Electronic health records (EHRs, also known as electronic medical records, or EMRs) have earned a lot of media attention in the years since the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in 2009. Unfortunately, a lot of that reporting was negative in nature.
Even though EHRs were heralded for their potential to make the provision of health care better, safer and more efficient, for the most part clinicians realized as many frustrations as benefits. Electronic charting can be laborious, made more exasperating by gaps in user understanding and proficiency. Toggling between screens during a patient encounter can be time-consuming and impersonal.
Rather than being “seamless,” interoperability between systems of other providers is lacking. Despite the evolution in user-friendly EHR platforms, software vendors haven’t been able to fully relieve the burden that rests on the shoulders of providers while still collecting and sharing all data with patients, providers and other clinicians in the health care arena. As a result, health IT-related burnout is not only real but becoming a significant concern for providers and health systems.
Electronic Health Records IT Still Experiencing Growing Pains
Despite growing pains, EHRs still offer useful benefits that advance the provision of health care, especially for clinicians. The immediate accessibility to patient information allows clinicians to analyze diagnostic findings, place orders immediately and communicate remotely with the patient. Sharing data is also possible between patient’s various providers and via health information exchanges.
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IT providers need to help health-care stakeholders achieve a new perspective toward EHRs, starting with those positive aspects and looking to the potential of using technology to accelerate patient care and management. The purpose of charting is to document an accurate reflection of the care given to the patient and to communicate that care to other concerned providers. Time spent on charting is valuable to the overall care of the patient. Documentation in the fast-paced world of medical offices, hospitals and ASCs can result in loss of productivity, but it doesn’t have to be. After all, no one ever wants to go back to paper charting.
In the context of a more positive perspective, what might the future of EHRs look like with new high-tech tools being developed, it seems, weekly? Here are some key industry insights into these advances.
Information for this eWEEK Data Points article is provided by Maura Cash, R.N. and Director of Clinical Services for HST Pathways, a respected software solutions company for the ASC industry.
Data Point No. 1: Voice recognition
Imagine dictating a text message to your spouse, telling him or her you’re heading home from the office. Now, imagine a surgeon completing an operative report while wrapping up the procedure. New software tools that use voice recognition can reduce added documentation time, relieving some of the burden on providers and improving charting compliance. While first-generation voice recognition software was associated with an unacceptably high error rate, the majority of errors were caught and eliminated after clinicians reviewed the record and signed off on the documentation. Newer partnerships with technology leaders offer promise that transcription capture will improve, potentially minimizing or even eliminating the need for a comprehensive review process.
Data Point No. 2: Remotely-generated health data
Consumer wearables, such as Fitbits, created an opportunity to collect, summarize and integrate patient vital signs like heart rate and sleep patterns into a medical record. More recently, Bluetooth-enabled devices have enabled additional integration, including remote blood pressure and glucometer readings and medical imaging, which can flow seamlessly from point-of-capture to a provider’s remote device and then to storage in the health record. This stored capability offers a longitudinal look at patient data, saving valuable time during the office encounter and changing patients’ medical records from “snapshots” to comprehensive bio-profiles.
Data Point No. 3: Patient Health ID
Last year, the U.S. House of Representatives voted to repeal the ban on funding for a national patient identifier, a number or code comparable to a Social Security number and assigned to U.S. health consumers. When integrated with personalized biometric information and widely implemented, patient identifiers will help with interoperability between medical offices, hospitals and ASCs, reducing the potential of errors and ensuring that all encounters and procedures are correctly captured in the right patient EHR.
Data Point No. 4: Master drug databases
Patients’ comprehensive prescription histories remain one of the most fragmented segments of all health data. In the last 10 years, state-prescribing databases have been used primarily to track controlled substance prescriptions and identify patients who may be misusing prescription medications, such as opioids. But increasingly, drug databases will be integrated into EHRs to provide fingertip access to all prescribing history, across all states and clinical support for new prescribing during the normal course of workflow.
Data Point No. 5: Artificial intelligence
There is tremendous excitement around the potential of AI to improve health outcomes by combining individual patient data with medical algorithms to approximate conclusions without direct human input. Some of those advances include the ability to approximate risk based on aggregate medical data and use predictive algorithms for clinical decision-making and treatment strategies. But AI will also impact EHR documentation, helping clinicians through a cognitive system with everything from personalizing the charting process from the preferred order to complete the chart in and presenting the fields in that order, to remembering physicians’ usual and standard input, orders, plan of care and offer these options for rapid charting.
Data Point No. 6: In conclusion
The EHR ball is rolling, and there is no stopping it. We have an opportunity to guide it in a positive helpful direction. Using all the new technologies toward the goal of increasing productivity and improving the quality of the documentation is where we need to focus our energies.
While we are not quite to the point of outsourcing charting to Alexa, it may not be as far away as we think.
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