President's Message
Technology and Quality of Patient Care: Medical Management Systems at the Millennium

A. Allen Seals, M.D., President

A. Seals, Jacksonville Medicine, Jan 2000

The need for continued efforts to improve quality of patient care is a stated mission of most physicians and healthcare organizations. It is also commonly recognized that physician management systems, especially systems that enhance the integration of current and future technologies, will significantly enhance our ability to practice medicine in the very near future.

However, when it comes to the adoption of technology, the health care industry in general has been among the last to embrace high-technology solutions. The physician is often characterized as part of the problem, with limited vision in the potential of modern data management systems. But, according to Dr. Richard Slack, author of a book detailing the experience of building a clinical computing system, doctors are unfairly tagged as technophobes because they have not yet jumped on the computing bandwagon. He lays some of the blame on clinic and hospital administrators who focus far more of their resources on financial computing systems with no thought given to how to improve their relationships with patients and patient care. "Blaming the already beleagured doctor for being too old, or too conservative is a handy excuse for bad computer systems. In our collective experience, if computing is helpful and easy to use, clinicians will use it."

The real challenge in expansion of medical management systems is how best to bring information technologies out of the front billing office, to the real heart of the medical practice - the exam room and the physicians office. These office systems, known as electronic medical records (EMR) are now becoming a standard medical office tool

The transition to electronic medical records may be the most important project that a medical practice can undertake. What benefits should one expect from a successful EMR project?

1. Improved Clinical Efficiency, Patient Care, and Service. The EMR system includes a number of features that significantly enhance the clinical practice including: higher quality documentation (legible, organized, complete), built in clinical protocols (clinic based "critical pathways" based on the most authoritative published clinical guidelines), clinical reminders (for chronic disease management or preventative health maintenance), improved medication management (electronic prescription pad _ eliminating pharmacy confusion with a physician's prescription), more efficient completeness of charts in a timely fashion, greatly enhanced capabilities to apply internal quality control on a continuous basis, and improved clinic ability to respond confidently to external quality review requests
2. Improved Administrative Efficiency: Successful EMR physician practices are more efficient than traditional doctor offices. Clerical effort is greatly reduced with an EMR system (less chart pulls, less filing and less lost charts) while maintaining universal access to the chart (often by more than one person at a time). Coupled with effective intra-office email system, these systems improve physician,/staff communication (reduce phone tag messages and and call backs from pharmacies). Importantly, EMR systems greatly streamline compliance with managed care chart requests and enhance compliance with external chart audits. As a result, the number of staff FTEs required to support physicians is often lower.
3. Cost Reduction: The productivity and efficiency gains of an EMR system translate into lowering the hard dollar cost of running a practice. EMR practices report savings in the following areas - reduced (or in some cases, eliminated transcription costs), decreased clerical costs, reduced internal/external copying and printing expenses, reduction in malpractice insurance premiums, and reduced nursing costs.
4. Revenue Enhancement: An EMR system can impact the top line of a practice by improving the completeness of documentation and the accuracy of coding, increasing the number and level of services offered. In many clinics, the increased productivity realized with an EMR system allows for an increase in the number of patient visits per day while maintaining a higher level of quality of patient care.

One of the obvious key elements of any successful EMR system is to present relevant information without overwhelming the clinician with unnecessary details. Just as a medical student learns, to succinctly present a case to his/her attending, a computer EMR system must also present the relevant medical options to the clinician user. However, EMR clinic databases have the capability to on demand, instantly recall every single fact and minute detail from the patient's past medical history, while at the same time can access a medical information library (either clinic based or internet based) for published medical literature on the specific clinical problem.

In addition, the EMR can act as the physicians' personal assistant and generate letters, email or faxes to the referring physicians or other consultants (including medical images of EKGs, Xrays, or other imported images), and then print patient information hand-outs for patient education; all within a single patient clinic visit. Try to find any medical student who can do all that!

One example of improved medical care with an EMR system is in the area of physician reminders. Older systems have frequently had "physican reminders" to alert the doctor or nurse when, for example, a patient was late for a routine test such as a Pap smear or immunizations. For example, EMR systems are available that remind doctors that a diabetic patient has not had an eye exam in over a year. The comparison is often made to a pilot's checklist before take off. Even though a pilot has made thousands of take offs and knows the instrument panel cold, the pilot and co-pilot go through a detailed checklist. In an analogous manner, a busy clinician cannot be reasonably expected to remember every detail of a patient's care.

More recently, sophisticated EMR systems are being offered that anticipate the need for diagnostic information and treatment plans and options based on the patients clinical history and physical examination information. These systems have the ability to "learn" a physicians' clinical practice, and anticipate physician needs and provide information. An important aspect of these newer systems is that they are in a "continual update" mode, meaning that the software actually updates itself on a continuous process, based on the individual clinicians work. Some observers in the computer industry have commented that these systems are the beginnings of "medical artificial intelligence". For physicians, the promise of these EMR systems is a huge step forward into the 21^st century, with a "virtual assistant", available to not only do simple reminders, but to offer meaningful medical assistance to directly improve overall patient care, evaluation and management documentation, and increase the accuracy of medical billing.

According to Joe Hawkins of MedCare, a Jacksonville based physician management service company specializing in data management systems including EMR, the best approach for most physician offices in gearing up for these sophisticated systems, is through an "application service provider" or ASP. Analogous to an Internet provider, an ASP is a secure, local integrated network of "supercomputers" that can handle the high-end requirements of these patient management and EMR systems. These ASP networks are absolutely secure connections between the physicians office and the central data system, with practice data security provided through a series of secure locks and passwords. One example of the many advantages of an ASP approach is the availability to advances in software engineering, with improvements in medical software rapidly shared across the entire network.

In summary, the EMR vision has now become reality, and well-designed systems are currently available. There is becoming a rapid recognition that medical practices without these systems will be at a serious disadvantage. Clinical research has now proven the worth of these systems in head-to-head comparison with old clinical standards, documenting that physicians and EMR systems really do provide a higher quality of patient care, while at the same time improving their overall efficiency, thus providing the "holy grail" of better medical care at a equal or even lower costs!

FREQUENTLY ASKED QUESTIONS ABOUT EMR:

What about dictation? Dictation is usually greatly minimized (or often eliminated) with EMR. However, doctors who continue to prefer the familiarity of dictation, most EMR systems will incorporate dictation (either by transcription or voice recognition). Some innovative EMR systems have incorporated limited audio files as a part of the record, so that the record can be supplemented with a verbal note from the physician.

How secure is the EMR? EMR security is ensured by network-only access limitations and multiple levels of security access once an individual is in the network. Absolutely no access is possible from outside the physicains office. In addition, most EMR systems offer highly granular security, allowing system administrators to define access and privileges according to the respective roles of office staff.

Is the record legally valid? The EMR offers a complete medically legal record with an audit trail, allowing the practice to track all changes to any textual record. This ensures document integrity within the practice and validates the record for medical legal purposes.

What happens if the system goes down? A standard part of any EMR system is system backup. This includes offsite tape data storage, uninterruptible power sources at the site, as well as fuel-powered backup generators at the data center.

What about patient acceptances of these systems? In general, patients have been wholehearted in favor of this evolution in medical record keeping. Patients seem to understand intuitively that EMR systems can improve overall quality of care. However, patients also understand the need for physicians to be "in control" of the medical record systems - especially in a "virtual environment". For example, errors on an EMR system can occur just as they do on a paper based system, and physicians need the inherent ability to add addendums to the medical record document.

Jacksonville Medicine / December 2000

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