July 2008

ELECTRONIC MEDICAL RECORDS A luxury or a necessity?

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The Indian medical fraternity, especially the unorganised private sector, has been over the years quite unconcerned about preservation of patient records. I know it is a very aggressive statement, but it is a fact and every clinician will admit to this even if not on the podium, surely in private.

The organised sector, though, is much better at records preservation systems, although most of these facilities are centered on manual preservation of records carrying with them all the inherent difficulties of the same.

I still remember the days when we, as postgraduates use to throng the Medical Record Office (MRO) to get some retrospective data on some disease entity. Be it for the thesis or for case reports or case studies. The kind of difficulties, which we faced were enormous. Today after 20 years, as I look at the effort my postgraduate students have to put in for similar work, I see that the status of records is quite the same in most institutes.

The question to be raised here is whether the times allow us to remain stagnant in this way? The answer is a clear no, simply because demands on the Indian healthcare scene are rising.

The Changing Scenario

Following are some of the factors which warrant accountability and also demand unambiguous, formatted, self explanatory and secured clinical data preservation:

  • The clinician today is legally more accountable. In view of the growing consumeristic trends, the records need to be accurate and formatted, since the patient, the consumer in this service industry is becoming more demanding, aware and conscious of what is due to him.
  • The arrival of health insurance will also make it mandatory for the records to be strictly in a more standardised format and be based on protocols.
  • The arrival of quality and accreditation on the scene makes a demand on clinician and healthcare organisation to have preservation of records on strict format.
  • We are now on the threshold of the very demanding sector of medical tourism. Naturally the records need to be in tune with international norms, plus they should be accessible on the web.
  • Globalisation of healthcare makes it a must to match international standards.
  • Advent and propagation of telemedicine demand the data transfer and hence reliable technological back ups for data preservation.
  • Moreover there is a need for precise statistical retrieval in current era to promote research, be it molecular, genetic or even simple registry based statistical.
  • Corporatisation of healthcare scene demands statistical retrieval be it for financial or professional reasons at a touch of a button on the keyboard.
  • Medical teaching and education in Institutes is awakening to the needs of Clinical research and the aptitude is taking shape amongst the new generation of Medicos. They will need easy access and retrieval of patient records.

If one surveys the level of automation across various industry verticals, healthcare industry is among the least automated. Studies have estimated that the healthcare industry as a whole is almost 20 years behind the rest of the industries in terms of automation of various processes. Whatever advances were readily accepted by Indian medical fraternity were mainly in Medical Electronics and Instrumentation. However, in terms of automated preservation of records, the acceptance of technology and/or systems has been very slow.

Electronic Medical Record (EMR) or Electronic Health Record (EHR) by definition is a patient's medical record in an electronic format, accessible by computers on a network for the primary purpose of providing healthcare and health-related services.

Even in the west, the acceptance of EMR has been quite slow and gradual. In fact, 2006 has been termed as a record year for EMR adoptation at large in the US. The reasons why the West adopted it faster than India is perhaps based on certain specific factors dominating the Western healthcare scene, such as increased patient awareness, new government initiatives encouraging EMR, high penetration of computers, new product innovations, economic pressures on healthcare organizations and increased legal compulsions for greater accountability and well-maintained records.

Advantages of EMR System

In India, costs and limitations in software, hardware and networking technologies has made EMR difficult to implement, especially in small, budget-conscious and multi-location healthcare organisations.

The term EMR is often used loosely to include even the demographics, which are usually included in simple patient management software. However, a true EMR system such as the 21st Century EMR, must technically be capable of handling the certain functions as a prerequisite, such as, that an EMR system must capture the entire patient data on a fixed format at the point of care. It should ideally be using a database, rules engine and knowledge base as the primary source of information; it should allow software integration of the EMR data with other data such as billing, practice management, laboratory, imaging and pharmacy systems. This saves time for the clinician by reducing double data entry in the other systems, while also ensuring the quality of data throughout the entire system.

A good EMR system has the capability of providing Clinical Decision Support (CDS), helping in developing and implementing a provider's decision making. Since, the capture of clinical and demographic data is in a pre-determined format, it allows several clinical attributes to the data processing like, clinical decision-making by accessing a rules engine to provide alerts, reminders, clinical protocols, coding assistance etc.

Further, since the system integrates with other components of hospital information and management systems like Lab, Pharmacy and Imaging, it can provide real-time data to the provider in its entirety, right from symptomatology, signs and investigations, thereby facilitating better clinical decision-making.

It also allows access to large amounts of data quickly, permitting to analyse and report data quickly and easily, including clinical statistics analysis, population health, and other reports.

Along with the above, basic attributes, a true EMR system should do justice to the following requirements:

  • Patient Charting
  • Order Communication Systems often referred to as Computerised Physician Order Entry (CPOE)
  • Document/Image Management
  • Patient Portal, which enable patients to access their health record from any computer with a secure Internet connection, from anywhere in the world
  • Statistics and Reporting

Data Entry

Data entry has always been one of the greatest inhibitions for clinicians. It was perceived that the data entry needed to propagate the EMR systems, is difficult, time consuming, needless and involves a lot of attention. This is also feared to take away the attention from a patient's disease and diagnosis. But one would realise within a short training period that these apprehensions are totally unfounded.
The ease with which information is entered into the EMR is directly proportionate to the length of the learning curve and the time required achieving the benefits that an EMR provides. Today's technology advancements have made things further simpler. There are many different ways that data can be entered into an EMR. One may use one or more or any combination of methods depending upon the type of system one chooses. The crucial point is selecting the right method, for the right people or job. The available options for data entry are:

  • Keyboard/touch screen – Basic Patient Data
  • Mouse/touch screens – History, Findings, Diagnosis, etc.
  • E Pens on Touch screen Monitor.
  • Cable Communications – DICOM, Non-DICOM Instrument and Digital Camera Data
  • Video Signal Transfer – Slit Lamp, Fundus Camera
  • Voice Storage/Transcription – Unusual Letters, Non-Standard Findings

Costs

Installing a comprehensive EMR system can be expensive. A system that will give the healthcare organisation all of the information available now in paper, including imaging capability, drawing, voice storage, instrument interfaces, visual fields, etc. is going to require a networked system in each examination lane. A computer will also be required at each location in the premises where information is collected from a patient or reviewed by a physician or staff member (screening rooms, visual field rooms, etc.)

The typical cost is factored by a) Hardware, Software, Training, Installation and System Customisation and b) The costing per workstation (computer) in a LAN (local area network) or on the basis of WAN (wide area network).

However, cost is a relative factor and one can get the returns on investment, if one takes into account the following clinical and patient benefits achieved in a comprehensive EMR System:

  • Electronic Medical Record (EMR) improve Clinical Decision Making (CDS). The CDS capabilities of EMR systems are a well known attribute. However, this is achieved only at the ultimate or penultimate implementation stage. 21st Century EMR is packed with many tools to help doctors make better decisions. These range from diagnosis to prescription generation to treatment plan recommendations.
  • Adverse Drug Events (ADEs) are responsible for 2.1 million injuries and 100,000 deaths every year. With medication dictionaries, the clinicians get ADE alerts, generic drug recommendations and dosage recommendations.
  • The EMR is also capable of making treatment recommendations based on a patient's diagnosis. (e.g. care guidelines from Milliman)
  • Health maintenance reminders help keep the doctor and his/her staff updated on what treatments or checkups the patient is due for, through an automatic alert or report in the EMR. These alerts can even be sent to mobiles and PDAs.
  • Due to the integration of data about the patient through the integration of external sources (labs, pharmacies, imaging centers, hospitals) the provider is informed and explained decisions quickly.
  • Enhanced documentation will protect both the patient and the clinician from complications in the future.
  • 21st Century EMR comes equipped with a security administration module enabling administrators to manage access to patient records only through user permission.
  • Most academic advantage of having patient documentation computerised is the ability to extrapolate data for reporting capabilities. This becomes very useful for research reports, statistics, health maintenance reminders, drug recalls and patient marketing.
  • Web consultations are a possibility, being able to access patient data from anywhere in the world via a secure connection even allows the doctor to conduct web consultations or generate reports from home. Telemedicine and Teleradiology is just one example of these extensions. The recent launch of Google Health and Microsoft's HealthVault portals is an indication of things to come.
  • Health maintenance reminders that can be automatically generated from an EMR system also contribute to providing improved patient care.

Conclusion

Overall, Electronic Medical Records enhance patient care, however, the benefit may be difficult to quantify at this stage. But with the increasing role of Health Insurance as payers, the increasing demand from informed patents for transparency and the ever increasing use of technology like Telemedicine etc. in the delivery of healthcare, I would recommend to healthcare providers to look at EMR adoption not from a ROI (Return on Investment) perspective but as a TINA (there is no alternative) factor!

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