Category: EMR

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Let’s call it EHS!

Doctors are widely using EHRs in different clinical specialties and sub-specialties. In a 2018 survey of physicians by Deloitte, only 10% accepted their current EHR systems.  The rest wanted at least one area improved. Different studies have reported mixed findings, and a significant result is reasonably consistent: doctors are not satisfied with their EHR systems, EHR is a place to store data or a digital filing cabinet.

The biggest complaint is that the diagnosis and treatment flow in EHRs does not follow the thought process of a doctor, most times, it is the other way around where the doctor has to follow the flow of the EHR. 

Doctors have to spend time clicking and search around. What is EHR’s competitive advantage if it cannot easily search and display patient information for diagnosis process and treatment plan?

Modern EHR is wrongly defined by its legacy name, R (for the record) does not reflect its role in medical practice, and R also blocks innovative thinking as a solution. We should call EHS (Electronic Health Solution)

The thinking design of EHS must have the capability to support the diagnostic process. In particular, support the providers involved in the diagnostic process and reduce potential errors.

The researchers have described the critical attributes of safe EHS, including:

  • Easy retrieval of accurate, timely, and reliable native and imported data;
  • Simple and intuitive data displays;
  • Easy navigation;
  • Evidence at the point of care to aid decision making;
  • Enhancements to workflow, automating mundane tasks and streamlining work, never increasing physical or cognitive workload.

The thinking design of an EHS must provide a continuous treatment plan function. The treatment plan is a set of actions at a defined period for the clinical objectives of a patient.  Doctors want to track the progress and alter it as it goes along. Especially for personalized medicine, the doctor or case manager must have the ability to allocate a treatment plan and monitor each patient’s process.  Most EHR systems have a treatment plan function but not a patient-specific plan; there is no cohort management function for the case manager.

A thinking design of EHS thinks about the user interfaces to a deeper level, i.e., be intuitive and straightforward. A typical example of a design concept is to bold the data-fields rather than the label fields.  It is simple and makes sense.  Doctors are looking at the EHR screen all the time in daily practice, and they know where the label “Gender” or “Name” is.  There is no need to see the labels in bold all the time. Instead, they need to see the data in bold so that they can glance at it once.

EHR has come a long way but still has a long way to go. It is time to transform from ‘record’ to ‘solution’ thinking. EHS is a solution to traditional EHR, and it is to build a platform for clinical intelligence; it is a tool for formulating personalized care paths that everyone uses.

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Rapid Change and Fast Implementation of EHR/EMR

The world is changing very fast. Big will not beat small anymore. It will be the fast beating the slow. – Rupert Murdoch

During the pandemic, many hospitals have shared their experiences of rapidly improving the existing EHR/EMR systems. Some reported their success stories about fast virtual implementation and go-live. Covid-19 requires rethinking and refocusing on priorities. The decision-making process has been shortened, and the actions have moved faster.

1.    WHY need EHR/EMR?

 COVID-19 pandemic exposes both strengths and flaws of EHR/EMR systems. However, despite the frustration and disappointment from the front-line clinicians, we must first acknowledge that EHR/EMR architecture and platform have enormous value in controlling the pandemic and other widespread public health emergencies.

Paperless EHR/EMR system is essential and assured for early detection of the risks, report of abnormal conditions, rapid diagnosis, and the appropriate treatment and life support. 

Eliminating all the paper and minimizing direct contact is a must in the whole of the caring process.  The workflows need to be connected seamlessly and communicate effectively, such as identifying patients, booking appointments, admitting to ward, referring consultation, coordinating MDT review, electronic print, bed-side care, and post-discharge follow-up, etc. Also, the recommended Covid-19 protocols evolve very quickly, and EHR / EMR enables hospitals to implement changes far more uniformly.

2.    What EHR/EMR systems are the choice?

There is a varied range of EHR/EMR products locally and internationally. Robustness, interoperability, organizational feasibility is of choice. The advantages and power of such choice have been proven during the pandemic, ensuring patient care safety and quickly protecting clinical staff at the same time. The capability of information sharing allows hospitals to track and report abnormal conditions faster and accurately.

3.    How to rapidly improve and how to fast implement?

Most hospitals already have workable systems of daily huddles in place. A fast virtual implementation during the Covid-19  strengthens a lean approach, i.e., rational use of resources without waste, implementing the necessary changes.

Hospitals are more likely to make fast decisions, consider much less about those concerns that may delay the change progress. For example, before Covid-19, the staff often spend time in scoping requirements and developing and testing solutions before rolling out changes. This process has been modified to implement changes quickly. New EHR/EMR features are constructed to enable quick back-end editing as processes and guidance change frequently.

During the pandemic, social distancing pushed the implementation teamwork online, which makes communication, testing, and system configuration much harder, and almost impossible to maintain the same level of support and security as onsite. However, those success stories show that new needs invariably create and drive new methods. As Amelia Earhart said, the most difficult thing is the decision to act; the rest is merely tenacity.

The Covid-19 pandemic has forced numerous changes in daily clinical practice. Rapid responses in EHR/EMR help beat the virus and defend the patients. Stay lean to go fast.

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How can EHR/EMR Improve Medication Adherence?

Research shows that approximately 50% of patients do not take their medications as prescribed. The treatment of chronic illnesses commonly includes the long-term use of medication; however, the therapeutic benefits are often not achieved or maximized if patients don’t take them or are not adhering to the prescribed regimen.  

The factors contributing to poor medication adherence vary, but in general can be summarised into three categories:

  1. Those related to patients; for example, lack of understanding, inadequate involvement in the treatment decision–making process.
  2. Those related to care providers; such as prescribing complex regimens, insufficient explanation of usage, ineffective communication about adverse effects.
  3. Those related to health care systems; for example, limited access to care, visit time limitation, and lack of health information technology. 

It is recognized that poor medication adherence contributes to suboptimal clinical benefits; increasing adherence may have a more significant effect on health than any improvement in specific medical treatments (Sabate, WHO, 2003). 

How to make patients cooperate? What is a valuable tool to assist patients in forming adherence habits? The solutions need to be multifactorial and sustainable, they need to integrate coordinated efforts between care providers, patients, and health care systems. 

The medications are prescribed by doctors in an EHR/EMR system; therefore, EHR/EMR has a role and responsibility to launch such a medication adherence platform:

Recommended workflow and data scope include: 

  1. Prescription information generated in EHR/EMR. The EHR/EMR has appropriate interaction checks, allergy checks, cumulative dose checks, etc.
  2. Medication collection information in EHR/EMR or in linked pharmacy dispense system. In China, medication collection status is recorded into the EMR / EHR system since the vast majority of pharmacies are inside and operated by the hospital.
  3. Once the patient collects the medication, prescription information includes generic and brand names, usage instruction (before/after a meal, etc.), time of taking medication, side effects will be available to patients on their mobile phone, or online.
  4. The time of taking medication can be automatically added to the schedule.
  5. The patient will be alerted when the time is due.
  6. Patients can easily record the outcome, e.g., when medication is taken, what are the adverse reactions, etc.
  7. The patient’s administration record can be submitted to their care manager or primary care doctor for review, the treatment plan and regimens can be adjusted based on the report outcomes.

Depends on the local health systems, bring payers to such a platform could enforce adherence. Pay for adherence, pay for real treatment, pay for outcomes can be achieved based on seamless data. 

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COVID-19 outbreak test EHR/EMR

Electronic Medical record (EMR) and Electronic Health Record (EHR) in hospitals are tested by the Coronavirus Disease 2019 (COVID-19) outbreak. An integrated and mature EMR / EHR can be a powerful tool in early detection, fast reporting, rapid diagnosis, strict isolation, and the right treatment.

In China, COVID-19 is classified as Class B infectious diseases; however, it follows the preventive and control measures for Class A infectious diseases. Pre-examination and triage is the first step in preventing and controlling virus spreads in hospitals.

I observed a 3-level pre-examination and triage screening workflows implemented in a hospital EHR system in a private healthcare setting in Beijing for the pandemic control

The 1st level screening occurs at the entrance to the emergency room and the fever clinic. Every person entering the hospital building must wear a qualified mask and receive preliminary temperature checking. Screening information, including fever, cough, dyspnea, and epidemiological history, is recorded. Suspected patients are guided to the fever clinic for further examinations. Patients with negative screening results can enter into the hospital. The triage nurse put a round and colored sticker designed by the hospital on the patient’s coat. The marked patient then has access to other departments. The color of the round sticker is changed every day in a weekly cycle.

The 2nd level screening is to avoid patient gathering. It is conducted by the patient self with the assistance of the triage nurse when necessary. Patients complete and submit screening information in EMR on an iPad. If patients have negative results, the EMR flags a green icon, and then the patient can move in the hospital after a second temperature checking. If patients have positive results, the EMR flags a red icon indicating a risk of COVID-19. The nurse will verify and re-check the patient’s temperature. If Patients have an unexplained temperature ≥37.3℃ will be transferred to the fever clinic for further investigations. If patients have not completed the COVID-19 screening, a blue icon is displayed in the EHR, indicating that preliminary examinations are required.

The 3rd level screening is conducted by the doctor in the consultation room. The doctor checks epidemiological history, body temperature, clinical symptoms, body signs, blood test results, chest X-ray results, and CT results in the EHR, and make a medical risk assessment. The level of risk again links to the color of flags.

This 3-level screening is a real-time workflow and process, it guilds decision of patient allocation and isolation during outpatient service and inpatient hospitalization.

The hospital EHR / EMR system shows the advantages of fast mobile access, connecting care providers, real-time monitoring, review, and tracing of outpatients and inpatients. COVID-19 data are always analyzed and reported accurately.

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EMR, EHR and PHR

Many people do not realize the differences between an electronic medical record (EMR), electronic health record (EHR), and a personal health record (PHR), often use the terms EHR and EMR interchangeably. However, some differences define medical and health apart, distinguish ownership of patient information. 

An EMR is a digital version of clinical workflows that record the process of medical practice. 

  • The purpose of EMR is to document care provided, orders, order execution, results, reports, and other information related while caring for a patient. Documenting must be complete if care was not documented; it did not happen then.
  • The patient does not have direct access to their EMR during their hospitalization. They can, however, request copies of their records after discharge. 
  • Healthcare organizations must comply with the requirements of the local regulations in terms of EMR system governance and management.

An EHR is a digital version of integrated health information about individual patient or population. 

  • An EHR has the capability of sharing and exchanging information across different health care settings via network or cloud. EHR includes a varied range of data, including demographics, medical and social history, medication and allergies, immunization record, laboratory, and pathology test results, radiology images, vital signs, BMI, excises, health risks and outcomes, and insurance and billing information and so on.
  • The patient usually has some access given by their healthcare providers and organizations to view their records. 

A PHR collects, stores, centralizes, integrates an individual’s and family’s health information, share when the patient wants, where the patient wants, and with whom the patient chooses. 

  • PHR should securely manage lifelong personal health information, including subjective data like individual’s care preferences and wishes, data from own wearable devices. 
  • PHR is maintained by the patient, is operated by healthcare organizations. The intention is to provide a complete and accurate summary of an individual’s medical history, which is accessible online. 
  • The purpose of PHR is to maximize individual health benefits.

These three terms reflect the revolution of technology in the healthcare field, i.e., the progress of understanding, acceptance, and embracement of technology in daily practice, the role change of patient. These terms may be defined and used differently in countries and regions. Admittedly, technology has empowered care providers and patient than ever.

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Doctors Must Help Transforming EMR

Doctors and patients often complain about EMRs, often for the same reasons. Both say that doctors spend so much time on the computer, i.e., the number of clicks, taps, scroll up and down required to execute a routine task, or to find a result or report, doctors spend less time focusing on patient’s real needs of care.

Many doctors assume that an EMR system should simply mimic their simple paper processes; this concept has caused many of the problems associated with EMR today. The doctor needs to understand that EMR capabilities are far more beyond paper; it stands to reason there would be differences and complexity.

However, there are ways to integrate EMRs well into the clinical visit, to improve the doctor-patient relationship:

  • Preview the patient’s history and current presentation in EMR: getting familiar with the pertinent chief complaint and other clinical information before greeting the patient
  • Value the first minute by talking to the patient, not using or being busy with any technology
  • Explain what you’re doing: be open about everything you’re doing with the EMR in the patient’s presence.
  • Value the EMR: talk about the benefits of the EMR, use it as a useful tool for engaging patients; for example, let the patient look at the screening while you enter data, read and interpret lab results, and specialists’ reports. Always encourage the patient to ask questions and confirm the accuracy of information.
  • Be positive: if you display negative emotion, it influences the patient, leaves a wrong impression of the visit. The patient will never complain about a lousy EMR but will remember the unpleasant clinical experience and a frustrated doctor.
  • Keep eye contact: maintain it as much as possible throughout the visit. When a patient starts discussing a sensitive or emotional topic, always turn away from the screen and look only at the patient.

These practices can build trust with the patient, ensure the accuracy of the information entered into EMR, educate the patient, make the patient feels more participatory in their healthcare.

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Dr Henry Plummer, a Diversified Genius

Dr. Henry Plummer was a diversified genius. He was a physician, scientist, and engineer. One of his significant contributions to clinical practice is the implementation of a unified medical record system in Mayo Clinic. The medical records of the same patient were always kept in one location, in chronological order. That was in 1907, and the first patient record was created on July 1.

113 years later, we are building electronic medical record systems, trying hard to unify medical record numbers for the same patient across clinics, hospitals, cities, health systems, countries, and regions.

We are now trying to connect and integrate patients’ information from all perspectives, including clinical conditions, health status, social determinants, objective data given by laboratories, modalities, devices, and subjective feelings, personal preferences about how we want to be taken care of.

In the near future, everyone is possibly going to be accompanied by a ‘data buddy’ knowing more about ‘Who I Am’.