1) Ready Access for Everyone
Paper medical records cause harm and in multiple studies have been shown to fail to deliver the necessary information to all the clinicians involved in care. In a study I quoted some years ago done by then Arthur Anderson they found that in less than half of patients cases the relevant clinical notes were neither available or could be found at the time the patient was seen. Digital records are available to everyone involved in the care of the team who has access. Instant availability provides referring physicians and specialists as well as the patients with a copy of medical record quickly and conveniently.
2) Digital Record are More Easily Kept Up To Date
New innovations and digitization allows for the capture of information by the patient prior to a visit. Almost every clinical facility asks patients to fill in forms as they sit in a waiting room – the information contained in these forms is marginal at best and locked away on a piece of paper. From a patient perspective the information has likely been provided to multiple other offices and clinical providers. Digital records are on the pathway to effective and meaningful sharing of clinical data that will remove the need to render or re capture the same information. Focusing on capturing it once and allowing the patient to review it for correctness and completeness at the time of the visit is likely to lead to a much higher quality more accurate medical record. It may seem foreign to many clinicians but the patient probably has the biggest vested interest in an accurate and complete medical record more so than anyone else involved in the clinical care process. In some cases the digital record can be shared with the patient ahead of time online in a secure environment and they can check, update and complete this before arriving for their appointment.
3) Filtering and presentation
Clinical information captured as data throughout the continuum of care can be presented in innovative and more useful ways ("Can Electronic Clinical Documentation Help Prevent Diagnostic Errors"; N Engl J Med 362;12 March 25, 2010 pdf).
4) No Need to Loose the Narrative
Capturing the whole story remains an essential component of any clinical record with the history contributing anywhere up to 80% of the final diagnosis. As part of any move to the digital medical record the inclusion of this narrative and the ability to record it without interfering with the normal workflow is a must. EHR’s have a wide range of tools and techniques for capturing and recording the patient record and there is wide variation in their use. Different specialties have different needs – in ophthalmology there are many data points routinely collected and form filling on a computer or digital tablet is likely to be efficient. General medicine on the other hand is dependant on the narrative and the detail behind the symptom. In this case it is important to provide tools to capture the data efficiently without adding to the time required for documentation. Historically these notes were hand written which probably induced an element of brevity. Hand written notes were replaced by dictation and transcription which while efficient for the clinicians introduced delays in the availability of information to the referring physician and other clinicians and proved costly. Recent moves introduced templates and forms along with tools to create these notes and while they work in some cases there are disadvantages of losing the patient story, and the inability to convey the meaning (“The transition from paper to electronic inpatient physician notes”; J Am Med Infom Assoc 2010; 17:108-111 abstract). Speech remains the most common means of communication and providing tools to capture the clinical story and convert that into a digital record have been successful in many settings (Fallon clinic Study). The key to success is offering a progressive blend of tools and methods to accommodate individual preferences and situational constraints. No one method suits all circumstances and all individuals and providing choice is the key to success. Present a choice and allow regular dictation and transcription while offering a pathway to more structured data entry, either through computer based forms entry or using speech recognition dictating directly into the EMR. (Save the clinical narrative)
5) Creating Structure and Data
If the narrative forms is an essential part of any clinical record so is structured data but generating both elements remains a challenging prospect for the busy clinician. New technologies on the horizon will automatically process the narrative and extract data elements to be placed directly into fields within an EMR. Using clinical language understanding (CLU) in conjunction with speech recognition technologies allows the clinician to document a succinct evaluation and description while automatically producing a discrete and codified problem list among other key clinical values. Codification renders this data useful to the EMR making it semantically interoperable. This forms the basis of the decision support, evidence based medicine and the error catching for ePrescribing solutions that have built in databases of contra indications based on specific clinical conditions (an allergy for instance) or careful monitoring and adjustment of doses based on renal function test (Gentamicin for example needs careful monitoring of renal function to prevent hearing damage)
6) Practical Clinical Support Tools
Human memory alone cannot guarantee the right questions and clinical information is gathered and applied to arrive at the most likely differential diagnosis. The landscape of clinical knowledge is rapidly changing and becoming more complex. Doctors need approximately 2 million pieces of information to practice medicine and subscribe to an average of 7 journals representing approximately 2,500 articles per year that they must read, process and then apply in order to stay current – an all but impossible task that is only getting harder (Sackett DL: Surveys of self-reported reading times of consultants in Oxford, Birmingham, Milton-Keynes, Bristol, Leicester, and Glasgow, 1995. In Rosenberg WMC, Richardson WS, Haynes RB, Sackett DL. Evidence-Based Medicine. London: Churchill -Livingstone). Digital records are the basis for applying knowledge and providing decision support to busy clinicians. While these alerts and tools are still in their nascent form, many are far to intrusive and can be triggered too easily. Refinement of these tools will bring about better quality of care helping prevent errors and facilitating informed decision making for patients and clinicians.
7) ePrescribing – The Key to Safer More Efficient Prescribing
Electronic prescribing appears to reduce the rate of medication errors and should be an integral part of any clinical system. While the process of entering a prescription can seem arduous initially efficiency is rapidly achieved through frequent use and user customized and system stored favorites and pre populated prescriptions can ease this pain. Add to that the value of legible prescriptions that are almost instantly available to pharmacies and help the patient and the pharmacist and clinicians deliver the right drug with the right dose to the right patient at the right time. And built in to the prescribing system are contra indications, allergies and drug-drug interactions that can be caught as part of the prescribing activity, reducing medication errors and improving the quality of care.
8) Timely and Failsafe Communications
Computers are good at repetitive tasks and once programmed never forget. Tracking results, tests and clinical findings and ensuring that urgent communications reach the intended recipient every time is easier using a digital record. Much of our personal lives are now organized using mobile hand held devices that include calendars, automatic alerts and alarms, so could be our digital medical record. I receive notification from my bank when an unusual transaction exceeding a specific amount is authorized from my credit card. A digital record can identify unusual or abnormal results and highlight the information to the clinical team including communicating the information to the patient. Even with the best intentions paper based communication can and do break down. There are many examples a condition being identified correctly but a breakdown in communication to the patient or the correct caregiver may have led to an unfortunate, but potentially avoidable consequences.
9) Security
While much has been made of security issues associated with digital medical records the reality is that medical records than the old paper records. Furthermore access is easily tracked and audited. Ensuring the right level of security is essential. There has been many stories of paper records that frequently “walked” out of hospitals, clinics and into the back of cars, offices and even dumpsters.
10) Mobility and Portability
We live in a rapidly changing world and recent natural disasters have demonstrated the need for mobility and portability. Hurricane Katrina demonstrated the need to create medical records that are available in more than one location and are effectively backed up. There were few patients affected by Hurricane Katrina that were able to leave the area and attend another facilities and receive care without significant interruption. For example Veterans who fled the area almost instantly had their medical records available in other VA hospitals. While this might be an extreme example of crisis mobility and extraordinary circumstances our population and society is far more mobile than ever before. People no longer live their entire life in the same location. In addition to facilitating mobility, digital records deliver built in redundancies and create backups and copies to ensure survivability of information. But mobility is not just about the record but the ability of the clinician to access the record from any location and at any time. Seeing patients out of hours has always been difficult with the lack of available information – digital records that are accessible from any location and even on portable devices can provide instant access to key data to help clinicians manage patients efficiently. Reviewing a medical record on a mobile phone may not be ideal but having access to information even on a small screen is preferable to having no information as the basis of clinical decisions on patient care.
Digitizing medical records is not so much a destination but a journey and one that we must all take. There are challenges but the benefits are clear. The question you must ask yourself as a physician is can you afford not to go digital and more importantly can your patients.
IMO
