Summit session outlines where medical record systems are going
By CYNTHIA DRAKE
Healthcare InfoTech Contributing Writer
SAN DIEGO, California "Womb to tomb" health records are the end goal. Americans would like to have their health records available to any caregiver, anywhere, any time. On the other hand, Americans don’t want to risk loss of privacy. Does the dentist need access to mental health records? Does the pharmacist need to see a woman's obstetrical history? These are only a few of the issues surrounding the nation’s move to electronic health records now also characterized as "telehealth."
What’s the best system for full, constant availability of health information? How will all the current medical record systems achieve intraoperability? How will today’s paper-based hospital medical records evolve into this electronic health record? A Summit Conference on Electronic Patient Record Strategies, sponsored by the Medical Records Institute (MRI; Newton, Massachusetts), held here earlier this month, helped attendees address some of these questions.
Contrary to what the general public may think, medical records systems in the U.S. and in other countries are less computerized far less, in many cases than many other service sectors, including banking and airlines, for example. More than 95% of all medical records are still in paper format. As a result, according to MRI:
• 22% to 38% of the time when a caregiver sees a patient, the relevant medical record information is not available.
• When other physicians need to be consulted, there is confusion in format, as well as the meaning of terms and codes. This can result in missing or misinterpreted information.
• When reviewing a lengthy medical record, the caregiver lacks to the ability to quickly find previous medications, treatments a lack of consistent indexing methods.
For these and other reasons, the Medical Records Institute believes that electronic health records (EHR) will be the nucleus of the emerging healthcare information infrastructure. This infrastructure is being encouraged by the Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996. According to C, Peter Waegemann, executive director of MRI, "The evolution from today’s primarily paper medical histories to a true electronic health record (EHR) will be a long-term journey. It will require continuous sharing of new concepts, approaches, experiences and technologies to nurture this evolution." Industry experts don’t expect electronic health records to be available before 2002.
Waegemann described the electronic health record as a computer-stored collection of health information about one person, linked by a person identifier. Whether the best way to carry around that information is a "smart card" or encryption in web-based XML language is not yet clear. But first, the healthcare delivery industry must evolve through several stages of increasingly sophisticated computerization.
At the completion of the five stages of computerization for patient information systems, the U.S. can arrive at a true electronic health record. According to MRI, stages 1 and 2 have been achieved, but stages 3 through 5 will not be possible for some time. What’s the holdup? Issues of security, confidentiality; implementation of HIPAA; making current department computer programs (legacies) able to cross-communicate (intraoperability) within the enterprise and with other healthcare delivery sites.
In stage 1, Automated Medical Records, paper-based medical records are still in use. As much as 50% of patient information is computer-generated and stored in the form of computer printouts within the medical record. In some European countries, many general practitioners use the computer for patient information but don’t always comply with signature requirements or intraoperability between other GPs and hospitals.
Some hospitals are experimenting with more ad vanced applications of automation, such as nursing/bedside computing, the creation of an enterprisewide master patient index, the linkage of various parts into an enterprisewide network, the development of interface engines and operational imaging. All of these hospital automation projects are parallel to the paper-based patient record.
In stage 2, Computerized Medical Records, providers are looking for ways to digitize the medical record, address a shortage of storage space and to create an electronically available record. This can be accomplished by scanning paper-based documents into a document imaging systems. Documents are created on paper, then indexed and scanned into a system that offers the same functions as paper-based systems.
Based on optical storage technologies, users of these document imaging systems count them successful when: caregivers like and use the system (due to instant retrieval); indexing is adequate; and it fits into the overall strategy of moving toward an electronic medical record system. For these systems to be part of the computerized medical record system, patient information must be scanned as one image. Document imaging methods such as optical character recognition (OCR) or intelligent character recognition (ICR) scan line by line and allow the operator to change or delete text. These would not meet stage 2 guidelines, because the user can modify the information.
In Stage 3, Electronic Medical Records, complete documents with their legal attributes such as date and signature are converted as a whole from the paper medium to computer. The enterprise controls patient identification, included information, retention period, security and functionality. The EMR, unlike a traditional medical record, has structure defined by computer processes rather than time-sequenced encounter documents. Security features such as access control, electronic signatures, data integrity, auditing, constant availability all must be addressed.
In stage 4, Electronic Patient Record Systems (also called Computer-based Patient Record Systems), the record contains all healthcare-related information concerning one person. This should include dentists, traditional caregivers, psychotherapists, podiatrists, etc. from more than one provider or enterprise. If acceptable to the patient, it may be a longitudinal record. One hurdle for this stage is the development of a national or international system of identifying all patients individually.
In stage 5, the Electronic Health Record, a more comprehensive collection is made of an individual’s health information. It includes wellness information, behavioral activities. It is maintained through cooperation between the individual who controls his or her own health information and the various caregivers. Existing software programs for families are the first step toward the electronic health record. As the country evolves toward a healthcare information infrastructure and integrates it into the broader national information infrastructure, benefits could include better population research, lower costs of care and better outcomes and bench marks.
But, intraoperability is still a major hurdle. Within an enterprise and certainly between enterprises, intraoperability demands a common language. Waegemann predicts this will occur through middleware. A chain of existing independent software packages (patient identification, diagnostic services, interventional services, post-en counter services, etc.) used within the enterprise will be held together by a common architecture. The architecture could be a web-based language that would encourage communication with other enterprises.
MRI believes electronic medical record systems won’t be widely available prior to 2005, although smaller, regional applications may be up before 2000 like the family recordkeeping application from the Health Information Institute (Bellevue, WA).
Progress made on a global basis will be sporadic due to different healthcare systems and resources.
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