Electronic medical record systems in developing countries (4)

Implementation in the other country

(3) The HIV-EMR system, Haiti
Background: Since 1999, PIH has run a communitybased HIV treatment programme in Haiti with its sister organisation Zanmi Lasante, expanding to seven public health clinics in an area with virtually no roads, electricity or telephone service.
Design: Based on the PIH-EMR. Satellite-based internet access at each site supports email and web communication.
Sites: Seven in rural Haiti.
Number of patients: 4000; 2000 full patient records.
Data entry: Doctors enter case histories and medications directly, whereas technicians enter laboratory results and pharmacists enter stock records. The data entry staff is being expanded.
Design: Open source web system backed by an Oracle database (the same as the PIH-EMR) with an additional offline client for data entry and review. Bilingual English and French.
Functions: History, physical examination, social circumstances and treatment recorded. Decision support tools provide allergy and drug interaction warnings, and generate warning emails about low CD4 counts. An offline component of the EMR was developed to overcome unreliable internet communications in some sites. This allows data entry and case viewing when the network is down, and has proven to be reliable and popular with clinical staff.
Pharmacy management: Full inventory system and drug regimen analysis.
Significance: The HIV-EMR shows the feasibility of implementing a medical record system in remote clinics in a remote area with virtually no infrastructure and limited technical expertise.

(4) Careware, Uganda32
Background: A team at the US Department of Health and Human Services has developed a medical record system to support HIV treatment via the Careware system.
Design: Stand-alone database built with MS Access.
Sites: US: 350; Africa: Two.
Number of patients: Several hundred in Africa, many thousands in the USA.
Data entry: Both direct by users, and on paper forms.
Functions: Provides comprehensive tools for tracking HIV patients and their treatment, including clinical assessment, medications and billing data. It is widely used in health centres and hospitals in the US, and has recently been internationalised and deployed in Uganda in October 2003.
Pharmacy management: Drug inventory support in international version.
Significance: Careware is an example of a US-based stand-alone EMR that is being adapted to developing country environments. An internet-accessible version that is under development will allow local data entry offline but provide networked communications and back-up.

(5) Lilongwe EMR, Malawi13
Background: Kamuzu Central Hospital located in Lilongwe, Malawi has made extensive use of a touchscreen patient management information system for a wide range of clinical problems in the 216-bed paediatric department since 2001.
Design: Runs over a local area network built on Linux/MySQL with Visual BasicTM for the client programs.
Sites: One.
Number of patients: 160 000 total; 6000 with HIV.
Data entry: Physicians, nurses and pharmacists perform all data entry using touch screens, including medication orders.
Functions: Data are collected on patient demographics, medication, laboratory tests and X-rays. A potential limitation of the touch screen approach is that it is difficult to enter free text, though an ‘on-screen’ keyboard is available and has been used by local staff to enter all the patients’ names.
Pharmacy management: Recording of regimens only.
Significance: The extensive use of this system directly by healthcare workers in a poor country with limited IT skills is a convincing demonstration of the potential of EMRs with user-friendly data entry mechanisms.

(6) SICLOM, Brazil
Background: The Brazilian public health system uses the ‘Computerized System for the Control of Drug Logistics (SICLOM)’ to deliver ARV treatment to over 100 000 patients – by far the largest group in the developing world.
Design: Separate EMR databases on each physician’s desktop periodically connect to the central server by dial-up to update records.
Language: Portuguese.
Number of sites: Widespread throughout Brazil.
Number of patients: More than 100 000.
Function: Used to support prescribing and track medication supplies (limited information available).
Significance: It is considered a ‘key factor(s) helping to overcome logistical challenges to delivery of antiretroviral treatment in Brazil’

Other EMR systems in developing countries
FUCHIA was developed by Epicentre, the epidemiology group of Me´decins Sans Frontie`res, to support their HIV treatment projects.35 It supports clinical care and long-term follow-up of patients, including scheduling of visits; it includes data on medications and investigations and generates reports. It was developed as a standalone system using MS Access and the Delphi programming language.
An information system was developed in Botswana to support the TB programme and is built using EpiInfo (a free stand-alone program from the US Centers for Disease Control [CDC] designed for data collection and analysis in developing countries). It includes reporting and analysis tools and has been successfully deployed to multiple sites in several countries.
PDA/Palm systems
A variety of PDA-based medical information systems have been proposed or implemented for projects in developing countries on the basis that handheld devices will be easier to use and support in remote sites. Such devices would seem to provide particular benefits for community health care, being simple and relatively unobtrusive to carry around. Palm-based devices tend to be favoured due to their excellent battery life and generally lower cost. In KwaZuluNatal, South Africa, a Palm-based system allows secure access to HIV results in remote clinics. In rural India, a Pocket PC-based system has been used to store health records for community nurses visiting remote villages. Palm or Pocket PC systems can be easily set up to view pages offline from a web-based EMR, though care is required to maintain data security. Satellife is using the mobile phone network in Uganda to link PDA-based medical records to a central site. Local healthcare workers collect data on Palm PilotsTM and then connect to a local battery-powered server that connects to a central database via a mobile phone modem.
Web-based collaboration and telemedicine systems
The web allows data sharing for remote consultation, and several projects have established systems that can be used to support diagnosis and treatment decisions in remote sites with limited bandwidth. The RAFT project permits remote collaboration, case discussion and data sharing over low-bandwidth networks between Geneva University Hospitals and Bamako, Mali. The IPATH server is a web-based tool for image sharing in pathology and radiology being used in South Africa and the Pacific as well as Switzerland. Telemedmail is a secure email and web-based telemedicine system under evaluation in South Africa and Peru.

HSF Fraser, P Biondich, D Moodley et al (countinued..)

Electronic medical record systems in developing countries (3)

Electronic medical record in case summaries of existing systems

Despite the difficulties in deploying information systems in developing countries, several have successfully integrated into clinical workflows. While none represent a complete or ideal solution, their successful use over several years, with combined patient records numbering in the hundreds of thousands, offers valuable insights into successful future deployments. This is not intended to be an exhaustive list; other systems might contain important ideas and designs but need to be validated in appropriate environments. Box 2 includes brief descriptions of other known systems deployed in developing countries. A recent report includes an assessment of medical information needs in African clinics and some additional systems.

(1) AMRS, Kenya

Background: Indiana University School of Medicine and Moi University School of Medicine (Eldoret, Kenya) have been collaborating for over 15 years. In February 2001, this collaboration led to the Mosoriot Medical Record System (MMRS). The Mosoriot Medical Record System (MMRS) was installed in a primary care healthcare centre in rural Kenya. In November 2001, the Mosoriot Medical Record System (MMRS) software was adapted to support the AMPATH (Academic Model for the Prevention and Treatment of HIV/AIDS) project and renamed to AMRS.
Design: Two networked computers running Microsoft (MS) AccessTM, powered by a UPS with solar battery back-up. For the AMPATH project, the network has expanded to seven networked computers linked to a single MS Access database.

Number of patients entered: 60000 patients and over 150 000 visits in four years. For HIV care, 8000 patients, 3300 of whom are currently receiving anti-retroviral drugs (ARVs).

Sites: Two, with the AMPATH site serving as a central repository for eight remote clinics.
Data entry: In the Mosoriot Medical Record System (MMRS), patients are registered in the system upon arrival, travel through the clinic with a paper visit form, and present the visit form as they depart. Clerks perform the registration and transcribe visit data. AMRS data are collected on paper forms at each visit, delivered to a central location for data entry, and then returned to the patient’s paper chart.
Functions: the Mosoriot Medical Record System (MMRS) provides both patient registration and visit data collection functions. Data are collected on all patients seen in the medical clinic, including their laboratory results and medications. AMRS supports comprehensive HIV care as well as mother-to-childtransmission prevention,while serving as a rich database for quality improvement and answering research questions.
Pharmacy management: Based on drug regimens analysis available.
Evaluation: A comparison of the clinic before and after adoption of the Mosoriot Medical Record System (MMRS) showed patient visits were 22% shorter, provider time per patientwas reduced by 58% (P < (P < style="font-weight: bold; font-style: italic; color: rgb(102, 0, 0);">Significance: The growing AMRS and the Mosoriot Medical Record System (MMRS) databases serve both clinical and research needs, generating clinical summary reports for providers and providing a centralised source of data for epidemiological research.
The next generation of the database, called AMRS, has a completely revamped data model, and uses new technology (MySQL, Python-based Zope and Plone, andMSInfoPath to allow web-based data entry). See http://amrs.iukenya.org for more information.

(2) PIH-EMR, Peru

Background: In 1996 Partners In Health (PIH) started a treatment programme for drug-resistant tuberculosis in the slums of Lima, Peru. (A patient that is multi-drug resistant is infected with bacteria resistant to isoniazid and rifampin, the two most efficacious anti-tuberculous drugs.) The Partners In Health (PIH)-Electronic Medical Record (EMR) is a webbased Electronic Medical Record developed to support the two-year treatment regimen for these patients. It was implemented in 2001.
Number of sites: Peru: three; The Philippines: one.
Number of patients: 4300; 2900 have received treatment to date.
Design: Open source web system backed by an Oracle database. Bilingual English and Spanish.
Data entry: Forms filled out by the chest physicians, as well as laboratory result forms. Medication data is entered by the nurses and their assistants who manage the patients in each district on advice from the chest physicians.
Functions: The Partners In Health (PIH)-Electronic Medical Record (EMR) includes a clinical record with initial history, physical examination, laboratory results and medications on all patients receiving individualised treatment for MDR-TB. The custom medication order entry system provides advice on potential problems and feedback to the nurses, who can consult the physicians if, for example, a patient has new evidence of resistance to the drug they have been prescribed. Laboratory tests for second-line drug resistance are entered in Boston and Peru and accessible by staff in both sites.
The Partners In Health (PIH)-Electronic Medical Record (EMR) is also used to create monthly reports for the Global Fund and the Health Ministry. There is an extensive suite of web-based analysis tools for reporting and outcome monitoring. These include graphs of culture conversion rates (time until sputum culture becomes negative) and search tools for patients with particular resistance patterns and drug regimens.
Analysis tools are used to assess drug requirements based on the medications prescribed. The system is being extended to include all MDR-TB patients in Peru and linked to the main tuberculosis laboratories there.
Pharmacy management: Full inventory system and drug regimen analysis.
Evaluation: The medication order entry system was shown to produce significantly fewer errors than the previous paper and spreadsheet approach (17.4% to 3.3%, P < 0.0075). Drug requirements analysis tools are based on the medications prescribed, and have been shown to match the usage data in the pharmacy to within 3%
Significance: The Partners In Health (PIH)-Electronic Medical Record (EMR) demonstrates the strength and flexibility of a web-based approach when internet connectivity is available.
(continue..)
HSF Fraser, P Biondich, D Moodley et al

Electronic Medical Record in developing country (2)

Potential benefits of Electronic Medical Records systems in developing countries

Although Electronic Medical Records systems have been shown to be feasible in developing countries, the problem of limited resources begs several questions. Do Electronic Medical Records systems contribute important benefits to healthcare projects? Is this use of information technology (IT) practical beyond a few well-funded pilot sites? Does it have a beneficial impact on patient care or the management of such healthcare organisations? What lessons can we pass on to other healthcare organisations to help them identify the most effective and sustainable technologies for Electronic Medical Records systems in these environments?
Rapid developments in IT have greatly reduced the costs of setting up information systems. Plans have recently been announced to develop a laptop PC for $100.16 Internet access is now relatively widely available in many developing countries (Peru, Ghana, etc.) and there exists a broad range of robust and flexible devices to manage data, including personal digital assistants (PDAs) and mobile phones.
In developing countries, healthcare information systems have been driven mainly by the need to report aggregate statistics for government or funding agencies.
Such data collection can be performed with simple paper forms at the clinic level, with all electronic data entry done centrally, but that approach tends to be difficult and time-consuming and may provide little or no feedback to the staff collecting data. Individual patient data that are collected and accessible at the point of care can support clinical management.
Clinicians can easily access previous records, and simple tools can be incorporated to warn of potential problems such as incompatible drugs. Physicians or nurses can check on the outcomes of individuals or groups of patients and perform research studies. Many of these functions will work well on paper or with simple spreadsheets for up to 100 patients but become very time-consuming and potentially unreliable with more than 1000 records, and virtually impossible with 10 000 or more.
Networked Electronic Medical Records systems allow laboratory data to be entered from distant sites, assisting prompt and effective patient management. Access to email or web communications allows staff to seek specialist advice from remote physicians. Assessing resource requirements and preventing drug stock shortages, while not normally a consideration for medical staff in developed countries, can be a critical issue in the developing world. It requires an accurate knowledge of numbers of patients with particular regimens or types of disease and knowledge of drug stocks and supply. Electronic Medical Records systems can also be used to track patient outcomes, compliance with therapy and to record surgical procedures. Finally, point-of-care data can be used to rapidly generate aggregate reports, which should be more complete and accurate because users will more likely recognise errors regarding their own patients. Incorporating multiple functions into the same information system allows reuse of data and should help to justify the basic costs of set-up and technical support. For example, in sites with no modern communications, a satellite internet connection might be justified purely to allow regular communication by email and possibly internet telephony. The benefits of web access for data management and medical education are additional.
summarises the benefits of Electronic Medical Records systems.

1. Improvement in legibility of clinical notes
2. Decision support for drug ordering, including allergy warnings and drug incompatibilities
3. Reminders to prescribe drugs and administer vaccines
4. Warnings for abnormal laboratory results
   
5. Support for programme monitoring, including reporting outcomes, budgets and supplies
6. Support for clinical research
7. Management of chronic diseases such as diabetes,hypertension and heart failure

( continue..)

HSF Fraser, P Biondich, D Moodley et al

Electronic Medical Record in developing country (1)

Introduction

The developing world currently faces a series of health crises that threaten the lives of millions of people. Many of the worst-affected developing countries lack resources and robust healthcare infrastructures.
Recent statistics suggest that treating the rising tide of human immunodeficiency virus (HIV) in developing countries requires that large-scale interventions are immediately put into place, and ambitious worldwide initiatives such as the Global Fund and the World Health Organization (WHO) 3 by 5 Initiative have begun to mobilise resources and manpower in response.
Early lessons from treatment programmer indicate that new systems of care are required to allow these efforts to scale rapidly to thousands or even hundreds of thousands of patients. Programmer must also support healthcare providers, many of whom have limited training. To achieve these ends requires the ability to manage large and often complex projects, including the initiation of new treatments, the followup and monitoring of chronic diseases, medication procurement, and reporting to governments and funders. Research must also occur concurrently with these efforts, as the pathophysiology of these diseases is not fully understood in these environments, and continues to change in response to our interventions.
Many of these goals require excellent information management in order to be successful. Concerns have been expressed that the lack of infrastructure and skills in developing countries will prevent large-scale treatment of such diseases as HIV and multi-drug-resistant tuberculosis (MDR-TB). While HIV, TB and malaria are the best known, other important problems must be addressed, including maternal and infant mortality, other infectious diseases, trauma, and rising levels of hypertension, diabetes and cardiovascular disease in developing countries.
Growing use of electronic medical record (EMR) systems in Europe and the United States (US) has been driven by the belief that these systems can help to improve the quality of health care. Decision support systems, particularly for drug order entry, are becoming important tools in reducing medical errors. Email is important and widely used in healthcare systems, and access to medical data including online journals is expanding.
Even in resource-rich nations, the development of electronic medical record (EMR) systems is still an uncertain and challenging task, calling for a sensitive matching of local needs to available technologies and resources. Experience with creating electronic medical record (EMR) systems for the developing world is much more scarce; requirements, priorities and local constraints are less well understood and probably more heterogeneous.
Some settings in the developing world are similar to a European or US healthcare environment and can use similar software; other environments have very limited resources. It is impossible, therefore, to suggest a single electronic medical record (EMR) systems architecture and implementation that will fit all environments and needs. In this paper we focus on systems that can support health care in the very challenging impoverished environments where the vast majority of the world’s population live. A handful of projects in developing countries have now met the test of actual implementation in such settings and are in day-to-day use.
We first discuss the potential benefits of electronic medical record (EMR) systems in developing countries and then present short descriptions of several systems with which we are familiar that are in regular use.We then provide a taxonomy of system architectures and technology choices and comment on their applicability in particular kinds of environments, drawing on our practical experiences and the examples of deployed systems.We also present a number of challenging issues including reliable patient identification, data quality management, and data confidentiality and security. Finally, we conclude with mostly non-technical lessons learned from experience in successfully deploying systems.
This is intended as a practical guide for deploying and using electronic medical record (EMR) systems in developing countries rather than a review of all existing projects. Unfortunately few systems have been described in the literature and fewer evaluated, but a systematic review of such systems was published in 2002. (continue..)
HSF Fraser, P Biondich, D Moodley et al

Electronic Health Record and Eficiency (2)

Part 2.


..Why such inconsistency? Physicians might resent the loss of professional autonomy or have limited tolerance for on-screen prompts. In one survey, 75 percent of physician respondents admitted ignoring reminder icons, and more than half seldom or never acted on the information. The Electronic Health Records also impedes addressing other immediate patient needs in a time-limited office visit.
Electronic Health Records advocates also point to errors of commission. For example, important information might be missing from paper records, including radiology or laboratory tests Accordingly, if inaccessible records are responsible for costly retesting, reductions should be readily achievable. This was not the case at Kaiser Permanente, where "use of clinical laboratory and radiology services did not change conclusively" over a two-year transition to the Electronic Health Records .
Excessive testing could be more a function of defensive medicine, ease, or fear of uncertainty. Electronic Health Records decision support tools—including peer management, guideline promotion, and alerts about cost or redundancy—might reduce this. However, an Electronic Health Records -based decision support system that is cost-saving, generalizable, and sustainable remains elusive. Finally, ancillary testing is an important source of revenue. "Profit center" laboratory or radiology departments will not necessarily welcome Electronic Health Records -based interventions that lead to fewer tests and less revenue.

Storage of other encounter data.
Medical records are notoriously vulnerable to damage or disappearance. Hurricane Katrina’s destruction of Gulf Coast physician office practices has been cited as an example of the need for electronic medical information storage. Yet Hurricane Katrina’s cost was not factored into any of the previous savings estimates; in fact, the president’s endorsement of the Electronic Health Records predated this disaster by more than a year. Furthermore, the history remains a time-honored and reimbursable feature of every physician-patient encounter. Aside from the few situations in which patients are too ill to communicate, patients’ recall of past medical facts is accurate across a wide range of conditions. It is also far cheaper than remote storage. (countinued..Medication error avoidance..)

Electronic Health Record and Efficiency (1)

Part 1.

As noted, the Electronic Health Record’s potential is based on its ability to introduce new efficiencies to health care delivery. Each is examined below :

Worker productivity gains.
One analysis showed that the Electronic Health Record increased documentation time among physicians by approximately 17 percent, while computerized provider order entry (CPOE) increased it by 98 percent. In a separate study, Electronic Health Record implementation at Kaiser Permanente resulted in a 5–9 percent decrease in office visits replaced by telephone contacts.9 Even if future "smart texts" or automated physician orders correct these inefficiencies, it is unclear whether the Electronic Health Record enables gains in provider-to-patient ratios. Rather, these studies suggest that a possible outcome is that the same providers would serve the same patients, with fewer office visits, more remote communication, and more documentation.
However, the Electronic Health Record can enable clerical staff reductions amounting to $13,000 per physician per year.10 For these savings to be realized, staff employment would need to be completely terminated. Although this is likely in outpatient settings, anecdotes of health care systems (where Electronic Health Record's are prevalent) offering displaced workers other employment opportunities (including in IT departments) are commonplace enough to dilute these savings.
Ultimately, if the Electronic Health Record consistently reduced labor costs, lower staffing ratios should enable insurers—representing the "front line" in managing health care costs—to reduce their fee schedules among Electronic Health Record-enabled providers. The same should be true for participants in consumer-directed health plans. There is little evidence that this is occurring among the 17 percent of practices possessing an Electronic Health Record.

Billing optimization.
Not only are the Electronic Health Record’s labor savings questionable, but increased billings are another likely outcome. Thanks to underlying decision logic previously only available to large institutions, the Electronic Health Record can "auto-populate" or scour the record to justify a greater intensity of service. Accordingly, "increased coding levels" account for the return on investment. Alternatively, better "capture of charges" and fewer "billing errors" can lead to a five-year $86,400 "benefit" per provider.
Although additional detail may warrant increased payment, the "content" might be unchanged from the point of view of the patient (the end user). Physicians are prone to under-documentation, but these Electronic Health Record enhancements, appropriate or not, arguably increase health care costs without any corresponding increase in quality.

Medical mistake avoidance.
Electronic Health Record advocates point to "decision support" that reduces errors of omission and commission at the point of care as a critical safety advantage. The Agency for Healthcare Research and Quality (AHRQ) has endorsed several IT interventions that promote patient safety (such as error tracking and alerts about the timing of tests); however, mention of the Electronic Health Record is conspicuously absent. In fact, AHRQ’s "20 tips to help prevent medical errors" also fail to mention the Electronic Health Record, versus interventions such as hand washing or relying on large-volume hospitals for complicated surgeries. The Electronic Health Record’s failure to pass muster with AHRQ’s evidence-based approach to translating research into practice might explain the necessity of funding a large number of projects to better evaluate the Electronic Health Record’s role in patient safety.
Indeed, the available evidence is decidedly mixed. Examples of omission-type error reductions include alerts about vaccination status among children cared for in the emergency department; inpatient vaccination and anticoagulation reminders; diabetes, hypertension, vitamin B12 deficiency, thyroid and anemia screening in the elderly; health maintenance and counseling in a pediatric practice; and hypertension identification and control. However, Electronic Health Record decision support has no effect on adherence to primary care guidelines for asthma or angina management; it leads to "variable" and "limited" adherence to diabetes and coronary artery disease reminders; it has no effect on evidence-based interventions for heart disease and heart failure; it causes no change in the care of patients with depression; it leads to "unwieldy" tracking and monitoring of preventive health and chronic illness; and it has no impact on diabetic glucose control.
Why such inconsistency? (continued..)

The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs

Electronic health record (EHR) advocates argue that Electronic health record's lead to reduced errors and reduced costs. Many reports suggest otherwise. The Electronic health record often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the Electronic health record is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the Electronic health record alone.

The Privacy of Medical Records (2)

Part 2.

The basic solutions that are being proposed are, first, to require record makers and keepers to implement a set of technical steps to protect the security of medical records and, second, to impose penalties on makers and keepers of records who release them for unauthorized or inappropriate purposes. Technical steps being touted include unique patient and access identifiers; "audit trails," which are electronic methods of detecting and recording the identities of anyone who accesses a record; encryption of external transmissions of record information; appointment of internal information security officers with responsibility to police record-keeping practices; and "firewalls," which are electronic barriers that isolate records systems from unauthorized access or penetration.

The Issues
The problem is that these techniques are expensive and no one is sure how well they work. I received a glimpse of how unrealistic these solutions might be at a meeting on medical records privacy I attended as a member of a joint working group of the Joint Commission on the Accreditation of Healthcare Organizations ("JCAHO") and the National Committee for Quality Assurance ("NCQA"), the organization that accredits managed care organizations. One member of the working group, the person in charge of medical records at a large managed care plan, pointed out that neither she nor anyone else in her organization knew what records existed or where they were! She suspected that this was likely to be true of most managed care plans and provider organizations. Moreover, she explained that the greatest single threat to the privacy of medical records was post-it notes: people jotted down their passwords and pasted them on or near their computers. The more passwords, personal identifiers and other electronic steps a person had to take to access records, the more these little reminders would be necessary, rendering the fancy security techniques ineffective.Some of the other issues that are being debated by policy-makers include:

• Whether electronic medical records requiring patient enrollees to authorize each release of medical records or only to require them to give a blanket release, say upon enrollment. Advocates of blanket releases argue that requiring a signed authorization for every record release would be burdensome and most patients don't care. Proponents of individual authorization respond that this is necessary to alert patients that their records are being disclosed so they can take steps to prevent inappropriate disclosures.
• Whether electronic medical records establishing uniform standards or minimum standards. Managed care organizations and other record makers and keepers like uniform standards because it tells them clearly what they have to do. Some patient advocates propose minimum standards to enable plans to compete for enrollees on the basis of how well they maintain privacy: plans that adopted more stringent security measures could publicize this fact to potential enrollees who have a choice of plan.
• Whether electronic medical records to enact a federal law that pre-empts stricter state laws. A uniform law would facilitate interstate business by allowing a managed care plan to comply with one standard nation-wide. But some patient advocates urge that states be allowed to adopt more stringent security requirements, if only to permit experimentation to see what works best at protecting privacy.
• How much electronic medical records control giving patients over what goes in and what stays in their medical records. Most privacy proposals would give patients the right to correct inaccuracies in their records but not to delete material. Some patient advocates argue that patients should have the right to block the entry or remove information that they fear would stigmatize them or lead to insurance or employment discrimination. Health care professionals are concerned that incomplete records could interfere with proper medical management. Patient advocates respond that, so long as the incomplete records are marked as such, patients should be permitted to weigh the risks of stigma or discrimination against the risks of a reduced quality of care.

There is almost certainly going to be federal legislation on medical record privacy. But this will not end the debate. Accreditation organizations such as the JCAHO and the NCQA will establish their own standards; managed care plans and provider organizations will adopt their own internal policies and procedures. Meanwhile, the science of electronic records and their security will develop, presenting new options and challenges. Stand by for further reports.

Maxwell J. Mehlman, J.D.

The Privacy of Medical Records (1)

Part 1

Within the past two years, a substantial amount of attention has been paid to the issue of the privacy of patient records. The Health Insurance Portability and Accountability Act of 1996 required the Secretary of Health and Human Services to make recommendations to Congress on ways to protect the privacy of medical records. Secretary Shalala submitted her proposals to Congress on September 11, 1997. The National Academy of Sciences and the National Association of Insurance Commissioners have issued recommendations of their own. Senator Robert Bennett (R. - Utah) has circulated draft legislation entitled the "Medical Information Confidentiality Act" that may well be the focus of congressional action.Two developments account for this flurry of interest. The first is the growth of electronic medical record-keeping in place of paper records. The National Academy of Sciences report states that the health care industry spent between $10 and $15 billion on information technology in 1996. Much of this expenditure is attributable to creating electronic medical records systems and converting conventionally stored data to electronic formats.
Electronic medical records ("EMRs") appear to present new threats to maintaining the privacy of patient-identifiable medical records. An Electronic medical records can be called up instantaneously by someone with access to the data system and the relevant passwords. Although a paper record can be photocopied and faxed, it is less easy to distribute widely, and requires physical possession for accessibility. Computerized records systems are "black boxes" to many health professionals who are otherwise familiar with traditional records systems; they fear losing control of the systems and having to rely on computer experts who may not have internalized the privacy-related ethics of the medical profession. At the same time, one hears proposals to link all medical records systems so that patient data can be accessed wherever and whenever patients require medical services. This raises the prospect that access to one portion of one record may afford access to all records on an individual.

The Managed Care Conflict
A second reason for the increased concern over medical records privacy is the growth of managed care organizations. In the traditional, fee-for-service model of health care delivery, patient records would be produced and retained by the physician or other provider of services. The patient's health insurer would be given access to selected records needed for claims review. Disclosure of the records required patient authorization, although, typically, patients executed these authorizations automatically and in blanket fashion. In a managed care organization, on the other hand, the provider of care and the insurer, in some sense, are the same entity. Any medical information in the possession of the provider also is held by the insurer. This is clearest in a closed-panel HMO like Kaiser but is present, to a varying degree, in all forms of managed care.The fear here is that the insurer will gain access to medical records that the patient and the provider would not normally transmit and that the insurer will use the data to take action adverse to the patient's interest, such as limiting benefits or terminating the patient's insurance coverage.Special problems are created by employer-sponsored health plans. Here, the plan is essentially the same entity as the employer and the concern is that the employer will have access to medical information possessed by the health plan and will use the information contrary to the employee's interests, such as to terminate employment.The basic solutions that are being proposed are, (continued...)

Why we must invest in electronic medical records (2)

Part 2.

Quite simply, the entire country should have the highest quality care we can afford, along with electronic medical records such as those used by the VA. That's why Sens. Hillary Clinton, D-N.Y., Mike Enzi, R-Wyo., Edward Kennedy, D-Mass., and I are working together to make sure that we do. We've proposed bipartisan legislation that would begin the process of setting up a system that allows data sharing, available everywhere, and protects privacy while rewarding quality.
To begin with, Americans should be able to access their medical records wherever they go. This ranks as a high priority, because existing systems like the VA's are useless outside of the organizations that build them. If two travelers get into a car accident a thousand miles from home, the emergency room they arrive at should be able to access a medical records system that can bring up their full medical history, their allergies and information about the medications they take. Right now, in fact, outdated government regulations stop many hospitals from setting up systems that would do this.
Making such a system available everywhere, however, will take a lot more than computers, satellites and fiber-optic cable. It will also require the government to work with hospitals and doctors to create common terminology for medical records and a common data format for sharing them. Because the federal government pays more medical bills than anyone else, its own health-insurance programs -- Medicare, Medicaid, the Indian Health Service and the State Children's Health Insurance Program -- should help take the lead in promoting the use of electronic health records for beneficiaries.
In addition, my colleagues and I also believe that the electronic medical records system should include legal and technological safeguards to ensure that, except in life-or- death emergency situations, nobody can access a patient's medical records without permission from that patient.
Finally, we should use the improved data we collect to reward quality care. Doctors and hospitals who do a good job should receive extra pay from both public and private insurers and those who experience problems should get help to improve. This should begin to erase many of our nation's disgraceful health-care disparities by raising the quality of care for everyone.
For far too long, America has invested too little in health information technology. It's time for a change. Patients around the country need to become full partners in their own health care and drive the system along. Electronic medical records will help do that. If we create privacy-protected electronic medical records for every citizen who wants them, we will save money and, most important, we will save lives.

William H. Frist

Why we must invest in electronic medical records (1)

Part 1.

At a Department of Veterans Affairs Medical Center just a few miles from my office in the United States Capitol, visitors can see the future of American medicine. Sitting at an ordinary desktop computer, Dr. Ned Evans hits a few keys on the keyboard and clicks his mouse a few times. Sample patient data spill out: X-ray images, lab notes and blood-pressure numbers. "Everything I might want, everything I need, I can see right here," he says. "It's a seamless part of life. It lets me do just about everything better."
And when the New England Journal of Medicine used 11 measures to compare VA patients treated in the VA's own hospitals with Medicare patients treated in a mixture of private and public hospitals, the VA's patients were in better health and received more of the treatments professionals believe they should. According to the VA's own medical professionals, a computer system called Vista is the key to their success. "I'm proud of what we do here, but it isn't that we have more resources," explains Stanford Garfunkle, the director of the Washington VA Medical Center. "The difference is information."
While the VA has invested a lot in its computer system, most hospitals, clinics and doctors haven't invested enough. Among America's important economic sectors, health care spends the smallest percentage of its revenue on information technology -- only about 3 percent. Industries such as banking spend 10 percent or more.
Our underinvestment in health-information technology has dire consequences for all Americans. Researchers at Dartmouth University found that America wastes as much as a third of the $1.8 trillion it spends on medical care -- much of the waste comes from disorganization and lack of information. This, in turn, results in orders for unneeded tests, ineffective procedures and simple human error. Sometimes our failure to use health information technology has deadly consequences. Doctors write about 2 billion prescriptions each year but, because of unclear handwriting, some get filled incorrectly; about 7,000 people die each year as a result. Even worse, enormous disparities exist in the quality of health-care patients receive. Members of some ethnic minorities, residents of rural areas and people with low incomes are more likely to have complex health problems than members of other groups yet are less likely to receive appropriate, high- quality care. At least some of the difference is attributable to the lack of good medical records. So good medical records is important.( countinued..)

William H. Frist

What Are The Potential Health Benefits Of Electronic Medical Record Systems? ( Part 2 )

Using Health Information Technology for short term/long term disease management

Using Health Information Technology for near-term chronic disease management. The U.S. burden of chronic disease is extremely high and growing. In one study, fifteen chronic conditions accounted for more than half of the growth in health care spending between 1987 and 2000, and just five diseases accounted for 31 percent of the increase. Disease management programs identify people with a potential or active chronic disease; target services to them based on their level of risk (sicker patients need more-tailored, more-intensive interventions, including case management); monitor their condition; attempt to modify their behavior; and adjust their therapy to prolong life, minimize complications, and reduce the need for costly acute care interventions.
Electronic Medical Record systems can be instrumental throughout the disease management process. Predictive-modeling algorithms can identify patients in need of services. Electronic Medical Record systems can track the frequency of preventive services and remind physicians to offer needed tests during patients’ visits. Condition-specific encounter templates implemented in an Electronic Medical Record system can ensure consistent recording of disease-specific clinical results, leading to better clinical decisions and outcomes. Connection to national disease registries allows practices to compare their performance with that of others. Electronic messaging offers a low-cost, efficient means of distributing reminders to patients and responding to patients’ inquiries. Web-based patient education can increase the patient’s knowledge of a disease and compliance with protocols.
For higher-risk patients, case management systems help coordinate workflows, including communication between multiple specialists and patients. In what may prove to be a transformative innovation, remote monitoring systems can transmit patients’ vital signs and other biodata directly from their homes to their providers, allowing nurse case managers to respond quickly to incipient problems. Health information exchange via RHINs or personal health records promises great benefits for patients with multiple chronic illnesses, who receive care from multiple providers in many settings.
We examined disease management programs for four conditions: asthma, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes (Exhibit 4 ) and estimated the effects of 100 percent participation of people eligible for each program. By controlling acute care episodes, these programs greatly reduce hospital use at the cost of increased physician office visits and use of prescription drugs. As shown, the programs could generate potential annual savings of tens of billions of dollars. Keeping people out of the hospital is, of course, a health benefit, but we can also expect important outcomes such as reductions in days lost from school and work and in days spent sick in bed.

Exhibit 4 also highlights an important disincentive for health care providers to offer these kinds of services or to invest in Health Information Technology to effectively perform them: The savings come out of provider receipts, as patients spend less time in acute care. This key misalignment of incentives is an important barrier to Electronic Medical Record adoption and, more generally, to health care transformation.
Using Health Information Technology for long-term chronic disease prevention and management. A program of Electronic Medical Record enhanced prevention and disease management should change the incidence of chronic conditions and their complications. We considered cardiovascular diseases (hypertension, hyperlipidemia, coronary artery disease/acute myocardial infarction, CHF, cerebrovascular disease/stroke, and other heart diseases), diabetes and its complications (retinopathy, neuropathy, lower extremity/foot ulcers and amputations, kidney diseases, and heart diseases), COPD (emphysema and chronic bronchitis), and the cancers most strongly associated with smoking (cancers of the bronchus and lung, head and neck, and esophagus, and other respiratory and intrathoracic cancers). Using our MEPS-based model, we estimated how combinations of lifestyle changes and medications that reduced the incidence of these conditions would affect health care use, spending, and outcomes (Exhibit 5 ).
Savings are evenly divided between the populations under age sixty-five and those age sixty-five and older, despite the fact that the older population constitutes only 13 percent of the total. Since chronic diseases are, by and large, diseases of the elderly, a large fraction of the long-term savings attributable to prevention and disease management would accrue to Medicare. Yet, to realize these benefits, people would have to begin participating in these programs as relatively young adults.
We combined the effects of the reduced incidence attributable to long-term prevention and management and reduced acute care due to disease management. We estimated the potential combined savings, again assuming 100 percent participation, to be $147 billion per year.
Realizing the potential of these interventions. Realizing the benefits of prevention and disease management requires that a substantial portion of providers and consumers participate. Since, on average, patients comply with medication regimens about half the time, it is plausible to assume that about half of the chronically ill would participate in disease management programs and, therefore, the health care system would reap about half of the estimated short-term benefits, assuming that Electronic Medical Records systems and community-based connectivity were operational.
Patients comply with their physician’s lifestyle recommendations only about 10 percent of the time. We assumed that in a future with Electronic Medical Records -based reminders and decision support and patient-physician messaging, we could realize at least 20 percent of the long-term benefits shown in Exhibit 5 .
Under these assumptions, the net savings would be on the order of $40 billion per year. We varied the participation in disease management and prevention activities parametrically to show the potential beyond these estimates.

Richard Hillestad

What Are The Potential Health Benefits Of Electronic Medical Record Systems? (Part 1)

Using Health Information Technology for preventive care

Part 1

Beyond safety, the literature provides little evidence about Electronic Medical Records systems’ effects on health. We must, therefore, hypothesize about both mechanisms and magnitudes of effects. We considered two kinds of interventions intended to keep people healthy (or healthier): disease prevention measures and chronic disease management.
These interventions are key to understanding Health Information Technology’s potential. First, they would exploit important features and capabilities of Electronic Medical Records systems: communication, coordination, measurement, and decision support. Second, they are potentially high-leverage areas for improving health care. Physicians deliver recommended care only about half of the time, and care for patients with chronic illnesses absorbs more than 75 percent of the nation’s health care dollars. Third, evidence from regional health information network (RHIN) demonstrations suggests that these are key applications of Health Information Technology.
Using Health Information Technology for short-term preventive care. Electronic Medical Record systems can integrate evidence-based recommendations for preventive services (such as screening exams) with patient data (such as age, sex, and family history) to identify patients needing specific services. The system can remind providers to offer the service during routine visits and remind patients to schedule care. Reminders to patients generated by Electronic Medical Record systems have been shown to increase patients’ compliance with preventive care recommendations when the reminders are merely interjected into traditional outpatient workflows. More systemic adaptation—for example, by Kaiser Permanente and Group Health Cooperative—appears to achieve greater compliance.
We estimated the effects of influenza and pneumococcal vaccination and screening for breast cancer, cervical cancer, and colorectal cancer, using data about the current compliance rate, the recommended population, and the costs. We assumed that the services are rendered to 100 percent of people not currently complying with the U.S. Preventive Services Task Force recommendation. We also applied the health benefit estimates from the literature to this population (Exhibit 3 ). We conclude that all of these measures, except for pneumococcal vaccination, will increase health care use and spending modestly. But the costs are not large, and the health benefits are significant: for example, 13,000 life-years gained from cervical cancer screening at a cost of $0.1–$0.4 billion.

Richard Hillestad

Is Electronic Medical Record same as Electronic Health Record ?

There are some confusion about EHR (Electronic Health Record) and EMR (Electronic Medical Record). EHR is different with EMR because An electronic health record (EHR) is a distributed personal health record in digital format. The EHR provides secure, real-time, patient-centric information to aid clinical decision-making by providing access to a patient's health information at the point of care. An EHR is typically accessed on a computer or over a network. It may be made up of health information from many locations and/or sources, including electronic medical records (EMRs). An EHR almost always includes information relating to the current and historical health, medical conditions and medical tests of its subject. In addition, EHRs may contain data about medical referrals, medical treatments, medications and their application, demographic information and other non-clinical administrative information. The ideal EHR system, as of 2007, has not been implemented by any software or other vendor.
The other side, An electronic medical record (EMR) is a medical record in digital format.In health informatics an EMR is considered to be one several types of electronic health records, so maybe we could accept this term that EHR is more completed and more complicated

Enny Rachmani