Curry, and Tang did research regarding the implementation of EMR at a general internal medicine practice at an academic medical center.  They were trying to establish if the physicians accomplished effectively communicating with their patients while using the EMR and the comparison between using paper charting and EMR charting.  The results showed that the doctors that used the EMR were more active in clarifying information, encouraging questions, and making sure the charting was complete by the end of the interaction.  “A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patient’s agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patient’s life)” (Makoul, Curry, & Tang, 2001).  Both sets of doctors focused more on the completion of the charts (whether paper or EMR) than on the interactions with the patient.  Also noteworthy was the time spent on initial visits (where the doctor and patient meet to discuss medical concerns for the first time).  The EMR doctors spent an average 37.5% longer than those who used the paper charts (Makoul, Curry, & Tang, 2001).  The overall results of this study yielded the following summary:  “An EMR system may enhance the ability of physicians to complete information intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified” (Makoul, Curry, & Tang, 2001).

    Another study performed by Boonstra and Broekhuis cited several issues found by doctors as well.  Financial concerns were a major concern for many doctors and included initial cost, high on-going costs, uncertainty of financial return (in relation to the expense of purchasing the EMR), and the common lack of financial resources (Boonstra & Broekhuis, 2010).  Another struggle faced by physicians was the technical aspect of installing and utilizing an EMR. Some of the highlights included the difficulty of use, the time and expense of adequate training for doctors and staff, limitations of systems, and lack of customizability and reliability.  Another big concern was that not all EMRs are made to be interactive with others, and there is no standardization between various EMRs.  This could be a complication if other hospitals and doctor offices are not compatible with other medical offices.  This would result in having to enter data all over again for each new office (Boonstra & Broekhuis, 2010).

    Time is money is just about any business, and the medical field is certainly no exception.  Just as noted in the Makoul, Curry, and Tang study, Boonstra and Broekhuis found that many doctors report an increase in time per patient when using the EMR and thus choose to use paper charting when directly interacting with the patient.  Then, later, the staff will take the paper notes and then enter them onto the EMR, thus creating a system of redundancy and potential for missed data or data entry errors.  This would be in combination with the need to transfer already existing patient files onto the EMR.

    Another finding included, “With the implementation of EMRs, physicians are concerned about the loss of their control of patient information and working processes since these data will be shared with and assessed by others” (Boonstra and Broekhuis, 2010).  Unfortunately, very few studies have included or considered this dilemma.

    Perhaps the biggest concerns relate to social and legal implications.  Doctors express concerns related to interference in the patient-doctor relationship, lack of management support, and privacy and security concerns.  Today’s society has become hyper vigilant I regards to their personal information and who can access it and share it.  There is concern that utilizing EMRs can potentiate the violation of HIPAA.

    According to the U.S. Department of Health and Human Services, Health Plans, most health care providers, and Health Care Clearing Houses are obligated to protect the privacy of patients and their individual medical records.  “health care providers” includes nurses, doctors, x-ray technicians, and even the cleaning crew who cleans the hospital rooms.  For example, as a nurse, if my Aunt Betty is admitted to my hospital on the medical/surgical floor, and I work in L&D, I cannot legally access her information unless I am somehow involved in her care at that facility on my floor.  Thus in that example, I cannot (legally, not necessarily logistically) access her medical file.  If she were on my floor and provided care for her, I would be within my rights to access her file.  If my mother called me the next day to ask how Aunt Betty is doing, I would have to explain that I cannot even confirm or deny she is receiving treatment at my facility, and certainly could divulge no information to my mother regarding Aunt Betty’s health status.  Doing so could result in the loss of my license to practice nursing.  We cannot discuss medical information regarding our patient with other nurses or medical personnel who are not directly caring for the patient without risk of violating HIPAA and losing our licenses.  It is a very serious issue, so implementing EMRs creates a feeling of concern in regards to patient privacy.  The only time medical staff can discuss medical records is when care is being coordinated, for insurance reimbursement, with family (ONLY WITH PATIENT PERMISSION), to protect public health (reporting flu or bacterial meningitis), and making required reports to law enforcement.

    EMRs have yet to be proven highly beneficial in many studies, so the benefits are inconclusive at best.  There are numerous concerns for patients as well as for medical personnel.  The relationship between a doctor or a nurse and the patient is one of confidence, trust, and reliability.  It often takes a considerable amount of effort to establish a trusting relationship, but it can be broken so easily.  Many patients (especially the elderly population – who happens to be the largest consumer of medical care) do not feel comfortable discussing the medical history and problems with a nurse that is typing away on a computer.  It is distracting for the nurse and uncomfortable for the patient to be entering data on a computer while discussing very personal details involving health.

    It is not just the elderly that have this fear.  Many people have reasons to be suspicious or concerned about their privacy and the use of EMRs during interactions in the hospital and medical facilities.  People who use or abuse illegal drugs or alcohol will be far more reluctant to be honest about their usage.  This could have a life or death consequence due to the potential for drug interactions and possible withdrawal effects during a procedure.  Women are also vulnerable.  Pregnancy is often a time of complete medical reviews and often can take place within the presence of their husbands, boyfriends, mothers, etc.  Information related to previous abortions, STD exposures, previous deliveries, and adoption placements may not be disclosed due to fear that their spouse or family member may find out.  So, even if the spouse isn’t present during the interview, knowing the information is going onto a computer, patients will often not disclose those aspects of their history.  Everyone understands how easy it is to access data from a computer, and it can be an intimidating factor for a patient.

    Further, from the position of the medical care giver, there is concern.  It is easy to become over-dependant on computers and take their digital data to be the most complete and accurate because after all, it’s “on the computer.”  Yet, mistakes or omissions made during data entry to can be detrimental to the patient and set the caregiver up for lawsuits.   Oversights and errors such as not listing allergies, having incorrect blood types, and not listing all medications can all have serious consequences if the caregiver does not ask the patient again about these issues.  Patients often become irritated at having to answer the same questions multiple times, but generally, this is why these questions become so repetitive. It is the care giver trying their best not to make a mistake.

    EMRs often can include the patient’s current list of medications taken daily along with medications being ordered by the doctor (particularly during a hospital stay).  The nurse accesses this chart frequently to prepare and administer medications.  It is not unusual that the medication record and the doctor’s order do not match, and thus the doctor is called for clarification.  But what if the nurse became complacent and accepted the medication record as accurate without questioning?  It IS “on the computer,” so surely it must be correct.  A little known fact is that the nurse is the person responsible in cases of medication administration.  If the doctor prescribed a medication that is incorrect for the patient’s diagnosis, prescribed a medication the patient is allergic to, or prescribed an incorrect dose, the nurse that administered the medication as ordered will be the one to face the lawsuit should it result in injury or death.  The person giving the medication is responsible for what is going into the patient, there are no exceptions.  It is critical that the information is correct, even more important that the nurse question EVERYTHING the computer reflects.

    The potential for privacy violations is considerable.  Yes, there are individuals who spend their days doing their best to access private information which includes medical records.  Some are quite successful, but it is not the norm.  But, what is more likely is while a patient is in the hospital, a nurse or doctor will access their EMR on a portable computer device (often referred to as COWs or WOWs – computers on wheels or workstations on wheels).  It is common that a caregiver will log onto the system, access the patient’s medical records and begin charting.  Inevitably, the nurse or doctor is called away from charting to perform a role-related task and will accidentally leave the computer logged on with that file left in view.  This is a direct violation of privacy and HIPAA.  Any person (medical or not) could easily access that information, and just that quick, privacy has been violated.

    Computer technology is generally a good thing, even in the medical profession.  But, for EMRs to be beneficial, they have to be affordable, time-saving, customizable, secure, and easy to use.  Unfortunately, not many hospitals or doctor offices want to be the one to lead the technological revolution in healthcare because it is risky.  Many patients are not completely comfortable with the idea of their very personal medical histories being stored on computers and easily accessible from most any location (including homes of doctors).  We have become increasingly complacent with technology and computers being used in just about every facet of our lives.  However, we generally have control of what data we put on computers and with whom we choose to share that information.  With EMRs, patients do not have that control.  Above all, allowing computers to dominate the medical records risks placing the relationships between people secondary to making sure all the boxes are checked and the information is entered into the right place on the EMR.  Human relations and the ability to provide compassion, attentive listening, and critical thinking is what makes the medical profession unique and those seeking medical service so vulnerable.  We must be careful to not forget the human element, and not trade our compassion and humanness for the sake of technology.

     

    References

    Makoul, G., Curry, R., & Tang, P. (Nov-Dec. 2001). The use of electronic medical records;   Communication patterns in outpatient encounters. Journal of the American Medical Informatics Association. 8(6): 610-615.

    Boonstra, A. & Broekhuis, M. (2010, August). Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Services Research 2010, 10:231 doi:10.1186/1472-6963-10-231

    U.S. Department of Health & Human Services. (2012, May  24). Health information privacy. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

     

    **TruXter Interjection**
    The issues I see with Electronic Medical Records is the inevitable. While we are trying to avoid the delay of record retrieval from some far off warehouse, and cut the costs of  getting X-rays taken a second time, and running another charge to your insurance.  The doctors and hospitals are supposed to not carry the bills over to the patient, but we all know that in the end the bill will be put on the customers.
    We will be paying for storage of our own medical records, being held responsible for the cost of our own information. To take the weight off of doctors and cut their costs. When in reality, we know that if the doctor himself has that many patients, he must be doing something right, and his bank isn’t whimpering a bit. Just remember, the reason you have insurance at all, is because the doctor costs a lot. A whole lot. but the cost of bandwidth and storage is going to be their arguement. and we will not be the ones to fund an attorney to fight the cost being pushed on to us.

    Now back to removing the storage facilities and warehouses. People work those places. In fact, I have worked in those places.
    What happens when the staff that works there is unemployed? The majority of the staff at the facility i worked in, were on welfare of some sort, and to keep their welfare, they had to put in a few hours with the temp agency. What happens to that guy when his job is removed?

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