The Electronic Health Record (EHR). A good augury for the doctor-patient relationship?

[This article is published in the October 2012 issue of Infomed (pgs:58-59)]

There is change happening in Health Care. In hospitals, and in neighbourhood clinics. The traditional method by which doctors and nurses recorded a patient’s visit in the outpatient or documented a patient’s progress in a hospital admission; using pen and paper, on sheets filed under the patient’s name and hospital number, and stored in the Records Department, is giving way to a new digitized method of record keeping called, Electronic Health Record or Electronic Medical Record (EHR/EMR). The terms are used interchangeably.

For decades now, computer technology has been slowly and successively integrating into traditional medicine at every stage of the patient-doctor-hospital system interaction – in the labs, radiology investigations, pharmacy and/ or nursing.  The change in documentation style happened early with labs and radiology because of the technological advances in diagnosis (lab reports, hospital summaries, and radiology studies are ‘printed out’ as hard copy or packed in CDs as soft copy). However, the actual physical interaction with a doctor, a physician assistant or a nurse continued to follow the traditional hand-written style and was stored as a paper file in storage rooms called ‘Department of Records’. With the introduction of interactive applications into computers within a hospital network; this last bastion has crumbled and pens and pencils on a doctor’s desk have been replaced by a mouse and a keyboard.

What are the advantages of this shift? Will all players and participants in the healthcare system benefit?

The US government recently invested 27 billion to incentivize and accelerate the transition from paper medical records to EHRs. The size and scale of this investment is a good indicator of the value addition of this technology. For healthcare providers, the immediately obvious advantage of the EHR is improved productivity and efficiency in workflow. Data entry is easy and there is greater confidence with data integrity and reproducibility. Medical records have now become potable and that makes them accessible from any location with an internet connection. Finally, the cumbersome storage methods of paper files have been dramatically condensed and transformed. However, the larger and more significant long term impact is in Data Analytics. The automatic accumulation of large volumes of data, that happens when records are digitized, can now be studied in depth across a host of areas that range from clinical research to behavioural pattern recognition and operational errors in the workflow of a hospital system. The transformational potential of Data Analytics is huge and will bring about a much needed streamlining of Healthcare delivery and costs.

Such potential for positive disruption is often accompanied by worries and medicine is no exception. Here too, the magnitude of the collected data volume has raised concerns about data security, mining and misuse. To address these concerns, it is now mandated by Law that all certified systems have inbuilt safety controls that include encryption and regular audit tracks (this is a list of who has accessed records and when). Further, patients too can access their records over the web and the access also includes both audit and encryption. Increasing transparency and inclusiveness in medicine is of direct benefit to both doctors and patients. Last week, the Annals of Internal Medicine1 published very heartening results of the success of the OpenNotes2 Project undertaken by three medical centres in the US. 70% to 80% of participating Primary Care Physicians and 92% to 97% of participating patients thought, patient access to a doctor’s notes to be a good idea and a welcome step forward.

These are well documented contributions of the EHR to the betterment of the clinical workspace. But how does a patient as a user of healthcare services benefit?

1. Improved Care: By having all your medical records in one place, your primary care doctors and specialists, as well as nurses and paramedical staff can coordinate treatment and care better. By putting all information about a patient in one place, a cooperative interaction between doctors and treatments is automatically effected and repetition of tests and prescription errors erased

2. Access: By having access to records and doctors’ notes; a patient is transformed into an active participant in his/her own health

3. Inclusion and Control: EHRs foster the doctor-patient relationship by promoting patient participation and inclusion. Patients also feel a greater sense of control by being able to access their own data. A few hospitals in the US have launched OpenNotes – an interactive format that allows patients to contribute and access a doctor’s notes in an outpatient setting. These simple measures are a first step to rebuilding trust between provider and patient. By having access to information, patients also are motivated to assume more responsibility over their own health

4. System change: Fewer prescription errors, reduced time of information sharing and reporting, and better follow up

5. Patient tools for self-monitoring: Often, variations and swings in symptoms and metrics like blood glucose levels, heart rate and blood pressure happen at home. A doctor is not witness to these fluctuations. Smart Phone applications for monitoring health metrics (currently in use for: blood sugar, blood pressure, ECGs) are making a rapid entry into home-health. This form of healthcare that uses smart phone and medical app technologies to facilitate home monitoring by patients is called mHealth (short for mobile health). mHealth allows self tracking by a patient and can alert both patient and doctor to early signs of change in a medical condition. In addition an easy and simple form of record keeping (by and for patients), of all this tracked data is being introduced and is called the Patient’s Health Record (PHR).

The Industrial Revolution in the 19th CE and the Information Technology Revolution of the 20th CE leapfrogged civilization in a matter of a few hundred years to extraordinary heights of achievement and excellence. The last three decades have seen great strides in the technology of medicine in diverse areas such as, diagnostic methods, robotics in surgery and stem cells and tissue engineering, to name a few. While dramatically expanding treatment options and cure, the takeover of machine was seen as dehumanizing. Patients and their care-givers dropped into the wide-split chasm between the technical wizardry they got and the human connect they sought. They bore the brunt of the struggle to comprehend the technology and its impact on their health outcomes. Patients have felt systematically excluded from the health system, as a whole, despite the fact that, ‘they’ were the consumers and in effect therefore, the drivers of the change. Happily, the more recent advances in computer applications like EHRs and mHealth are set to reverse this trend by promoting the very welcome change of greater inclusion and participation of patients with and in the system. That both doctors and patients are embracing the change is heartening and holds out hope for an industry that has been at the receiving end of much criticism in recent times.

Links to refs:

1. http://annals.org/article.aspx?articleid=1033220

2. http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/07/open-notes.html

———————————————————————————————————-This article was published in the October issue of Infomed. Link:

http://www.infomed.com.my/magazine/1685501518/index.html
(Pgs 58-59)

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