MD Leader

The implementation of our electronic health record is Ministry Health Care’s largest and most important patient safety and quality of care initiative.  Perhaps the largest improvement in patient safety will occur with improvements to our medication list allowing easier and more complete medication reconciliation.

Over the years, I have become convinced a patient’s outpatient current medication list just cannot be accurate without a total commitment to electronic prescribing.  Without an accurate medication list, medication reconciliation at every clinical encounter becomes very difficult to achieve. 

Medication reconciliation has become the standard within the hospital setting but is just now gaining momentum in the outpatient world.  Though most clinicians are reluctant to admit it, most of the time we are not 100% sure what medications the patient is taking. Patients often take medications differently than prescribed or are taking medications prescribed by other clinicians.  Pharmacies convert prescriptions from trade name to generic medications further adding to the confusion.  I have frequently found patients taking both the generic and trade name version of the same drug thinking they were actually taking different medications, not a double dose of the same medication. You will not reliably know what medications a patient is taking without a specific process of medication reconciliation that includes a monitoring for accuracy.

The electronic health record will allow us to have a single enterprise wide medication list that will be used for medication reconciliation at every outpatient clinical encounter and admission/discharge from our hospitals.

Our EHR Project is now officially underway with the Kickoff off at our Pilot. There are so many tasks needed to allow the Pilot to be successful but one in particular  will be preloading important data. Many organizations have choosen not to preload data, the philosophy seems to be that care teams learn how to use the EHR through the process of entering baseline data.  We believe the EHR should be of value to our care teams from the very first day. Entering data should be a by-product of patient care, not preparation for patient care.  

We have initiated a large project aimed at identifying what data from our paper chart, lab systems and hospital information systems should be loaded into CattailsMD before the EHR is used for patient care.  We are building interfaces that once established, will load current labs, reports, dictations, x-ray reports and links to x-ray images into CattailsMD. There are historical results that will be necessary to track essential preventive and disease management services. We  will identify and load these items into CattailsMD before Go-Live.

In addition, we will identify types of historical paper documents we will routinely scan and load into CattailsMD.  Care providers will also be able to identify those special documents unique to a patient that should be scanned and loaded.

Part of the pre-Go-Live process at each site will be to preload the current medication and allergy lists.  The more accurate the paper lists, the more accurate the initial EHR list will be.

From the very first use of CattailsMD, our clinicians will have access to all the documents and data loaded since the interfaces went live plus all the data we have preloaded.   Our efforts will be rewarded when our clinicians open a patient’s record for the first time and have a WOW moment because they see the value of EHR with their own eyes.

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Our decision to use Marshfield Clinic’s CattailsMD was featured in a story on AMNews (July 21, 2008), the newspaper of the American Medical Association.

http://www.ama-assn.org/amednews/2008/07/21/bisb0721.htm

CattailsMD was attractive to us for a number of reasons including the development of what the newspaper is calling a private RHIO. There is also a State of Wisconsin effort to develop a data exchange linking information from multiple health care providers. Our use of CattailsMD will make it easy for us to participate.  Patients are best served when health information is avialable to their health care providers.

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In a previous post, I stated there are there three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database

A data exchange provides a mechanism where information from disparate data systems is collected and then presented for viewing.  The data, while useful as a reference source, is of limited value because of a restricted ability to package the information in meaningful ways or be used as a driver of decision support. Patients are often not uniquely identified in the database resulting in duplicate records.  Some entities maintaining data exchanges do not adhere to the same patient confidentiality standards as the organizations that contribute the data. These exchanges are expensive and ongoing funding to support continued use has been problematic.  A data exchange can be useful when regional providers of care use either different electronic medical records or EMRs where the database can be unilaterally altered. It’s value will be high in the short term when entities merely wish to view data, but will be limited in the future when those same entities wish to use the data to provide decision support at the point of care.

A few EMR vendors offer a standard data base across their user base. Separate health care entities can utilize these records and have an identical database structure allowing alignment of patient records.  The resulting structure can allow the data to drive decision support or common determination of clinical benchmarks. Since the database has a standard format, custom programs for decision support can be easily shared between users. Though more useful than an data exchange, this format is limited in that patients may not be uniquely identified in aligned systems.

A single common medical record with a single patient database used by independent regional health care entities provides the most robust structure to share medical data and drive decision support.  Governance can be a real issue but the improvement in patient care is worth the effort. Data can be packaged and presented to meet the needs of each individual user.

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Think of an EMR as the equivalent of a patient’s paper medical record, the accumulation of one business unit’s information about the patient.  Typically, patient health care information is found in multiple paper medical records (or EMRs). Even in small isolated communities with a limited number of care options, records are kept in multiple locations. The hospital has medical records, most often organized as episodes of care. Even if all medical practitioners use the same outpatient medical record, dental and psychiatric records are often segregated. 

Some systems of care have taken the step of combining all the regional medical records; consider the result to be a combined medical record. The step involves considerable effort as each patient will need to be uniquely identified and the various health care entities will need to establish a common form and governance of the medical record, not an easy task.

If the system of care takes the concept one step further and embraces the concept that the medical record should be the complete record of the patient, they are on the path to an electronic health record.  The quest to obtain a complete record will never be finished as there will always be more information that can be gathered. However, the quest results in a record with ever increasing value to patients and caregivers.

An EHR is considerably more complex than a combined medical record because systems of care that are not directly aligned business units need to agree on common patient identifiers, common structures and governance. 

There are three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database.

I will discuss these types of EHRs in a future post

Our use of the term EHR, signified our intent to move towards a single health record for a patient. As you can imagine, the vision of having an EHR had major significance for selection of a vendor.

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