Home

Cover Story

Table of Contents

E-Newsletter

Article Archive

Editorial Calendar

Datebook

Writers' Guidelines

Orgs/Links

Opinion Polls

Reprints

Forum

For other articles and previous issues click here.

September 5, 2005

Big Challenge — Improving Healthcare Records, Safety, and Quality
By Kim M. Norton
Radiology Today
Vol. 6 No. 18 P. 13

Beyond Radiology
The spread of PACS throughout many hospital departments underscores the collaborative nature of healthcare. The higher up the management ladder you climb, the more you’ll need to interact with other parts of the system. This feature is part of an occasional series addressing topics that usually happen outside your department but can affect your career.

A recent article in The Journal of the American Medical Association (JAMA) stated that medicine is not much safer than it was five years ago when the Institute of Medicine released its landmark study on medical errors. Additionally, a recent study by The Commonwealth Fund found that physicians are not utilizing the methods available to them to make medicine safer and improve the quality of care they provide to patients.

According to the JAMA article “Five Years After To Err Is Human,” there have been small but consequential changes that have occurred in the healthcare industry; however, their overall impact is difficult to see in national statistics. The lack of impact seems to be attributed to the culture of medicine and the professional autonomy physicians have rather than unavailable technology, the authors say. The article was funded in part by The Commonwealth Fund.

“In order to improve safety within the medical community, not only is a culture change essential, but there must also be a redress of the office workflow for this change to have an effect,” says Kevin Palattao, vice president of Health Partners in Twin Cities, Minn. Electronic medical records (EMRs) have a role in improving medical safety.

EMRs have the potential to make a physician’s life easier in many ways, Palattao continues. First, there will be a reduction in drug interactions because the computer software alerts physicians when any drugs that may have an interaction with medications the patient is already taking. Additionally, EMRs will streamline patients’ visits because the entire medical history—including the most up-to-date information, such as lab results—will be at the doctor’s fingertips. Also, by replacing paper records, doctors’ offices will significantly improve safety and protect privacy, which is a growing issue.

Implementation Challenge
As advantageous as EMRs are, there are inherent problems with implementing such a system. The initial investment is approximately $60,000, which can be cost-prohibitive to a small firm, explains Anne-Marie Audet, MD, MSc, SM, FACP, of The Commonwealth Fund in New York. In addition to the initial investment, the annual operating costs can exceed $16,000, she says. “Quality is not a factor in most physicians’ compensation, which is still determined primarily by productivity,” adds Audet, who is the author of a recent Commonwealth Fund study that discusses physicians’ unwillingness to share quality data and accept new technologies.

Despite the cost, “free is not cheap enough,” according to Janet Sullivan, MD, chief medical officer of Hudson Health Plan in Tarrytown, N.Y. “Using the technology takes dedication to making it work.” Using the software requires physician training, which some physicians have little interest in doing, she adds.

Robert G. Berger, MD, director of medical informatics at the University of North Carolina Health Care System in Chapel Hill, points out another issue with EMRs. “It is faster to write out a prescription and scribble some notes than it is to type the information into a computer,” he says. “Time is essential in making the medical practice safer and this is sometimes more costly than the money needed to implement and maintain the system.”

A culture change must occur in the medical community for EMRs to be truly effective. Physicians must be willing to provide their clinical performance to their peers, patients, and the general public, Audet explains. “For EMRs to be effective, physicians must be more forthcoming with the quality of their care because the system cannot work if physicians do not share their quality data,” she adds. Only 55% of physicians want their patients to have access to their quality data reports and only 29% believe the general public should have access to this information, Audet reported in her study, “Measure, Learn, Improve: Physicians’ Involvement in Quality Improvement.”

Despite the drawbacks, several members of the medical community believe EMRs are the future of medicine and that their presence will not only make medicine safer but also improve the quality of care.

The future of medicine lies in EMRs, Sullivan asserts. “By moving away from the paper record and going to an entirely paperless operation, medicine will become safer and more thorough,” she says.

Another benefit of changing to an electronic system is that there will no longer be difficulty with reading prescriptions, which tends to be a problem because of poor handwriting. Additionally, there will be no confusion with drug names. Physicians will be able to select the medication they want to prescribe from a list of medications, which can eliminate deadly errors with patients receiving the wrong medication, Berger explains. With EMRs, there is a series of smart sets designed to guide physicians in ordering tests, prescribing medicine, and practicing population medicine—all to make the physician’s life easier and improve the patient’s quality of care, he adds.

If an office is unable to upgrade to an EMR system, there are other methods that can be used to improve the safety of a physician’s practice. Among these methods are a diligence to clarity in recordkeeping, a workflow change to identify mistakes or errors, and the use of a registry.

Registries and EMRs
Hudson Health Plan and the New York Diabetes Coalition have worked together to develop a registry for diabetes care, CareFocus. Under the direction of Sullivan, the registry is a computer spreadsheet for keeping track of a diabetic patient population in a specific practice or health plan. “Prior to using a registry like CareFocus, physicians were unaware of the care they were providing to their diabetic patients and most were even unaware of how many diabetic patients were in their practice,” Sullivan says.

CareFocus is not limited to one patient population; it can be tailored to any patient population to provide better care for that group. It is specifically designed to improve the quality of care a physician gives to a subset of patients. CareFocus assists physicians in identifying which patients with diabetes are due for their annual eye or foot exam as well as which patients have had hemoglobin testing and which are in need, Sullivan explains. By the next generation, Sullivan predicts that a registry will become a standard EMR function.

Registries and EMRs can work together seamlessly, Berger explains. The registry can be built into the database the physician uses so each EMR will have a series of subsets that covers common conditions and routine tests to care for patients with diabetes or heart disease. When the doctor logs on, a series of alerts will pop up on the screen with the patient’s information, including test results and any tests that need to be ordered.

Instituting a Nationwide Network
Despite the progress being made to transition to EMR systems, Sullivan explains that the safety and quality benefits of electronic health information will not be realized without a national healthcare network that can foster communication between physicians and with hospitals, labs, and pharmacies. When systems are not integrated, it can be as difficult to use information from an EMR as it is to use a paper record. “There are several nationwide initiatives underway to establish a national network but because of how privatized medicine is in this country, it is difficult to truly exchange information across the nation,” Sullivan says.

One solution to the barrier against the national exchanges of EMRs is giving responsibility to the patient. The recent unveiling of www.ihealthrecord.com from Medem, Inc. allows individuals to create a personal health record (PHR) of their own at their leisure. The record belongs exclusively to the patient, but through the iHealthRecord Web site, patients have the ability to share this record with whomever they choose, according to Medem CEO Edward J. Fotsch, MD. The site, which is provided by physicians associated with Medem, also allows patients to communicate via e-mail with their doctors and have online consultations.

In April 2004, President Bush called for the creation of a personal electronic health record for most Americans within 10 years. To that end, several Web sites have been developed to allow individuals to establish their own PHRs. In that vein, iHealthRecord.com is currently offering an interactive network of thousands of doctors. On the site, anyone can document their medical history to create a PHR at no cost. Once created, the record can be shared with a physician or loved ones.

Some healthcare professionals are skeptical. “With a patient-controlled record, the information is easily changed and the issue of its reliability is raised,” Sullivan explains. Another potential problem with patient-controlled health management via the Internet is that proper communication with the provider can be neglected. Additionally, without the records being fully integrated between the physician and patient, duplicates of information can exist, Palattao says.

Although the PHR at iHealthRecord is patient-dominated, once the physician is made aware of its existence it can be linked to the EMR that is on file for the patient, Fotsch explains. Physician-patient communication through the Internet can by no means replace a face-to-face consultation. However, if the issue does not require a visit, the Internet service can save patients time and money by allowing them to receive their doctors’ advice for the cost of a copayment from the comfort of their home or office, Fotsch adds.

Patient Control
Within the Medem network of doctors, the patient’s physician can view the PHR once a password and user name have been established to ensure privacy. In addition, the record can be shared with anyone outside the network once a user name and password have been established for others who are granted access to the PHR by the record’s owner.

The idea of a national healthcare network that enables physicians to communicate with patients through computers is a natural progression for medicine. “However, a national network is far from being realized because our country’s healthcare is so segmented that there isn’t a system to integrate,” Sullivan says. Currently, our healthcare system is a series of individual companies that restrict the communication between doctors at other healthcare plans, offices, and hospitals, she says.

Audet also believes that for a national network to emerge there must be some retooling of the current mentality in medicine. In her study, she outlines several options for increasing the quality of care and improving the safety of medicine. First, Audet envisions physicians being more forthcoming with clinical performance—not only with their medical directors and hospitals but also with their patients, peers, and, most importantly, the public. Audet realizes that a physician opening his clinical performance to the general public is “the equivalent of the physician being on the front page of the news.” However, this mentality must be abandoned, she says.

The current attitude in the medical profession is that the physician is to be trusted, Audet explains. However, with patients being more proactive in their own health, they are interested in their physician’s performance. They want to know they are receiving the best care and make educated decisions about their healthcare providers.

According to the AMA, one solution to eliminating the autonomous nature of medicine is to change the reimbursement structure. It reasons that by switching the reimbursement method to pay for performance rather than procedures, medicine will intuitively become safer. Physicians and hospitals will not be able to bill for unnecessary or duplicitous services and, rather than the healthcare provider being paid for the process, it will be paid based on the outcome, Audet explains.

“This method of reimbursement will tailor the quality of medicine to the patient and to the situation rather than being driven solely by financial incentive,” she says.

— Kim M. Norton is a freelance journalist.

Subscribe to Radiology Today Magazine!