In the first installment of this discussion, I talked about the challenges facing database professionals and others with respect to healthcare data integration. In this post I’ll talk about the first part of the problem: a lack of adoption of the required technologies and/or methodologies. I’ll also describe when an electronic health record really isn’t.
We’ve all seen it; it is still the de facto standard of medical documentation. You sit in the reception area and the nurse or clerk gathers the initial information: demographic information to confirm your identity, insurance information, the reason for your visit, and metrics such as your blood pressure, pulse, or weight. He also asks you about any medications you’re taking and any other physicians you are currently seeing, which you provide from memory as best you can. This information is written down on your chart, a collection of dead trees that is then hung on the door. You wait for a while and the doctor arrives, writing still more information on your ever-growing paper chart. She writes your prescriptions on yet another piece of paper. You’re then dismissed with a stack of papers – your prescriptions, a carbon of your hand-written visit record and diagnosis, a scribbled referral to a specialist, and a business-card size reminder for your next appointment.
Several concerns come to mind in this scenario. If the patient forgets to remind the physician about another medication she’s taking, the doctor fails to note a stated medical condition, if a portion of the paper record is lost or destroyed (or simply illegible), or if a required piece of information is not collected, the system can break down. Further, recording information in this manner will restrict significantly the ability to index, search, aggregate, or mine the data. What if the provider wants to find out how many patients required hospitalization after presenting with a particular symptom? Perhaps ER staff need to know if an unconscious patient has a particular allergy or medical condition? Somebody’s going to be surfing through paperwork to answer these questions. The most frightening part about that is that those answers are often needed immediately, and no dead-tree storage system can provide that.
What’s The Problem?
The problem is not a technological one, nor is it new. So why does it still exist? Simply put, this archaic way of storing and accessing healthcare records usually works, and it has for decades. Patients usually receive the care they need, providers almost always get paid, and most of the time the records workflow does not negatively impact patient safety.
I’ve encountered a small number of physicians and other healthcare professionals who prefer to keep things the way they are. Paper records work fine, so why change? On the other side of the fence are those who see value in collecting and analyzing patient data, individually and in the aggregate, to improve patient care and overall process flow. Support of EHR implementation is especially prevalent in the under-40 crowd, though there are exceptions that transcend every age demographic.
The chief arguments against implementing an EHR system are that 1) it’s expensive, and 2) it won’t bring much additional value. The first point is true; EHR systems don’t come cheaply, and usually require significant soft costs as well (staff retraining and system upkeep among them). To the second argument, there is rarely an immediate return on investment, but the long-term return can be significant. With a fully electronic record system, staffing needs may be reduced because sending a patient’s health records to another provider requires only a few clicks and keystrokes rather than the time-consuming manual retrieval of paper and film. Billing and collections can be streamlined by eliminating multiple points of data entry, further reducing workload and the potential for human error. Patient safety is enhanced by allowing the rapid analysis of a patient’s data when making treatment or medication decisions.
Electronic Health Records that really aren’t
In my experience, there are few shops that are fully reliant on paper. Healthcare providers often use a hybrid approach, tracking information such as patient demographics and scheduling with a modern database application but retaining the paper-based workflow of documenting diagnoses, procedures, and prescriptions. Others modify this workflow and scan in the paper records after the fact, sometimes calling this an EHR. Paper-to-electronic scanning solves a few of the problems (storage space and portability among them), but other challenges still remain. To research a patient’s treatment history, someone still has to place eyes on each document in the person’s record, and it’s almost impossible to aggregate this information. Even though these records are stored in an electronic form, they do NOT represent a true EHR system. Scanning of hand-written paper records is a half-step toward the solution, but doesn’t cure the problems at hand.
Finally realizing the importance of electronic health records, the federal government has mandated and is in the process of defining rules which will govern EHR adoption and usage. Although they won’t be forced to use a true EHR system, providers will see their payments from Medicare slashed significantly if they fail to comply. Further, there are significant short-term financial incentives for providers who implement EHR systems by the 2011 deadline.
In the next 20 years, we’ll see the use of paper healthcare documentation come to an end; shops that work on paper will be as common as crank-handle cash registers. Government regulations and consumer demand will bring on a level of data availability and transparency not currently available in healthcare data; patients will have immediate, on-demand access to their own health records, and more importantly, will have the ability to research aggregated healthcare data to help take charge of their own treatment and evaluate the quality of their providers. Further, healthcare outlets will be required to share information with one another for the benefit of all patients (I’ll talk more about sharing data in the future).
To Be Continued
In my next post in this series, I’ll discuss the sharing of healthcare data, including the challenges it presents and the possibilities it brings along.