Some Personal EHR Stories

I am a patient at two separately owned and operated healthcare provider organizations that are within walking distance of one another. Fortunately, both organizations use the same “core” EHR system.  Unfortunately, the EHRs currently do not talk to one another or even look or act alike.

Because also I am a health information management and health information technology professional, I’ve found several flaws in these providers’ EHR systems. The organizations either do not know how to correctly configure their EHR systems or have failed to do so properly.

Flaw 1: Male with Cancer

I requested the release of my medical record from one of the organizations. The transcribed procedure report header listed my correct name, date of birth, and medical record number. However, the report body included two pages describing me as a male and having cancer. Neither is accurate.

This kind of mistake is common. Either the provider mistakenly dictated on the wrong patient under the correct header information sent by the EHR system, or the transcriptionist mistakenly keyed the wrong patient information under the correct header information.

Flaw 2: Updating Orders

One of my care providers repeatedly ordered the same lab work, even though the lab work had been performed months ago and the results were stored in my EHR. Deleting the order and updating the EHR with the previous lab results required several handwritten notes, photocopies, and telephone calls to the provider.

Flaw 3: Duplicate Tests

EHR systems should be configured to alert providers of all tests performed in the past. Recently, when one organization’s physician ordered a routine TB test, there was nothing in the EHR system to alert the provider that the same test was performed at the organization seven months earlier. Consequently, the test was unnecessarily repeated seven months later, costing an additional $398.

What One Needs To Know About Electronic Records Management

Below is a step-by-step, basic, electronic records management guide — to help protect those electronic records that need to be protected while allowing access to to those electronic records that need to be shared; to gain value from using various computer applications while addressing compliance and governance standards.

First, clearly define as “documents” all content generated in (for example) GoogleDocs, SharePoint 2013, Dropbox or Box.  A document is any analog or digital, formatted, and preserved “container” of structured or unstructured data / information.  A document can be word-processed or it can be a spreadsheet, a presentation, a form, a diagnostic image, a video clip, an audio clip, a template of structured data….

Second, for legal and compliance purposes, declare as “records” those “documents” in GoogleDocs, SharePoint 2013, Dropbox or Box that 1) follow a life-cycle (i.e., the “documents” are created or received, maintained, used, and require security, preservation and final disposition, such as destruction); 2) must be assigned a retention schedule; and, 3) the content must be locked once the “document” is declared a “record”.  Records are different from documents.  All documents are potential records but not vice versa.

Third, and again for legal and compliance purposes, designate all the records as either “official” records or “unofficial” records.

Official records include those documents that were generated / received in GoogleDocs, SharePoint 2013, Dropbox or Box and subsequently declared as records according to the above records characteristics.  In addition, official records 4) are created or received as evidence of organizational transactions or events that reflect the business objectives of the organization (e.g., receiving reimbursement for services provided, providing patient care); and, 5) qualify as exercises of legal and / or regulatory obligations and rights (i.e., have evidentiary and / or regulatory value).

Unofficial records include those documents that were generated / received in GoogleDocs, SharePoint 2013, Dropbox or Box and subsequently declared as records according to the above records characteristics.  However, unofficial records will NOT further organizational business and / or legal / regulatory needs if the records are retained.  Typically, unofficial records are retained only for the period of time in which they are active and useful to a particular person or department.  Often organizational retention policies allow unofficial records to be retained for x number of years after last modification, but typically no longer than official records.  Examples of unofficial records are (what are typically but erroneously called) working “documents”, draft “documents”, reference “documents”, personal copies of documents or records, and copies of official records for convenience purposes.

Fourth, retain / store all the documents and official / unofficial records in GoogleDocs, SharePoint 2013, Dropbox or Box in separate, physically, but logically-linked electronic repositories.  For example, “documents” can be stored on individuals’ hard drives.  Once documents are declared “records”, the official records (e.g., patient records [including patient-related text messages / email messages /social media entries], employee records, patient spreadsheets, etc.) must be parsed and placed into a secured electronic repository, similar to the organization’s line-of-business system / systems-of-record repositories; e.g., EHR, Vendor Neutral Archive, financial system) — with audit trails, access controls, etc.  The unofficial records (e.g., working documents, reference records, etc.) can be stored on organizational shared drives.

Accent on Objects

It has been many years since I acknowledged patient record subpoenas for medical malpractice lawsuits and other legal actions as an HIM professional and designated custodian of records (COR). But the process was memorable.

During the 1970s, one was not able to reproduce analog paper and photographic film or send records by postal mail or courier to the courts.  Rudimentary paper and film photocopy machines only recently were introduced into healthcare organizations, and the courts required the personal delivery of “original” source documents and records by a COR.  Consequently, upon receiving patient record subpoenas, I took a large cardboard box and collected from each department the “original” source documents required by the subpoenas. The contents included the patient’s paper financial and medical records.  The medical records also included all film-based diagnostic images, tape-based medical dictation, cine-based ECGs, and pathology slides.

During the 1980s, when I established my related career in HIT and because of my COR experiences during the “analog” years, I knew well that electronic patient records consisted of more than just the structured data typically found in electronic patient financial and medical records. (Structured data are the record’s binary, discrete, and computer-readable data elements that, typically, are stored in relational databases with predefined fields.)  Electronic medical records (EMRs) also consisted of digital diagnostic images, audio file-based dictation, and ECG waveforms. In fact, such unstructured data make up at least 75% of all the data in a typical patient’s EMR.  (Unstructured data are the record’s non-binary, non-discrete, and often human-readable data elements that, typically, are contained in text-based reports, emails, and web pages and include symbols, images, video clips and audio clips.  In some vertical markets, unstructured data are referred to as a record’s intellectual substance or content.  In technical arenas, unstructured data are referred to as “objects”.)

Just like healthcare organizations, the courts finally have entered the digital age. Today, secured electronic files of “original,” electronic source documents and records as well as “copies” of original, electronic source documents and records are admissible in courts as long as the healthcare organization can substantiate (1) the trustworthiness of the system(s) used to store and retrieve the documents and records; (2) the accuracy of the organization’s records management policies and procedures; and (3) the documents and records were not created (or altered!) just for a court case. (NOTE:  Always one must verify the courts’ acceptance of digital records on a state-by-state basis.)

Large cardboard boxes have been replaced by EMR (or other system) features that promote single points of personalized access through which to find and deliver electronic information, applications, and services. As such, in either hybrid or full EMR environments, designated CORs, Release of Information professionals, and even patients—after rigorous authorization and authentication processes—merely click on hyperlinks and instantaneously retrieve “original” electronic source documents and records required by subpoenas or other requesters.

While our industry continues to pursue the best “highways” to securely transmit the documents to and acknowledge receipt from requesters, today’s day-to-day challenges involve the current mechanisms used to transmit unstructured data and the shameful output of structured data generated by most EMR systems.

For example, the transmission of the large and ever-growing number of patient diagnostic images (primarily radiology images), which remain hand-carried or sent by postal mail or courier from hospitals, physicians / groups, specialty (e.g., cancer) centers, etc., to other hospitals, physicians / groups, and specialty centers on CD storage media, is completely unmanageable. Many of the CDs containing (e.g., radiology) diagnostic images cannot be imported into the receiving Radiology PACS due to the way the images were burned into the CDs.  Although most of the CDs include the senders’ viewers for measuring, window / leveling, etc., often the CD files arrive corrupted.  Frequently the CDs are misfiled and / or lost.  Consequently, transmitting diagnostic images on CDs has lead to duplicate testing with more patient exposure to radiation.  In addition, when the CDs contain diagnostic images other than radiology images, often the receivers have no corresponding PACS for these other, “ology” images.

Thankfully, popular, standard, inbound (i.e., CD ingestion and electronic receipt of diagnostic images) and outbound (i.e., report and image distribution to referring physicians, referral centers, etc.) image sharing solutions exist.  However, most are too expensive for the healthcare provider masses.  In addition, few, if any, non-standard image sharing solutions exist, whereby direct connections are established between two or more organizations for readings, consultations, and 2nd opinions and inbound and outbound electronic reports accompany the images.

Also, there is not a healthcare professional that has not experienced the reams of paper output generated by EMR systems because the systems’ structured data are not report-formatted for output. This is one reason why a patient still cannot receive his/her entire patient record from a portal!  Not that I promote hard copy printing; however, healthcare providers still must maintain a legal archive from which to generate the electronic document presentation as proof for exception and dispute handling.  In other words, providers must have the document presentation for legal purposes and NOT an informational statement or data representation of the document, which, unfortunately, remains common in today’s electronic patient record system output.

Quality Information For Quality Healthcare

I promise not to provide another comment regarding the “Meaningful Use” of the electronic health record (EHR).  That’s because I strongly believe that health professionals should be more concerned about the meaningful use of the health information than of the EHR.

Patient health information comes from a multitude of sources – hospitals, physician offices, pharmacies, off-site laboratories, radiology facilities, long-term care facilities.  Therefore, instead of raising questions regarding the meaningful use of implemented EHRs, health professionals must raise other questions that need immediate answers, such as how will all this information be compiled? Who will be ultimately responsible for this information’s maintenance and storage?

More importantly, health professionals must find ways to achieve quality data in the EHR, because only with quality data can health professionals develop quality measurements and clinical quality indicators. For example, did the procedure shorten the length of the patient’s stay? Or, did the procedure cause the patient to have more doctors’ office visits at the end of the organization’s episode of care?  When such questions are answered and realized across the continuum of care can one implement the systems to capture and meaningfully use the information as well as produce better information for better decision-making.

One suggestion to accomplish this is to begin standardizing on terms, categories, and practices, at least within the organization.  An organization can get assistance from the National Quality Forum’s Healthcare Information Technology Expert Panel, which is directing its non-profit efforts on a next generation quality data set with a universal terminology for the design of quality measures.  Another suggestion is to vigilantly monitor the EHR’s common problems, including but not limited to user input errors, abuse of default settings, and abuse of the copy / paste function.

In my thirty year healthcare career, the first half debated whether or not quality could be defined.  The second half debated about whether or not quality could be measured.  I hope the debate now will focus on whether or not the information generated for quality purposes will be accurate.

 

 

Digital Information is Great, but Only if it’s Accurate

I am a patient at two local healthcare provider organizations that use the Epic suite of clinical information system modules for their base EHR. Both organizations must not yet have installed Epic’s CareEverywhere because currently, the two Epic systems do not talk to one another (or even look / act like one another). But with time, the installation of CareEverywhere should occur at both.

However, the reason I write this article is that either there is a flaw in Epic’s MyChart, the organizations do not know how to correctly configure MyChart, or there remains an important Epic user training issue. When I visit my providers at both organizations, I receive a hardcopy summary of my visit, which I must assume gets generated by MyChart because also I can view the data online via MyChart. Among many items listed on the summary are Current/ Future/Recurring Orders.

1) Orders listed on the summary and in the system cannot be corrected easily by an organization user, even the provider. I don’t know whether this is a user training issue (e.g., how to easily DC or cancel electronic orders that have been performed but, for some reason, not automatically canceled as Future Orders), a system flaw, or a poor implementation of the function. But for one set of lab orders, I was repeatedly asked for lab work to be performed when the lab work was performed months ago and I had the documentation to support this. Unfortunately, it took several handwritten notes and phone calls from me to the provider to finally update and delete the already performed lab orders from the system.

2) If orders listed on the patient’s hardcopy visit summary are incorrect (e.g., numbers of milligrams, duplicate orders, q 4 months not q 2 months, etc.), again these orders cannot be easily corrected by an organization user. That’s because, according to the organization’s users, these orders come from a different “database” than the “real” orders, which are correct in the system, but don’t print to the hardcopy correctly!

3) Either the Epic clinical system does not include or the provider organizations have yet to install or know how to install the following clinical decision support function: Recently, when my provider at one organization ordered a routine TB test, there was nothing in the system to alert the provider that the same, routine TB test was performed at this organization in July 2009. Consequently, this test was repeated in February 2010 at a cost of $398. When I complained about this, the provider organization commented that it is the provider’s responsibility to look back at all the orders in the system to see if a TB test had been performed within the last several years. I don’t blame the provider for not wanting to scroll through several years of past orders to determine this. And I was sorry I didn’t have my “paper” PHR, which I have kept for at least 30 years, with me at the time to double check this.

Now that electronic PHRs and visit summaries are appearing and patients are beginning to “use” (indirectly) organizational EHRs, not only will the organization’s internal users be complaining about system flaws, poor configurations, or outstanding training issues — but external users, the patients and recipients of health information exchanges, will be added to the lists. Consequently, it’s time our industry professionals address the management of the information, not just the technical and operational mechanisms for the sending and receiving of the information. Because it’s great to receive digital PHRs and visit summaries from provider organizations, but only when the information is accurate! Just ask ePatient Dave!

(Originally posted: http://histalk2.com/2010/03/24/readers-write-3242010/)

They’re all Synonyms!

I don’t know how many times I delivered a presentation / authored a published article when I had to explain why two healthcare information technology (HIT) trade organizations (one so large that it won’t be mentioned in this article and the other, federally commissioned at taxpayer expense and no longer in existence) adopted definition differences between an electronic medical record (EMR) and an electronic health record (EHR).

This only further confused my healthcare professional audience / readership who, for years, have had a complete understanding that charts, records, patient charts, patient records, medical records, health records, etc. are synonyms! Walk into any hospital or clinician office and always one will hear an assortment of such synonyms without ever questioning the meanings.

True, in the late 20th century, synonyms of adjectives, such as computer, computerized, automated, or electronic were needed to differentiate between (what is known in the greater IT world as) analog vs. digital charts, records, patient charts, patient records, medical records, health records, etc. However, still the use of the synonyms of adjectives with the synonyms of nouns made no difference to practicing healthcare professionals, except to differentiate, when necessary, between analog, digital, or hybrid.

Thankfully, we might be getting close to ending this nonsense. Recently, one HIStalk reader correctly pointed out that NOWHERE in the 2009 American Recovery and Reinvestment Act (ARRA) with its Health Information Technology for Economic and Clinical Health (HITECH) Act is there a distinction made between an EMR and an EHR. Only the term electronic health record and acronym EHR is used — for health information exchanges, for hospitals, for physician offices. That’s probably because every healthcare industry-bred author / reader / interpreter of this legislation has a complete understanding of what is being conveyed.

On the floors or in clinic rooms, let’s continue to use whatever synonyms (adjectives and nouns) come to mind, because we’ll continue to understand what is being communicated. In addition, let’s give credit to the 2009 legislation for dealing one of the final blows to this “trade organization made up EHR/EMR” definition debate and all agree to use EHR (as used in the ARRA / HITECH legislation) as the standard terminology in presentations / published articles / vendor products, etc. Only then will we be able to move on to more important discussions.

(Originally posted at: http://histalk2.com/2010/02/08/readers-write-2810/)