Myths and realities of electronic medical records: 9 vital functions combine to create comprehensive EMR - Medical Records

Physician Executive, Jan-Feb, 2002 by Robert Hodge

IS THE ELECTRONIC medical record (EMR) a myth?

A myth, according to the dictionary, is a traditional story of historical events that helps people understand their world or understand a practice, belief or natural phenomenon.

A mythical story is what I often hear when physicians talk about their EMR. They explain the history of their EMR and justify why it meets, or fails to meet, their needs.

Rather than describing the functionality of their EMR, all too often physicians say the system was purchased in the past, some applications were added and it doesn't work well.

Major problems that physicians often experience with the EMR are:

* Lack of sufficient functionality

* Poor performance

* Lack of access to the computer

* Lack of training (typing and computer skills)

Functionality is key

Although the global purpose of EMR is to improve patient care, the myth is perpetrated when functions are added without an overall focus on patient care.

Computers are supposed to make our lives easier, but many clinicians may doubt that as they struggle to use their EMR system.

How can a physician executive sort through the myth to assess what type of EMR the organization currently has and plan how to make it useful for clinicians?

Let's examine a model to assess the functionality of the EMR. We'll focus mainly on the clinician's use of the EMR in direct patient care, keeping in mind that physicians from specialties such as pathology and radiology demand a much different type of functionality.

One way to appreciate the multi-functionality of the EMR is to focus on a concept developed at the University of Missouri Health Care called the Patient Care Cycle. The cycle lists what a patient experiences from start to finish for a clinical encounter.

A patient in the outpatient clinic takes 12 steps to receive care:

1. Awareness of services available

2. Request for service

3. Registration

4. Creation of visit

5. Patient arrival

6. Interaction with nursing/clinical support

7. Interaction with provider

8. Formulation of impression/plan

9. Documentation of services provided

10. Implementation of plan

11. Ancillaries/follow-up

12. Billing

Look how some of these steps play out for a patient going to a facility with a fully functional EMR.

The patient:

* Learns about the services provided from the organization's Web site.

* Makes an appointment on the secure site.

* Submits the necessary registration information on the site.

* Arrives at the clinic and has the appointment confirmed at the front desk.

* Is seen by a nurse who accesses the patient record and updates the patient's medications, allergies and other data elements stored in the EMR. In addition, the patient's vital signs are entered directly into the record.

* Is examined by the provider who looks at the record to view previous clinical notes, and consult reports and laboratory results.

After the patient is assessed, the provider:

* Formulates the impression and plan.

* Implements the plan that includes prescribing medications and ordering therapies, laboratory tests and X-rays.

* Enters the E/M and ICD9 codes for billing.

* Enters the information directly into the EMR with a choice of typing, clicking with a mouse or using voice recognition software.

Other functions of the EMR may also come into play.

After updating the record, the provider may send a copy of the report to the referring physician. Also, while prescribing a medication, a warning may appear in the EMR of a possible drug interaction. While coding, a notification may let the provider know that some documentation is missing to justify that level of care.

The EMR is not just an electronic copy of the paper record. Added functionality can make it a very useful tool.

Evaluating EMR systems

To evaluate an EMR system or prioritize future development of the EMR, it's helpful to categorize the functions. The nine functions of an EMR are:

1. View

2. Manage

3. Document

4. Share

5. Bill

6. Remind

7. Comply

8. Gather

9. Educate

View

This is the electronic version of the paper chart and the first priority for getting clinicians to use the computer to find information. Unless 95 percent of data is available to view, the EMR will languish as an added burden rather than as a useful patient care tool.

The major challenge for this function is getting the data systems to talk to each other to exchange information. This is done by setting up interfaces and can take much effort and time.

Examples of viewable types of data include:

* Demographic information

* Clinical documents including notes, operative procedures, nursing notes and problem lists

* Laboratory information including chemistry, hematology and pathology

* Radiological reports including X-rays, MRIs and CAT scans

* Other lab information on arterial blood gases, pulmonary function tests, EEG's and endoscopies

* Scheduling information

* Billing data (although, sometimes this is contained in a separate system with an interface needed to exchange information)