Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

The Electronic Health Record: Keeping the Illegible From Becoming the Illogical

Joseph J. Tepas, III, M.D.
Professor Surgery and Pediatrics University of Florida-Jacksonville Campus
8-1-1 In November 1999, the Institute of Medicine released “To Err is Human” in which it reported that approximately 98,000 unexpected deaths occur every year in American hospitals. The fact that these patients were dying unnecessarily in the very places designed to preserve life is the core of the national mandate for a safer system of health care delivery. The report identifies, as a major system deficiency, the innumerable barriers to accurate and timely information exchange among members of the health care delivery system. One of the first recommendations for correcting this problem was the rapid implementation of electronic medical records as an alternative to dealing with illegible scrawl on prescriptions and in health records.   Shortly thereafter, many informatics companies began to market their versions of electronic medical health records, almost all of which today produce unstructured textual representations of what used to be written on a piece of paper tenuously attached to a notebook at the patient’s bedside. As the transformation of our health care system progresses, this tsunami of unstructured textual data will gradually evolve to a more specific structured format that will precisely define system performance and track clinical outcomes. Most importantly, this data will become the substrate for accurate clinical decision support. Until then, there are a number of factors regarding the emerging application of electronic health records that directly relate to the current daily practice of medicine. As always, these factors present both risks and rewards.   The rewards are fairly obvious. The display of information on a screen in front of the physician rather than on a piece of paper in no way implies better or more efficient health care. However, the fact that an electronic system contains all of the records that heretofore the physician had to dig out of endless paper files does provide immediate benefit.  This, in concert with concurrent display of ancillary information, should facilitate the process of clinical care. Ultimately, accumulated data from numerous health records will emerge as an evidence base that will stimulate a more precise level of disease management and improve the overall quality and efficiency of health care.   The risks may be less apparent, but are no less real. The intent of electronic health records is to make information more accessible, accurate, and available, however, each presents significant potential for system or individual error.   Access:   The continued evolution of informatics technology now makes it possible to track information from practically anything with a circuit board and electric power source.  Every one of these devices represents a potential breach in the security that should surround virtually every piece of data related to personal health information (PHI). Electronic HIPAA violations carry the same penalties as those sprung from pencil and paper. The availability of new smart devices creates a new potential for unauthorized disclosure and demand for accountability from those who elect to access patient information using them.  Fortunately, the core of electronic medical record systems is based on client-server design. This is intended to assure that no piece of health information is actually stored on a remote device, just the security portal that enables the device to access the appropriate server. The next statement should, therefore, be obvious.  Never copy medical data, including images, to an unsecured portable device, or send such data via unsecured e-mail. While managing “secure”, complex passwords can be annoying; criminal or civil prosecution for violation of federal law can be personally and professionally devastating.   It is easy to imagine how a well-intentioned health care provider could attempt to leverage modern technology into more efficient care without realizing the possible litigious and potential criminal, implications. For instance, a resident wanting to send critical information to the attending could easily photograph record images with a smart phone and send them via text message, or another healthcare provider could innocently take photos of an interesting surgical case to discuss in an educational forum. Until a secure configuration of existing technology is in place, the risk of good intentions potentially becoming disasters will increase as smart devices continue to proliferate the health care sector.     Accuracy:   Physicians have been writing illegibly in health records since the concept of bedside record keeping was espoused by Halsted in the 19th century. In some cases, information put to paper has been irrational, illogical, or, totally inappropriate.  Other than instances where poor clinical record documentation behavior has triggered an external audit or has compromised what should have been a defensible medical malpractice case, this phenomenon has essentially gone undetected. With the evolution of electronic health records, however, the process of transforming clinical thought to ordered electronic words involves interface with a keyboard, dictation recorder, or other similar device. Despite the proliferation of a “keyboard generation,” many clinicians are not efficient typists or proof-readers. Thus, the following risks emerge.

● The likelihood of entry of the right data on the wrong patient is a continued threat that must carefully be considered.

● The temptation to “cookie cutter” one progress note onto the next to meet the rule of the law of electronic documentation will all but assure that the information so entered is essentially worthless.

● The mandate to document that reviewed clinical information as well as data entered meets established reimbursement criteria must still be recorded accurately and consistently.

  Availability:   One of the major advantages of transition to an electronic health record is that information about a patient who lives in Florida should theoretically be available to physicians in Kansas who may be treating this patient for an acute emergent event. The process of availability must be well defined and well understood. The “meaningful use” requirements promulgated by the Centers for Medicare and Medicaid Services includes a mandate that patients have access to their electronic medical records, and that physicians can provide critical information for patients regarding management of their disease in a readily available electronic format. What is done with this data, as well as the reliability of its origin, may be problematic unless specific policies and procedures regarding how and to whom this information is dispensed exist. Thus, the issue of availability mandates system-wide governance that oversees what should be immediately obvious to the patient’s treating physician, what is readily transferable to consultants, and what must be transportable to assure the patient that his or her health information does indeed follow them wherever they go.   In summary, an electronic medical record system that provides readily available, accurate and complete data is clearly a significant asset for improving the efficiency and cost effectiveness of health care.  As indicated by some of the issues noted above, however, it can also be a source of endless adverse effects if the health care provider who is using this system does not fully appreciate all of its potential risks and understand the processes by which these risks can be minimized for both the patient and provider.   Is all of this really necessary? Absolutely! There is no question that an investment by clinicians in effective use of an electronic medical record management system can be of enormous benefit to the system of health care. In October 2010, the Technology CEO Council, a group of executives from the leaders of the high tech industry, issued a report entitled “One Trillion Reasons”.  They demonstrated that one trillion dollars could be saved from the federal budget by 2010 by simply improving and standardizing the information technology infrastructure of the government. No additional taxes are needed, no budget cuts are mandated; just intelligent application of existing technology. This challenge by leaders of an industry that cannot survive without profitability should be clear evidence to every clinician that mastery of the emerging tool of EHR will improve patient care, save time, and become an essential weapon in the battle to rein in the uncontrolled costs of modern health care.