Electronic Medical Records
Heather Taylor
David Sibell
▪ INTRODUCTION
Occasionally, a technologic innovation will cause a fundamental change in the field in which it is used. The electronic medical record (EMR) is such a tool and is altering the manner in which health care is provided, consumed, researched, and even conceived. EMR is a broad term and refers to a range of software packages, including relatively simple systems used in a single physician’s office, Web-based tools that allow patients to enter health information, or complex software systems used by global health care organizations. Although these systems vary widely in complexity, they share some common components. According to the Institute of Medicine, functions of an EMR include the following:
A longitudinal view of the patient’s full medical history
Results reporting including labs, radiology, and other reports
Computerized ordering and prescribing
Vital sign recording
EMRs can also include a decision support system (DSS) to assist health care providers in making treatment decisions.
Until recently, health care organizations have been slow to adopt EMRs. Common obstacles included the cost of the software, cost of implementation and training, and lack of integration with other health care software. Recent changes in technology and federal financial incentives have accelerated the adoption of EMRs in small practices and hospital systems alike. The specialty of anesthesiology has been particularly slow to adopt EMRs, due in part to the operating room (OR) environment and the unique documentation requirements of the anesthesia record. Indeed, several of the major EMR vendors are only now releasing perioperative medicine suites, including preoperative evaluation, intraoperative anesthesia, surgical, and nursing care, and postanesthesia care. Heretofore, there were few software packages that could support these needs and integrate with the larger EMRs, which tend to focus on clinic and hospital ward medicine requirements.
To meet these challenges, several EMRs specifically designed for the anesthesia department have been developed and are referred to, collectively, as the Anesthesia Information Management Systems (AIMS). In many cases, larger software vendors acquired, modified, and integrated software packages originally developed by anesthesiologists.
▪ BASIC COMPONENTS OF EMR
Because the majority of AIMS currently available are used within hospital environments, the remainder of this chapter focuses on hospital EMRs and AIMS. The EMR has grown from recording simple health information to complex integrated systems that can improve the efficiency and quality of health care delivered to patients. Historically, hospital information systems centered around individual departments (e.g., the laboratory industry developed software to automate lab results reporting; the radiology industry developed specialized software to archive and retrieve digital radiologic studies). Hospitals frequently utilized a “best of breed” approach to select the best software systems available for each department. Unfortunately, these systems were not integrated and could not “talk” to each other. Increasingly, hospital administrators and health care providers seek departmental software systems only if they are integrated with other hospital information systems, as this eliminates the inefficiencies and redundancies inherent in having separate systems that do not communicate
with one another. The most recent trend is that a few large hospital information systems vendors have begun to dominate the market. They offer completely integrated hospital information systems that include an outpatient EMR, inpatient EMR, lab system, radiology system, financial and billing system, scheduling, facilities and supply chain management, and pharmacy operations. Only recently have they begun including the perioperative environment. These departments and systems are linked though an enterprise-wide intranet and also allow remote access through the Internet. All access to patient health information through these systems must comply with the security and privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
with one another. The most recent trend is that a few large hospital information systems vendors have begun to dominate the market. They offer completely integrated hospital information systems that include an outpatient EMR, inpatient EMR, lab system, radiology system, financial and billing system, scheduling, facilities and supply chain management, and pharmacy operations. Only recently have they begun including the perioperative environment. These departments and systems are linked though an enterprise-wide intranet and also allow remote access through the Internet. All access to patient health information through these systems must comply with the security and privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Core functions of a modern EMR include the following:
Management of the patient health information and data. This encompasses the “charting” function of an EMR, to allow health care personnel to enter and record clinical documentation (e.g., notes, vital signs, consults, history, and physical examination). This also includes documentation of allergies, special patient information, and comprehensive medication information (current and past).
Presentation of results and data acquired from outside sources such as labs, electrocardiograms (ECGs), procedures, and imaging
Computerized physician order entry (CPOE). Any order traditionally written by hand is entered electronically in these systems (e.g., prescriptions, lab orders, and requests for testing).
Integrated DSS, which can include prompts and alerts for clinicians during order entry and results viewing. For example, an alert may appear if a physician attempts to order a medication that is on the patient’s allergy list or interacts with another medication the patient is taking. Decision support tools can also assist health care providers by displaying evidence-based treatment guidelines for patient diagnoses and providing “order sets” that include suggested medications or testing for a given condition. For example, a physician may be prompted to order prophylaxis to prevent deep vein blood clots for a patient who is having total joint replacement surgery.
Secure communication tools used by clinicians, nursing, and ancillary staff. These have the advantage of being contiguous with, and recorded as part of, the patient’s medical record.
Secure communication tools for patients to allow patients to communicate with their providers, view test results, manage demographic information and appointments, request prescription refills, and access a variety of health information.
Integrated administrative and financial tools
Anesthesia technicians will be called upon to interact with EMRs or hospital information systems in a variety of ways: equipment/supply ordering, results reporting and retrieval, documentation of quality control testing results, and information entry in AIMS.
▪ ANESTHESIA INFORMATION MANAGEMENT SYSTEMS—THE EMR SPECIFIC TO ANESTHESIA
Anesthesiology departments have been slow to adopt EMRs into the OR. Only 1% of anesthesiology departments use electronic charting in the United States versus the much higher rates in other disciplines. Anesthesiology providers have been hesitant to incur the costs and perceived complication of integrating EMR into anesthetic practice, as it was not clear if they or their hospitals would benefit from adopting AIMS. Things have changed on both sides of the equation:
Hospital-wide systems are now starting to incorporate information suites that apply to the perioperative setting.
AIMS improve continuing quality improvement and medicolegal record assessments.
Improved efficiency due to standardization of documentation and ordering across different clinical departments in the same organization.
Federal financial incentives: The American Recovery and Reinvestment Act has specific provisions for health care organizations to implement EMRs.Related posts:
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