There is an elephant in the room. It’s big and powerful and kind of scary. Maybe it’s going to trample on the furniture; maybe it’s going to break something with its big, swinging trunk. It sure is hard to sit politely with teacups balanced on our knees, trying to ignore it. So let’s talk about it, instead. Maybe there’s something we can learn…
Electronic medical and health records are here. The days of typing medical reports from microcassettes, and schlepping them back and forth are coming to an end, as are the days of printing the reports on sticky paper, pasting them in paper medical files, and keeping them in millions of color coded manila folders in back rooms of medical offices. This change can be perceived as a threat—a big stinky, potentially destructive elephant in the parlor—or as an opportunity.
There are some definite benefits to having medical records in an electronic form.
In the aftermath of natural disasters that underscore how fragile paper records are, and how easily lost, the security benefits of keeping medical records in an electronic form become very clear. Thousands of records were scattered, and destroyed by high winds and water in hurricane Katrina, for instance, not only making these records unrecoverable, but putting sensitive information at risk from anyone who might happen upon a stray document at any point in the aftermath. If this information had been backed up in a server in another location, none of it would have been lost.
Another benefit of electronic records, of course, is ease of transferability. Electronic documents, images, and sound files can be quickly and easily sent wherever they are needed or wanted, without mailing/courier time, or the risk inherent with sending such information offsite, in the hands of non-medical personnel.
Still another benefit is the ability for doctors to provide more effective care to patients. Even though the electronic medical record is not necessarily “plugged in” to a wider network, the information is already formatted to easily become part of a network, so it can be shared by medical caregivers across the country.
You’ll notice the term electronic medical record, or EMR. There is a lot of discussion regarding the difference in meaning between EMR and the EHR, known as the electronic health record. Not everyone agrees, but the understanding among most sources is this:
1. An electronic health record (EHR) consists of information gathered at the point of care, in a particular setting (like a clinic or hospital), for a single encounter. The EHR belongs to the clinic, and exists, at least initially, within the internal electronic system of that clinic or hospital only.
2. An electronic medical record (EMR), on the other hand, consists of the long-term, continuous record of a patient’s health history, from birth to death. It has been proposed that the patient should own this information, but at the present, this question is not settled. The EMR is intended to be shared over a large network. The EMR is, theoretically, made up of many EHR records.
Imagine, for instance, dear Uncle Harry comes from Baltimore to visit you in Spokane. You’re thrilled to see him because he has some health conditions that make him a little nervous to leave home; it’s a measure of his fondness for you that he made the trip. During his visit, however, he develops severe chest pains and needs to go to the emergency room for evaluation. You have some general knowledge of his medical conditions, and you grabbed a few pill bottles from his nightstand when you left for the hospital, but you can’t give very detailed information—and neither can he, because he is frightened and feeling awful, and moving in and out of consciousness.
You can remember the name of his doctor, however, and you know the clinic he visits. Luckily, Uncle Harry’s records are in an EHR, so the doctors at the hospital in Spokane contact his clinic in Baltimore and request them. Within minutes the doctors in Spokane have access to his medical information, including stress test results, full medication list, and his detailed medical history. If the doctors have access to Uncle Harry’s EMR, they can simply log into the network to see his medical information.
This is great. When doctors have access to prior test results, it reduces cost incurred by rerunning tests—and medical tests can get expensive! It also reduces wear-and-tear on Uncle Harry by eliminating those extra blood draws and MRIs, and saves a great deal of precious time, as well. It also helps immensely to determine the most appropriate course of action. Instead of learning from scratch how to take care of Uncle Harry, the doctors in Spokane can pick up appropriately from his last point of care, working in tandem with his primary care doctor in Baltimore. It’s clear how the ability to quickly share information electronically can help provide more consistent, efficient, and cost-effective care to patients.
These potential benefits are exciting, and patient care should be the first concern. Of course, the issue is larger than the scope of this article. I know we haven’t mentioned other concerns like offshoring, protection of privacy, and accuracy (if you’ve ever seen your own medical records, or even your credit rating, you know mistakes can and do exist in current records). One thing at a time. Yes, the days of paper medical files, color coded in millions of manila folders in back rooms of a medical offices are coming to an end. It is a change from the systems we’ve used until now, but change is inevitable, and change can be very good. If new systems result in better patient care, we should embrace them and adapt.
Medical documentation will always be an important part of any healthcare system; there will always be a need for well-trained professionals to make sure the records are correct, clear, accurate, and produced in a timely manner. Doctors, lawyers, and patients are interested in being protected with accurate records. As medical documentation professionals we will learn to use new programs and protocols, and grow and change with the industry—if we can view change as an opportunity, instead of a threat. If you position yourself as one of the cream of the crop you may very well find yourself happily working on the cutting edge of the industry.
Maybe-just maybe-we can slip a harness on this elephant, climb up on its back, and use its strength and power to carry us forward. While many questions are waiting to be answered with the healthcare industry and medical documentation, it’s a good policy to be as informed as possible so you can be ready to participate in the results of change instead of being left behind with a parlor full of broken teacups.
Let’s ride this elephant!