CASE A medical practice in disarray
An ObGyn reported the following signs of a problem to a colleague: “Our practice was literally drowning in paperwork. An exam room was recently converted to hold more charts, and 2 warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to the ongoing costs and storage problems.”
What are the treatment options?
Electronic medical records (EMR) have progressed from arcane, slow, cumbersome documentation systems to sophisticated, complex, comprehensive ones. These modern systems hold the potential to reduce administrative and management costs by 30% or more, improve clinical workflow, reduce medical errors, facilitate communication between patient and physician, and enable analysis of data for best practice methods, best outcomes and identifying risks and complications.
For practices like the one described in the preceding paragraph—not a fictional account but actual testimony provided by an ObGyn—EMR offer a powerful potential solution to the problems that result from an overwhelming amount of paper documentation, correspondence, charting, claims, and financial transactions. In this article, I offer a general introduction to EMR; in the next (August) issue of OBG Management, I’ll speak with a group of ObGyns and medical practice managers about their experiences—and inexperience—with EMR.
Progress and paradox
Physicians and scientists have made substantial progress over the past 25 years in pharmacotherapeutics, diagnostic technology, procedures, and treatment protocols. In obstetrics and gynecology alone, consider the array of technologies—3-dimensional ultrasonography, minimally invasive surgery, receptor-specific drugs, in vitro fertilization, long-acting reversible contraceptives—that have advanced the quality and effectiveness of care. Yet little progress has been made in the process of caring for patients.
The fact is that physicians, and other health-care providers, are rooted in paper-based processes that sustain inefficiencies, increase costs, and defy the gains that other industries have made by adopting electronic technologies for handling information. Why are we so stuck?
The state of EMR
EMR—of varying functionality—have been available for longer than 20 years. Early models were developed by physicians who had an interest in software coding and design, and were of limited functionality, arcane, and difficult to use in a clinical setting. Some of those early models, and even a few commercial systems in use today, rely on scanning paper documents into computer files. Such systems may eliminate some paper and facilitate document retrieval, but they do nothing to ease management of the complex transactions of health care, and they do not address handwriting illegibility.
Development of complex EMR systems was limited by primitive technology, inadequate distribution channels, and programming that was cumbersome and expensive to maintain. But these barriers have been overcome with fast processors, inexpensive and abundant memory, broadband Internet connectivity, and programming languages that facilitate automated software development.
Modern EMR systems are not simply data repositories: They also support workflow from the beginning to the end of a patient’s consultation with a health-care provider—an event that generates multiple transactions with multiple recipients. A single consultation may, for example, generate orders for lab tests, imaging studies, a surgical procedure, consultation with other physicians, prescriptions, and counseling, and record the subsequent financial transaction. EMR systems by necessity interact with multiple organizations, institutions, instruments, and other software systems. To software developers, and to the clinicians who use their systems, the challenge is to deftly navigate the complexities of health care.
Forces accelerating adoption
Momentum from the Executive Office. In 2004, President George W. Bush set a goal: nationwide adoption of EMR—to include all medical practices—within a decade. In a speech that year at Vanderbilt University Medical Center, the President said: “One of the amazing discrepancies in American society today is we’re literally changing how medicine is delivered in incredibly positive ways, and yet docs are still spending a lot of time writing things on paper.”1
Certifying body arises from the private sector. Subsequently, the US Department of Health and Human Services (HHS) established the Office of the National Coordinator for Health Information Technology and the American Health Information Community. The sweeping goal of these bodies? Better health care by application of information technology and creation of standards for certifying EMR systems that provide core functionality.