EMR use in the ED: Scant data connect EMRs with positive outcomes, but experts advise managers, providers to consider long-term benefits
Take steps to minimize distractions, maintain patient-provider communications
Few would take issue with the notion that there is vast potential for electronic medical records (EMRs) to improve emergency care and boost efficiency. However, there is also little argument that such benefits have yet to be significantly realized in many EDs. Not only is there ample grumbling over the time it takes to sort through the often massive EMR files, but experts warn that use of EMRs can actually diminish physician-patient communications if providers are not careful. Further, much of the outcomes data that have been collected with regard to patients seeking care in the ED suggest that EMRs are associated with only marginal benefits at best.
For example, investigators looking at the impact of EMRs at three Minneapolis, MN-based EDs found mixed results.1 The researchers conducted a retrospective study looking at quality and efficiency measures for more than 5,000 patients with heart failure (HF) who presented to one of three EDs for care over a 19-month period between June 1, 2006 and December 31, 2007.
"We needed to focus on a specific disease in order to make any measurements," explains Donald Connelly, MD, PhD, the lead author of the study and director, Health Informatics Division, Masonic Cancer Center, University of Minnesota, Minneapolis, MN. "We focused on HF because it is very common, especially in the elderly, and it is a cause of frequent hospitalizations."
What's more, patients with HF tend to have plenty of health care records available from ambulatory care settings as well as hospitals. There are typically frequent encounters with the health care system, says Connelly. "If EMRs were going to have a positive impact, we thought HF patients appearing in the ED would be a good, specific [group] to study."
Patients were categorized as "internal" if their health information was included in an EMR and "external" if there was no information in an EMR. The researchers hypothesized that patients who had an existing EMR would ultimately receive better quality and more efficient care than patients who did not have an EMR. And this type of evidence was, indeed, observed at two of the three EDs. In these settings, patients with an EMR were less likely to die if hospitalized, they underwent fewer laboratory tests, and they were prescribed fewer medicines during their ED visit. Also, at one of these two sites, HF patients with EMRs were less likely to be hospitalized than HF patients without an EMR.
However, at the third ED site, there were no positive differences observed between HF patients who had an EMR and those who did not. In fact, the patients with EMRs at the third site experienced a longer length of stay (LOS) in the ED.
Consider the complexity involved
While the study concluded that EMRs were associated with some positive benefits, Connelly observes that there is plenty of room for improvement in the functionality of EMRs. "I think it would be fair to call them second-generation systems because at least they are now somewhat standardized," he says. However, he points out that there is too much redundancy in today's EMRs, noting that in some cases, providers keep copying the same information into the EMR, making it difficult and tedious to separate the valuable information from the chaff.
"You may have a 50-page document, but only three of the pages are unique," he says. "Electronic medical records are here to stay, but they have got to be improved so that they are much more usable and shown to have a positive impact."
Shaun Grannis, MD, MS, FAAFP, an associate professor of family medicine at Indiana University School of Medicine, and director of the Indiana Center of Excellence in Public Health Informatics in Indianapolis, IN, one of four Centers for Disease Control-funded public health informatics centers in the country, suggests that part of the problem is that most health care information technology systems are built to satisfy particular administrative, billing, and regulatory needs. "In doing that, they actually often further encumber, rather than unencumber, providers," he says. "Some people say EMR stands for empty medical record system because a lot of information generated for a particular patient in the course of care is not necessarily generated at the point of care."
Nonetheless, Grannis is a strong advocate of EMR systems, and he anticipates that they will improve greatly in the next few years in the same way that computer operating systems have gradually become more user-friendly and visually appealing to the end-user. "The delivery of care is an incredibly complex process, so it is hard to simplify or even model the work flows of such complex processes in electronic software," he says. "We are in the Model T days, if not the horse and buggy days of end-user friendly clinical applications, and there is a great deal of work to do." (Also, see story on study showing that people tend to seek emergency care at multiple sites over time, below.)
Take steps to minimize distractions
While the EMRs themselves need to be improved, experts suggest that ED providers also need to take steps to ensure that the way they are using EMRs enhances rather than detracts from provider-patient communications. "If you rely too much on the medical record as your source of information, as opposed to asking the patient directly, you may miss out on important information," explains Ann O'Malley, MD, MPH, a senior health researcher at the Center for Studying Health System Change in Washington, DC, who has studied this issue.2 "People just assume that because something is in the record and it is electronic that it must be correct."
Instead, it is important to take the time to validate what is in the record with patients, says O'Malley. For example, an EMR may indicate that a patient is taking a particular medication at a particular dose, but when you talk to the patient, you may find that he or she never filled that prescription, or some other provider may have changed it, she explains. "That is a very obvious thing that frequently has to be reconciled," she says. "You can't assume that because it is listed in the EMR that it reflects reality."
Also, an EMR can never be a substitute for human interactions, observes O'Malley. "If a patient is experiencing some sort of depression or anxiety, you've really got to sit down and see that patient in person to pick up on those signs," she says. "You need to see their body language and see their affect or facial expressions. There is so much that you get from the human interaction that you cannot get from the record."
To ensure that EMRs don't get in the way of human interactions, O'Malley advises health care administrators and providers to think about how to strategically position computer monitors so that clinicians can maintain eye contact with patients even while reviewing or adding information to an EMR. Alternatively, she suggests using electronic tablets to track and record such data.
Another useful strategy is to engage the patient in the information that you are reviewing on the EMR screen, explains O'Malley. This is not always possible in an emergency situation, but when patients are alert and able to communicate, it can be helpful to show patients how problems such as diabetes can be related or impacted by other problems, such as high blood pressure or underlying heart problems, she says. "When you show them their record and you pull them into the screen, sometimes it helps patients feel less disjointed and less alienated by the computer screen," she adds.
O'Malley stresses that health care organizations need to establish clear guidelines about the use of electronic tools in the presence of patients in order to help providers minimize distractions. For example, she notes that while instant messaging can be a helpful tool for exchanging information with clinical staff, it can also be distracting to receive an instant message while interacting with a patient. "You need to learn as systems and organizations, as well as individuals and providers, how to manage those distractions," she says.
Mark Frisse, MD, MBA, MSc, a professor of biomedical informatics at the Vanderbilt Center for Better Health in Nashville, TN, suggests that while it is clear that EMRs can diminish physician-patient interactions and create distractions that impact decision-making if improperly used, he points out that it is important to consider the value that an investment of time on an EMR can have on subsequent visits, whether they involve ED visits or visits to another provider. "The key here is not to think of a single interaction but to ask how, over a span of time, a community of disparate clinicians investing time in efficient EMRs can contribute to overall [care]," he says. "People don't get to that point very much."
O'Malley calls on clinicians to demand from vendors EMR tools that can be used for clinical care, as opposed to tools that have a primary focus on documentation for billing. "This is going to require higher-level changes in payment incentives so that we are not always just thinking about how to code in a way to maximize payment from health plans, but rather how do we reward clinicians for providing high quality care and how can we design records to support that care."
References
- Connelly D, Park Y-T, Du J, et al. The impact of electronic health records on care of heart failure patients in the emergency room. J Am Med Inform Assoc. 2011 Nov. 9. [Epub ahead of print].
- O'Malley A, Cohen G, Grossman J. Electronic medical records and communication with patients and other clinicians: Are we talking less? Issue Brief No. 131, April 2010, Center for Studying Health System Change, Washington, DC.
Sources
- Donald Connelly, Director, Health Informatics Division, Masonic Cancer Center, University of Minnesota, Minneapolis, MN. E-mail: don.umn.edu.
- Mark Frisse, MD, MBA, MSc, Professor, Biomedical Informatics, Vanderbilt Center for Better Health, Nashville, TN. E-mail: [email protected].
- Shaun Grannis, MD, MS, Associate Professor of Family Medicine, Indiana University School of Medicine, Indianapolis, IN, and Director, Indiana Center of Excellence in Public Health Informatics, Indianapolis, IN. E-mail: [email protected].
- Ann O'Malley, MD, MPH, Senior Health Researcher, Center for Studying Health System Change, Washington, DC. E-mail: [email protected].
Study: Patients seek emergency care at multiple sites There is new evidence that, contrary to commonly held views, patients tend to seek emergency care at multiple sites over a period of time. A study by researchers at the Regenstrief Institute at the Indiana University (IU) School of Medicine in Indianapolis, IN, looked at patterns of emergency care across the entire state over a three-year period. They found that 40% of ED visits were by patients who visited more than one ED.1 The researchers found that roughly 2.8 million patients generated 7.4 million ED visits over the three-year period. And while the high volume didn't raise too many eyebrows, the fact that the number of visits per patient ranged from one to 385 was unexpected, according to the research team. What's more, the researchers report that nearly all of the EDs in Indiana shared patients with nearly every other ED. While the findings pertain to Indiana, investigators point out that patterns of ED use are likely to be similar in other states since there is nothing unusual about emergency care in Indiana. Consequently, the research offers important considerations for health planners and policy makers, explains Shaun Grannis, MD, MS, a co-author of the study, an associate professor of family medicine at IU School of Medicine, and director of the Indiana Center of Excellence in Public Health Informatics in Indianapolis, IN, one of four Centers for Disease Control-funded public health informatics centers in the country. "A general assumption that most folks make when contemplating how to design and operate health care systems is that patients are generally locked into a single health care system, a single entity," says Grannis. "The results we found suggest that is not the case — at least for ED care where four out of every 10 ED visits in Indiana were by patients who had data in somebody else's system." Grannis adds that the findings directly challenge the notion that patients are "somehow captive to a particular health care organization," and they clearly have implications for medical homes, accountable care organizations, and similar models. "We need to be mindful of these types of phenomena when we think about how to incentivize, build, and pay for health care in the future." Certainly, ED leaders should clearly have a voice in these developments, but Grannis suggests they should also play an active role in making sure that their departments have access to the kind of clinical information they need to provide optimal care. "Particularly if you have patients like we have found who travel to different EDs, you need to be engaged in an initiative that is able to develop a coalition among hospitals and health care systems in your region to create a common, shared medical record, like what we have in Indiana, that allows us to see what we discovered in this study," he says, noting that Regenstrief built one of the country's first health information exchanges. Reference
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