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Electronic Medical Records

Obamacare by mandate, providing Medicare Advantage and Medicaid to uninsured Americans as an entitlement for the poor will enrich insurance companies and Big Pharma and bankrupt our economy.

Medical Informatics

Medical Computing

ObamaCare

Healthcare Reform

Roger H Strube, MD

Electronic Medical Records - Chaos at Light Speed.

 

Patient medical records have made great advances since medicine became more of a science after 1900. Most “doctors” had little or no college or medical school training. At that turn of the century, physicians were little more than snake oil salesmen and skilled barbers. The axiom, “Je g pansay et Dieu le guarist" ("I treated him, but God healed him") attributed to Ambroise Paré, a barber-surgeon considered the father of modern surgery, has held from his time in the early 1500s. Most healing occurred in spite of treatment. Medical records were virtually nonexistent. Records kept at the time were very abbreviated accounting balance sheets used to manage the “business” of snake oil sales and Barbery.

As medicine became more science based and more complex, patient information record keeping became more important. In academia, these records were critical for the accumulation and advancement of medical science but essentially were no part of the everyday practice of medicine. However, for the general practitioner and surgeon, accounting for transactions remained the most important function of medical records. Practitioners needed to follow the money.

Early in the last century, before WW2, surgical techniques became more refined as knowledge of physiology and pharmacology increased and skill of those practicing anesthesia progressed. Nevertheless, few effective medications were available and the family doctor was as more a counselor than a healer. Prior to the discovery of insulin by Dr Frederich Banting, a Canadian surgeon, in 1921, and mass production of insulin by Eli Lily Company a few years later, Type I diabetes was a death sentence. The family doctor could do little but console the family.

I started solo practice in 1973. I completely remodeled a vacant medical office located above a drug store that could have been in a Norman Rockwell painting. The office had been empty for many years following the death of the physician who practiced there. During the remodeling, I found an old 3’ by 5” card holder box as debris was being removed. The box was at least twenty years old. Inside were financial records that had to be the only record of patient visits. These records must have been used to track a patient’s visit, diagnosis, treatment and fee for the service. The fees were one or two dollars. I destroyed these very old records.

To this day, medical records kept by most physicians and many hospitals have not changed significantly compared to the 3” x 5” cards I found in my first office. Patient medical records continue to focus on billing for a service or procedure. The paper chart is larger and contains more stuff. It may appear more organized, containing a complete history and physical exam, a problem list, a medication and allergy list, paper copies of consultations, and copies of all laboratory and X-ray findings. However, the information remains buried in a manilla folder on a shelf or in a file cabinet until retrieved for use by a provider practicing incident medicine. It might as well be a faded 3’ x 5’ card stuffed in a shoe box.

When the patient is seen, the chart is pulled, the service is noted, orders for medication and testing logged and the patient billed the fee for the service. The chart is then buried back in the record room. When new laboratory or imaging paper report reach the office, the chart is pulled and the test results are place on a page with other like data. The chart is presented to the provider to evaluate the results. A decision is made using the flawed global subjective memory based process. The patient may be notified of the results. The expert decision and patient interaction are logged in the chart and the chart is once again filed in the record room. Tons of paper travel between physician offices, testing facilities and hospitals. This is what I call the parchment blizzard or parchment storm.

The primary reason for development of Electronic Medical Records (EMRs) has been to shorten the billing cycle. Using computers and software programs to automate the standard shuffle of paper medical records decreased time to access patient data and billing information. For the physician, the only advantage Electronic Medical Records (EMRs) have over paper based medical records is rapid access to patient data or information from any location using a computer with a wireless connection. This may appear to be a quantum leap forward but a leap into what? Rapid access to patient information will not effect the quality of care delivered. The same flawed global subjective memory based decision making process is operational. It is not helpful to do the wrong stuff faster. I believe the leap has been made to “Chaos at Light Speed.”

Medical record programers simply automated source oriented paper records. The electronic chart is a paper chart represented on a computer screen. The chart may be rapidly searched for buried information, but the data remains isolated from the patient and unrelated to the patient’s problem. EMRs continue to be used to facilitate physician memory based decisions while they practice incident based medicine. The focus is on the billing code, for the test ordered, for the diagnostic code, for the disease suspected.

New tools allow humans to do work more efficiently and, more importantly, help create new ways of approaching and solving problems. To do so new tools must not be limited to direct application to old, inefficient processes. New computer technology and software programs have not been applied to improve how medicine is practiced or how decisions are made. The old, inefficient processes have been automated. The power of these new tools is being wasted and old, inefficient ways of practicing medicine hard wired.

In other words, Electronic Medical Records may inhibit and delay implementation of quality medical care as proposed those advocating the Patient Centered Medical Home(PCMH) model. Records must be oriented to center on the patient and their unique problems, not on the source of the individual services (read “billing”) rendered. Source oriented Electronic Medical Records (EMRs) must morph into Problem Oriented Electronic Medical Records(POEMR).

 

Problem Oriented Electronic Medical Records

The POEMR will facilitate integration of clinical epidemiology and evidence based medicine with our health care system. The structure of this form of electronic medical record assures the scientific basis for medical decisions is known. The number of memory based decision errors is reduced with resulting decrease in cost and improvement in quality.

Placing a “problem list’ on a paper chart does not magically turn it into a problem oriented medical record. Placing a problem list on a page in an Electronic Medical Record does not make it a “Problem Oriented Electronic Medical Record.” The structure and presentation of information differ widely between the two. This goes beyond simply organizing patient medical information based on the problem being addressed rather than on where the information came from (source orientation). After all, software programs can organize source oriented electronic data to masquerade as POEMRs. The real power of the POEMR is the organization of patient medical information to improve communication between the physician and the patient and between the physician and the specialist. The POEMR openly tracks the physician’s decision making process, the rational for decisions made, the care delivered and the outcome expected and realized. This organization of information based on the patient’s problem may be diagramed as follows:

The Problem List. These may be as simple as a list of patient complaints. The list must be composed of problems that are consistent with the know facts. The PROBLEM is not equivalent to a WORKING or RULE OUT DIAGNOSIS. If the problem is “cough” the diagnosis could be “pneumonia,” or “tuberculosis,” or “oat cell carcinoma,” or “GERD,” or “asthmatic bronchitis,” or etc.. You get the picture.

Plan of Treatment for each problem. This is where the physician’s decision making process is documented. These data are the core of a POEMR.

  • Goal of Treatment
  • Problem Basis Statement
  • Problem Status
  • Disability Caused by Problem
  • Treatment Ordered and Parameters to Follow (Patient Symptoms & Objective Tests)
  • Diagnoses to Rule Out (Further Investigation - by What Means?)
  • Complications Anticipated - What to Do

Progress Notes for Each Problem.

  • S - Subjective symptomatic information
  • O - Objective, directly observed and test data
  • A - Assessment of the status of the problem
  • P - Plans for the next steps to be taken.

The main reason for the transition from source oriented paper charts through EMRs to Problem Oriented Electronic Medical Records is to facilitate an effective physician thought process and approach to decision making. Human physical and mental diseases (and their classification codes) number in the tens of thousands. There are over ten thousand codes for billable medical goods and services. The number of drugs, their indications, counter-indications, interactions and side effects are mind boggling. The complexity is too great for the human mind to manage. Watch this:

http://www.youtube.com/watch?v=cL9Wu2kWwSYW

Contrast this with the 300 or so “problems” that may afflict humankind. Electronic medical records must be organized so that the patient and the patient’s problems are the central focus. A standard, reliable, reproducible problem solving methodology is taught to and used by the physician. The tests, procedures and medications ordered use the standard codes and are used for financial management. However, this billing function is not the primary reason for, or use of the electronic medical record. The relational database software used to store the data tags the medical care delivered to the patient’s problem. The resulting haystack becomes a small handful of needles.

Important physician decisions and patient information are tied together and easily communicated to other providers as care is managed in the delivery system. When a necessary referral is made to a specialty consultant, the electronic chart provides immediately accessible information about the patient’s problems, what has been evaluated, the results of testing, and why the tests or procedures were done. Appropriate, effective, efficient treatment and clear communication are the goals of implementing the POEMR.

Inefficiencies will remain. Although using the power of a relational data base to organize patient information to focus on their problems is a significant improvement, it is not the complete answer. Facilitating the physician’s thought process and problem solving ability through use of the POEMR will improve quality and lower the cost of medical care but the power of the new tools is not maximized.

The real power is in the data base structure of the electronic medical record. The power is maximized when clinical decision support tools are developed to mine the data in the records. Pattern recognition software tools will find critical relationships buried in the mountains of patient data. These software products produce automated standard query language (SQL) reports. The reports are physician user friendly.

Use of the POEMR will improve patient-physician communication and understanding. The quality of care may improve limited only by the continued use of physician global subjective memory based decision making. Improved quality and improving the efficiency of diagnosis will decrease the incidence of patient injury and malpractice. The clarity of the record and documentation of the use of appropriate care will help the provider defend any frivolous malpractice litigation.

As we practice medicine, we rely on snap decisions made using our memory banks. Few physicians have realized that the central cause of the American Health Care System crisis (both financial and medical quality) is the result of the failure of the global, subjective, memory based decision making process. The human mind is not capable of integrating the universe of medical knowledge with the uniqueness of the individual patient in real time as we practice medicine. We need help. We need to use the POEMR and apply intelligent medical decision support tools as patients are treated. America needs this new technology with a human touch if we are to solve our health care and economic crises.

Software programs to assist with developing cost effective diagnostic and treatment paths are being developed. Such tools will present the physician with the most appropriate, effective and efficient options for evaluating and treating the patient’s problems. Using tools developed through clinical epidemiological studies is call evidence based medicine.

These advanced tools may be referred to as: Medical Artificial Intelligence (AI); Clinical Decision Support (CDS); or Medical Decision Support (MDS). The physician remains the decision maker. The options generated by these new tools may be openly discussed between the patient and physician, so reasonable expectations regarding the outcomes of possible therapies may be known. Decision support tools are presented on my “Medical Decision Support” page.

The biggest roadblock to this inevitable evolution to advanced knowledge based tools for the practice of medicine is the physician. Most physicians highly value their education, training and skill at diagnosing disease. We are trained as memory based experts and our concept of self worth and value to our society rests on the size of our memory banks. We become “experts” when we pass the certifying examinations of our memory banks. Half our lives and considerable treasure is spent achieving certification of our memory banks. We attempt to maintain our memory banks through continuing medical education seminars. We participate in lifelong learning with the belief the more we know, the better our memory based decisions will be. We universally fail.

Physicians will remain the decision makers, however, our value to our patients, society and ourselves must change. We can no longer afford to base our worth on the size of our memory banks or certifications achieved. Physician use of global subjective memory based decision making has resulted in the dual American health care crises of cost and quality. Physician value must be based on Medical Judgment and Outcomes. The POEMR and Medical Decision Support tools will facilitate sound judgment and allow more accurate tracking of outcomes. Production and publication of accurate health care quality and cost report cards for physicians and hospitals will be possible. This will facilitate proper reimbursement for the “good guys.”

 

What’s Taken So Long?

Follow the money. The promise of Electronic Medical Records is the reduction of cost and improvement of quality. Admittedly, substituting the Chaos at Light Speed of EMRs for the Parchment Storm of paper records, could cut cost and improve quality. But would the improvements off set the cost of development, training and implementation? In my book, “Creative Design for Health Care Reform,” I present the concept that a conservative practice style saves between 10 and 15 percent of the medical care dollar. I was able to document these savings in my practice.

Electronic Medical Records that require a physician to think, and document their decision rational, could save at least 10 percent of the cost while improving quality. However, EMRs now in use do not document the clinical epidemiology justifying medical decisions or facilitate problem solving. The parchment storm has been automated. Chaos at light speed takes over and the physician continues using the flawed global subjective memory base decision making process. The dysfunctional decision making process has been automated. As a result, studies have failed to show spectacular savings in cost or improvement in quality. EMRs do provide a much more accurate and reliable way to document the mediocrity of medical care delivered in America.

Lets assume the EMR does morph into a POEMR and, as a result, physicians decision making process becomes more open to review and more conservative. When this happens, the Medical-Industrial Complex loses 10 percent of their revenue. Lowering the cost of health care by $220 billion dollars might be good for most segments of the American economy but what happens to the doctor and the rest of the Medical-Industrial Complex? The multiplier effect is about 10 to 1. If $220 billion dollars is taken out of the Health Care System, $22 billion of those dollars come out of the pockets of physicians. If the doctor sees fewer patients, or does less stuff, or orders less stuff, the doctor makes less money. There are no physicians lining up to invest in technology that will result in revenue loss.

For office (or hospital) computerization and EMRs to make financial sense, they have to improve the efficiency of billing (cash flow) while remaining neutral on dollars billed. This is being accomplished with standard, source oriented medical records. The change from paper to electrons is a change in the tools used but not the process or expected outcome. Many physicians are resistant to computerization because any change is difficult. They will adapt because source oriented EMRs will not effect how they make decisions or outcomes for patients. Most do not understand the profound financial and practice pattern disruption conversion to effective, efficient POEMRs will cause. This sea change is over the horizon but it is coming.

 

Why is the Change to EMRs Happening Now?

Recognition the American Health Care Crisis contributed to our financial crisis is the primary driver. The quality problems and high cost of the Medical-Industrial Complex have increased the cost of labor to the point American goods are no longer competitive in the global market. In my opinion, are experiencing the “Second Great Depression.” To pull out of the ditch, we must fix the economy by reducing the cost of labor (employee benefits). This means we must fix the Health Care Crisis.

Because the American people need a nationwide fix for our health care crisis, the federal government must mandate the changes necessary. The feds and many private corporations use slightly different jargon than some of us, long in the tooth, medical types. I am accustomed to problems, not challenges. I spent many hours in Medical Records Rooms completing Medical Charts. “Medical” sounds to medical for some folks. The government prefers “Health.” It sounds more uplifting. Some of my patients had medical problems and were sick. They were not “health challenged.” The long and short of this mini-rant is that the government prefers “Electronic Health Records” (EHRs) and “Health Information Technology.” These terms will appear in the sections below.

Those who understand the Health Care System crisis agree the first step is implementation of Electronic Health Records (EHRs) system wide. Candidate Obama recognized this fact and campaigned on fixing health care. President Obama signed a bill that regulates insurance, rather than reform health care. However, the law does have several interesting incentives, both positive and negative, to drive acceptance and implementation of EHRs. The US Department of Health and Human Services (HHS.gov) web site has more than you ever wanted to know about health care reform in general and the efforts to promote EHR implementation.

Keep in mind the federal government is mandating use of Electronic Health Records to cut the cost of Medicare and Medicaid by assuring proper efficient billing and assessing the “quality” of outcomes resulting from medical care. The government attack is on fraud and abuse in an attempt to save tax dollars while serving the best interest of the public. The power of the federal government is being used to required health care providers to upgrade their record systems to approved EHRs. Time limits and fines for noncompliance have been determined. Nevertheless, these reforms do not address the core cause of dysfunctional problem solving and improper decision making. The failure of the global, subjective, memory based decision making problem will continue. The quality of outcomes will not improve substantially and may have some questioning the fiscal responsibility of the programs.

 

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http://www.hhs.gov/recovery/programs/hitech/factsheet.html

Health Information Technology Extension Program

Facts-At-A-Glance

  • The HITECH Act amends Title XXX of the Public Health Service Act by adding Section 3012, Health Information Technology Implementation Assistance. This section provides supportive services for the rest of the HITECH Act. Section 3012 (a) establishes the Health Information Technology Extension Program (Extension Program).
  • The Extension Program provides grants for the establishment of Health Information Technology Regional Extension Centers (Regional Centers) that will offer technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of Electronic Health Records (EHRs). The consistent, nationwide adoption and use of secure EHRs will ultimately enhance the quality and value of health care.

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http://healthit.hhs.gov/portal/server.pt?open=512&objID=1495&mode=2

Health Information Technology Extension Program

    The HITECH Act authorizes a Health Information Technology Extension Program. The extension program consists of Health Information Technology Regional Extension Centers (RECs) and a national Health Information Technology Research Center (HITRC).

    What is the HITRC?

    The HITRC will gather information on effective practices and help the RECs work with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support.

    What are the Regional Extension Centers (RECs)?

    The RECs will support and serve health care providers to help them quickly become adept and meaningful users of electronic health records (EHRs). RECs are designed to make sure that primary care clinicians get the help they need to use EHRs.

    RECs will:

    • Provide training and support services to assist doctors and other providers in adopting EHRs
    • Offer information and guidance to help with EHR implementation
    • Give technical assistance as needed
  • The goal of the program is to provide outreach and support services to at least 100,000 priority primary care providers within two years.

    ONC has funded 60 RECs in virtually every geographic region of the United States to ensure plenty of support to health care providers in communities across the country. Two series of awards were made:
    • February 2010: 32 awards announced
    • April 2010: 28 awards announced
  • Information & Resources
  • For questions relating to the Health Information Technology Extension Program, please email:
    regional-center-applications@hhs.gov.

 

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Electronic Health Record vs. Intelligent Medical Chart

Patient medical charts contain a great deal of data but little information. Much of the data focuses on documenting those patient interactions that generate a billable encounter and how to maximize that billing. Virtually all medical charts, on superficial evaluation, present the same data sets. To evaluate an Electronic Health Record software program one needs to assess whether or not the data sets are being turned into information and if intelligent decision support tools are being applied. If neither is true, the software program is just chaos at light speed. To do this software evaluation, the standard components or data sets of a paper or electronic health record must be understood.

Appointment Schedule: The electronic record integrates the daily patient office schedule with the patient chart. This system page allows the office staff to schedule appointments for each office physician. The names of the patients become “hot links” to their individual electronic health records. The office staff arranges the appointment schedule and the nurse/physician clicks on the name of the patient to call up the record. Once called up, the individual record displays pages or links to additional data about the patient. This is like going to a web site and clicking on the hot buttons to find additional pages. A sample of some pages found in paper and electronic health records follows:

Patient Demographics: This is all the data that facilitates billing for medical goods and services provided. It provides the patient’s address, phone, contact information and billing (insurance company) information. This information is linked to the software financial module so medical goods and services provided during the office visit may be billed the same day.

List of Allergies: This page is usually near the front of any chart. The idea is to prevent an error of prescribing. If using paper charts, the doctor must remember the patient’s allergies. As a first level of automation, a software package may link allergies to an educational materials module. For example, if a patient is allergic to peanuts or gluten, the relevant information may be printed out and given to the patient as she leaves the office. The software may track this event to satisfy some “patient education” quality improvement requirement.

More sophisticated software might integrate allergies with other data tables. For example, if a patient is allergic to a medication or chemicals accompanying the medication (preservatives, other proteins, etc.), the software could link this data to the table of medications and to the prescribing module, to prevent the physician from ordering a medication that could harm the patient. This would be a smart application but not really an application of medical artificial intelligence.

Medication List: This is like a grocery list of drugs, current and past, used by the patient. No additional information here on a paper chart. A low level EHR might compare medications looking for duplications and drug interactions in a separate prescribing module that would automate the prescribing process.

An intelligent Clinical Decision Support (CDS) tool would relate each drug to a listed diagnosis. It would determine if the diagnosis used to justify the drug was established by objective findings documented in the chart. It would check for more appropriate medications. If use was justified, it would recommend proper dosing for the physical size and sex of the patient. It would cross check the Review of Systems (ROS) for “Signs and Symptoms” of complications to the medication or conditions that could be made worse by prescribing the drug. The provider could override the recommendations documenting rational for the deviation including prescription of the drug for off label use.

Problem List: The problem list is a short version of the patient’s review of symptoms. It may be very short; just the complaint of the day or why the patient is being seen at this time. It is a list of patient all complaints, present and past, resolved or not, that may or may not need further evaluation. Some practitioners confuse this with a list of diagnoses or diagnoses to be ruled out. A paper chart does not connect these data with anything. An automated EHR might use key words in a problem list as hot links to other data in the chart.

For example, a 40 something women could be seen for a complaint of shoulder pain after pushing open a heavy door. The problem shoulder pain could be linked to an X-ray right shoulder order. The radiology report is sent to the provider’s office. If the EHR is the usual chaos at light speed software, the report is a dumb scan. It may have been sent to the provider’s office via the Internet but it might as well have been a paper report sent by US Mail. The physician would read the report, then enter the radiologist’s finding on the list of diagnoses. The report, whether paper or electronic, would be “source” filed with other imaging studies.

Chance favors the prepared mind (-Louis Pasteur). Usually, but not always. The patient history and even the examination might favor a diagnosis of injury. The doctor is looking for a shoulder injury. If the provider perceives the report is essentially negative, showing some arthritic changes only, a diagnosis of DJD or sprain/strain could be made and the patient placed on a non-steroidal anti-inflammatory drug.

However, the report could have had a significant finding, missed by the physician. What if the report showed an abnormality of the third rib? Possibly a pathological fracture. A smart EHR would report this finding and require a response from the provider. An intelligent medical decision support tool would have scanned the entire chart finding the family history of ovarian carcinoma and would suggest the most reasonable next steps for consideration by the physician. Without intelligent medical decision support the provider could have missed the diagnosis and would have to use global subjective memory based decision making to determine the next steps.

Confirmed Diagnosis List: In a paper chart this is a laundry list. Each diagnosis may or may not be supported by the objective clinical facts of the case. In an EHR each diagnosis may or may not be linked to the test done to confirm the diagnosis. Each diagnosis may or may not be linked to the medication used to treat the condition. The medication prescribed may or may not be linked to a current formulary. The diagnosis will probably not be linked to any source of up to date clinical epidemiology publishing the most appropriate medications recommended for use for the specific condition. In fact, relating various data tables in this way is the opposite of how the process should proceed.

An EHR supported by intelligent CDS tools would not allow a provider to directly enter a confirmed diagnosis. The system would enter the diagnosis, with the approval of the provider. How should this work? Based on readily available documented objective facts and subjective observations by the patient and physician, a “working diagnosis” is entered by the physician. The intelligent CDS tool may suggest a list of possible working diagnoses. The most cost efficient evaluation for this working diagnosis is undertaken, modified as additional information and facts are collected. At some point during this process the intelligent CDS tool proposes a final diagnosis (a statistically significant Dx, based on information gathered). The physician determines if the proposed diagnosis is entered into the Confirmed Diagnosis List. (After all, the physician is licensed to DIAGNOSE and treat patients). The physician confirms the recommendation or rejects the proposal. If rejected, the rational for rejection is logged into the system. In an intelligent system, this list is a living document that undergoes modification as additional objective facts and subjective observations are made.

Physician & Nurse Progress Notes: These have been presented in the above section discussing:

Problem Oriented Electronic Medical Records

Review of Systems (ROS): This is a check list of possible problems associated with the various anatomic and physiological systems of the human body. These systems include the skin, circulation, kidneys, bowels, etc.. The checklist is as important for the negative checks as the positive ones. This page documents the provider has asked all the appropriate questions of the patient. Some results find their way to the problem list. The documentation is partially used to justify the level of complexity of the office visit for billing purposes. The more interaction between the patient and the provider, the greater the fee. For example, a short visit for a blood pressure check would result in a minimal uncomplicated office visit fee. A long visit with a complete review of systems, complete history and physical, review and adjustment of medications could be classified a complex office visit of an hour or so and justify a several hundred dollar fee. An EHR might generate a proposed problem list for approval by the physician.

History and Physical (H&P): The history and physical examination is the core of both paper charts and EHRs. Generation of the data is the first step in the process of physical diagnosis, or PhyDog as we called it in medical school. The physician takes a complete medical history, including the history of the present illness or problem. A complete, head to toe physical examination is performed. All subjective information and objective observations are recorded by the provider in the medical record in the H&P. Problems are identified and placed on the paper or electronic problem list. The physician then attempts to integrate global memory based medical information with the patient data to formulate a “working diagnosis.” The physician develops a plan of further evaluation to confirm the diagnosis. Prescriptions for testing are hand written or logged into the EHR. A plan of treatment for the problem is formulated, again using the global memory of medical science to make the decisions. Prescriptions for drugs or referrals are hand written or logged into the EHR.

The functions of intelligent Clinical Decision Support (CDS) tools applied to a properly configured EHR relative to the problem list, working diagnosis, evaluation plan, treatment plan and use of prescription drugs is described above.

Laboratory Results: Laboratory tests stand alone in both paper and most EHRs. They are source filed in both. This means the lab test is taped onto the lab sheet in the paper chart or electronically filed with all other lab studies in the EHR. They are tagged to the patient and insurance company for billing purposes. They are much more accessible in the EHR but neither system relates the study to the patient problem diagnosis or other medically related issues. The results of laboratory tests may be readily called up and even flow charted but this requires the active intervention of the physician. The electronic version may have an automated warning system that flags lab test results that are too high or too low. The physician is notified of the abnormality but offered no suggestions regarding what to do about the results. Any action directed by the physician presented with the abnormal finding is the result of integrating the unique patient information with what medical science is remembered.

An intelligent CDS would integrate the unique finding with all other parameters of the individual patient record to recognize patterns predetermined by the clinical epidemiology programed into the software. The most probable causes for the abnormality would be presented to the physician.

Imaging (X-ray & other scans) Results: Imaging studies are descriptive prose. Reports for both paper and EHRs are source filed. Although easily retrieved from the EHR data base, they are the written word and not well suited to flow charting. As standardized coding systems develop for medical jargon used in these reports, they will become more valuable information for intelligent clinical decision support tools.

Consults: Reports from consultants are processed like H&P, ROS and Hospital Records. They are source filed (with all other consults) and may be easily called up from the electronic data base of the EHR. Intelligent CDS tools would apply as they do for other elements described above.

Hospital Records (Admission & Discharge Summaries): These documents are in the main prose, but do have some coded elements, for example, procedures performed and confirmed diagnoses. These documents, paper or electronic, are source filed. Intelligent CDS tools would apply as they do for other elements above.

There are other elements to paper and electronic health records but by this time you should be getting the idea. EHRs are a little better than paper charts but do little to improve medical decision making. Until physicians recognize that our awesome error rate is the result of the failure of our global subjective memory based decision making process, nothing of significance will happen to improve quality or reduce the cost of health care. Until physicians embrace problem oriented electronic medical records (POEMRs) and intelligent medical decision support tools, our error rate will continue at about 50 percent.

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Do you need more information

about Electronic Medical Records?

How do Electronic Health Records work?

All useful electrical and electronic devises comply with industry standards developed by the National Electrical Manufacturers Association (NEMA). These standards allow the devices to connect to power sources and with each other. The Association’s website may be reviewed here.

The power cords turn the lights on, but for the devises to talk to each other, a standard code is required. Most electrical and vertually all electronic products contain computer chips that use a standardized code that tells the device what to do and allows it to communicate with other devises. Most electronics use ASCII binary code to document programs and communicate. Binary simply means two. The code is like a row of light switches that are either off - “0” or on - “1”. Letters of the alphabet and numbers are represented by a series of zeros - “0” and ones - “1”. The code was developed at the dawn of the computer age.

Medical records are essentially a collection of Alpha-numeric codes for the diagnoses physicians make and for the goods and services they preform. For those using paper charts, the codes are typed or hand written in the record and on insurance forms. These codes have been with us since the dawn of the computer age. Insurance company computers love codes for claims adjudication.

The application of computers and Electronic Health Records (EHRs) to our medical delivery system required the development of a large set of new standardized codes that describe, in ASCII Binary code, all of the prose and poetry of medical care. If the electronic chart was composed of a large file of scanned documents (pictures of reports), they would be no more useful than a thick paper record. The computer is so powerful because the important stuff used to make medical decisions is entered in code. Medical software can look for needles in all those haystacks and find them instantaniously. But all that prose and poetry had to be reduced to a standardized set of codes. That standardization fell to a subdivisions of NEMA, the “Digital Imaging and Communication in Medicine” and the “Medical Imaging and Terminology Alliance.” Standardization of coding for all the stuff written in the record has made computer medical software programs possible.

 

See the following Patient Centered, Problem Oriented Electronic Medical Record (POEMR) site. This may be the only true problem oriented EHR in America:

Problem Knowledge Couplers (PKC Corporation):

 

 

See the following source oriented medical record web sites:

Microsoft Electronic Medical Records (Source Oriented):

 

Pulse, Inc., Wichita, Kansas based software medical EHR company. Now owned by Groupe Cegedim, a French software “holding company.” http://www.cegedim.com/

 

Cerner Corporation: Health Care Information Technology Systems

 

 

 

 

 

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