Patient Safety
Timely Access to Complete Patient Information
Today a fragmented and pluralistic healthcare delivery system processes information for the hundreds of millions of physician, clinic and hospital visits made annually in the United States. The patient records produced are either on paper or in separate computer systems that typically have limited, if any, ability to exchange data electronically, except for purposes of reimbursement. In all those files of paper and streams of data, no one has a bigger stake in the information (from a specific clinical encounter) than the patient. And in nearly all circumstances, no one in the system can know more about the patients life than that patient.
In few other settings is it more important to provide the right information to the right people at the right time in the right format. Yet health professionals currently have no way of accessing, compiling or managing all of the important information about their patients medical conditions and histories. The fragmented nature of medical information systems and the difficulty of providing timely access to complete patient information are the primary obstacles to enhancing the overall safety of our patients. Better dissemination of medical information is imperative to accelerate and enhance patient care.
The electronic health record (EHR) is an essential tool for integrating the delivery of healthcare and putting patients at the center of their care. It can support the shift from episodic and acute care toward improved and continuous healing relationships with healthcare professionals. It represents a transition from a patient record that is often physician- or institutionally centered, retrospective and incomplete to one that is patient-centered, concurrent, prospective as well as retrospective, interactive and complete. The EHR can play an important role in enhancing the safety of patient care in many contexts, from monitoring and appropriately disseminating product recall information at the patient level to enhancing our ability as the U.S. health system to better hardwire national best practices that are shown to enhance outcomes and quality of life.
Adoption of Technological Standards
A lack of interoperable systems and data standards is a key barrier to EHR adoption. The healthcare industry has too many standards in place for disparate systems to convey patient data reliably. Healthcare professionals across a variety of settings experience difficulty in finding an EHR solution that is not fragmented over several vendors or IT platforms.
This has created a source of confusion for caregivers who believe that almost everything can be interfaced, because in the past we have been able to interface very basic clinical and administrative information about our patients. In fact, there is an implicit belief that interfaces and integration are the same terms: The logical thought is that if we build ways for systems to talk with each other through interfaces, these systems will send and receive all patient data just as if all the data were housed in one clinical system.
But the data being used by the systems today are much more complex and are coded in so many various and dissimilar ways that the path toward truly integrating our view of the patient now makes the decision to attempt interfacing disparate clinical systems an unsure, risky and sometimes impossible path to take. The safety, quality and efficiency of patient care will only be achieved if such systems are interoperable, integrated applications are seamless and electronic connectivity is accomplished, providing clinicians with key information when and where it is needed: at the point of care.
An example: One vendor may utilize its own coding system to classify patients allergies, while another vendor employs an entirely separate classification method.When it is found that these systems cannot reliably exchange information between each other, two separate silos of (partial) truth about a patients allergies and hypersensitivities are created. As a caregiver, this raises serious process issues related to trying to understand which system may be correct, and for patients this creates a safety risk if a new allergy is entered into one system, but not the other.
Benefits of the Longitudinal Record
Patient-centric IT enables proactive improvements that are difficult or impossible to achieve through an interfaced network of specialized systems. True collaboration among multiple health providers and their patients requires a centralized, longitudinal record, as well as common systems to put the data to use. The completeness of the record, both historically as well as for each patient encounter, is critical. Instead of focusing on each encounter, a longitudinal record gathers information from both inpatient and outpatient encounters. The value of having a complete ambulatory record integrated with the acute care record allows for migration across time as well as across multiple areas of care.
The longitudinal record is exemplary for monitoring the use of medication. One example is the use of chemotherapy agents such as anthracyclines where exceeding certain lifetime maximum dosages is associated with a high risk for irreversible heart failure. Another example is for documenting vaccinations which could occur anywhere in the physician office, clinic, workplace, community, hospital, rehabilitation and long-term care settings. A longitudinal record captures information across every encounter, allowing the relevant healthcare providers access to a broad spectrum of data across care environments and administrative functions.
Missing Links Between Ambulatory and Acute Care
Even as we begin to address the integration of the record across acute care settings, we are most often missing enormous amounts of information in the outpatient setting. For example, the healthcare industry does not know how many patients are on a specific medication at any one time: When a new, significant adverse event is reported to a pharmaceutical company or the FDA, it represents one more number in the numerator but there is no idea as to how large the denominator really is. Because patients now can fill and refill their prescriptions at too many points of access (e.g., local pharmacy vs.mail order), there are even more opportunities for drug interactions and allergy issues to occur than when patients once used a primary pharmacy (and often, pharmacist) for all their medication needs. Each healthcare entity, public and private, gathers and holds its own information, most often in paper form, in other types of silos of (partial) truth. Only a fraction of their data is accessed and transferred digitally; the vast majority of healthcare transactions are still conducted by phone, fax or mail.
As a result, critical information is not available when and where it is necessary to support both clinical decision making and patient care as patients navigate a complicated healthcare system. If a patient enters an emergency care facility, alone and unconscious with a high fever, clinicians are often forced to deliver often lifesaving care with incomplete information about the circumstances behind the patients condition. Caregivers still rely far too much on patients and their families to carry medical records and reports across the boundaries of a fragmented health system. Since many patients see different doctors for different medical conditions, physicians never have access to all of the information collected over the course of all those visits. The absence of readily available, comprehensive and patient-centric health information negatively affects healthcare at every level and puts the patient at greater risk.
Raising the Bar for Patient Safety
For the EHR to heighten the levels of patient safety, records must be easily accessed by patients caregivers, contain extensive medical histories that encompass all medical encounters and share a standardized format for the storage and exchange of data so that caregivers do not need to know or access multiple sources of information. Only a common framework can support improved health information exchange nationwide while protecting patient privacy. The new health information environment should be based on open, nonproprietary standards and methods for their adoption, connectivity built on the Internet and other network types and uniform policies that protect privacy and assure security.
We are already behind in addressing these safety issues while we are soon to be facing the next horizon of clinical information, such as genomics. For example, today we understand that some chemotherapy regimens can be curative in some patients and not work at all in others, but why this is occurring may be due to variations on a genetic level that would be vitally important to characterize and capture so that clinicians can make far more meaningful decisions about what agents to use and how to use them to enhance their therapeutic affects and minimize toxicities. Genetic information such as this, paired with clinical data, will be integral in making care decisions, and customized care can be developed through the application of data mining, pattern recognition and clinical decision tools to EHR. The scrutiny of patients medical histories, genetic composites and health risks, combined with access to the most current data available on breakthrough treatments and genomic research, can result in better treatments and faster recoveries. The ideal infrastructure is one that links EHR with clinical, genetic and other research data from all healthcare institutions.
Conclusion
The most compelling reason to implement the EHR is that it allows healthcare providers to offer safer and more consistent care to all patients. All relevant information needs to be available and legible whenever and wherever patients are seen in acute settings, clinics, examining rooms, nursing stations and offices. All components of a patients medical record including progress notes, test results, images and medications, advance directives, future appointments and demographic data need to be readily accessible at the point of care.
