Healthy Living News — August 2009

      Electronic medical records have featured prominently in the health reform debate as a vehicle for improving outcomes and reducing the cost of health care.  CRMA has been using an electronic record for several years called the Longitudinal Medical Record; “The LMR”.  The LMR is the electronic health record for the vast majority of Partners Healthcare physicians.  Thus CRMA physicians share the same patient record as physicians at Massachusetts General, Brigham and Women’s, Newton Wellesley, and North Shore Medical Center.  If more than one physician from those organizations is treating the same patient, they’re all looking at the same medical history, problem list, test results, and notes.  Compared to state and national benchmarks, CRMA is far ahead of most health organizations in terms of integrating care and using the electronic record.  But we still have a long way to go; the purpose of this article is to highlight what the LMR can do now and some of the challenges and opportunities we face going forward.

Integration
    Currently all CRMA physicians use the LMR to some extent. At a minimum, CRMA physicians are using the LMR to store their office notes, generate prescriptions, and maintain up-to-date problem lists and allergy lists.  All lab testing done in the CRMA lab is interfaced to the LMR.  Radiology testing done in our soon-to-open Imaging Center will also be interfaced.  Our goal is for all care done within a CRMA facility to be easily accessible to other CRMA providers in the LMR.  In addition, most care delivered in other Partners facilities is already accessible in the LMR.  Thus, if you’re referred to a specialist at Brigham and Women’s, she will have your entire patient history available and any tests/notes she enters will be available to your CRMA physician.  Unfortunately, providers who don’t use the LMR are out of the loop.  Your CRMA PCP will interact with these providers just like 15 years ago, i.e. via paper, fax, phone call.  CRMA can scan their notes/tests into the LMR, but a scanned document isn’t the same as an internally generated document for reasons we’ll go into below.  In the future, we plan to establish electronic interfaces with other providers (such as our local hospitals).  As more information is put into the LMR and more patient history exists electronically, it will become more useful to physicians and the benefits of integration will increase.

Operations
    The LMR has the potential to support practice operations and improve efficiency.  The prescription module, for example, is excellent and will soon get even better once we are electronically interfaced with the pharmacies (no more lost faxes!).  LMR-generated prescriptions are never misspelled and clearly typed, not hand-written.  Refills and renewals are much easier than via paper.  Office staff generally love the LMR because the volume of filing has dropped as well as faxing to other physician offices.  Many offices have adopted “clinical messaging” where phone messages are typed directly into the LMR, which the physician can read and reply to the staff in between patients … no more lost post-it notes and the messages can be permanently saved in the LMR if they’re clinically important.  One shouldn’t oversell the “paperless office” concept, though.  Unless all providers of health services use the same electronic record, CRMA providers will continue to interact with non-LMR providers using paper that will have to be scanned into the LMR.  Electronic interfaces are difficult to setup and maintain so non-CRMA physicians who use other electronic records don’t have an electronic link to the LMR.  The biggest challenge, though, is adapting physician workflow to the LMR.  Some physicians aren't comfortable using computers.  Most physicians prefer to face the patient during a discussion and that’s much easier to do with a paper chart than with a laptop or keyboard/screen.  When looking for an old note, it’s much easier to flip through 20 pieces of paper than to click through 20 e-notes in the LMR.  Thus, our challenge going forward is to refine the LMR and physician workflow so it’s viewed as a time-saver rather than a time-consumer.

Decision-Support

    When experts talk about electronic records transforming care and improving efficiency, this is where most of those efficiencies come from.  The intent of decision support is to help physicians make better clinical decisions and utilize “best practices”.  Large organizations such as Partners Healthcare, the Mayo Clinic, and the Veterans Administration use decision support to help ensure the best treatment protocols are employed throughout the organization.  Diabetes, for example,is a chronic disease that can be controlled with close monitoring.  Patients have certain tests that must be done routinely and most are on several medications.  If the LMR knows a patient is diabetic, several reminders are triggered so when the physician sees the patient, even if it’s for something unrelated to diabetes, he is prompted to make sure the patient has had her required tests.  It also gives the physician the ability to do “population management” initiatives, such as identifying all the patients in his practice who are overdue for a particular test or whose blood test levels are out of compliance or who haven’t been seen recently.  Decision support is employed extensively with drug prescriptions, identifying potentially unsafe allergy or drug interactions and highlighting alternative medications.  The LMR employs a “health maintenance” module where typical screening tests such as mammograms, colonoscopies, and cholesterol tests are tracked and the physician is reminded if a patient is overdue.  Decision support’s effectiveness is governed partly by the features designed into the LMR but more importantly by the quality of information input.  For example, if the physician doesn’t tell the LMR a patient has diabetes, then none of the diabetic decision-support can be triggered.  Or if the physician inputs data in a way the computer can’t recognize, i.e. free-text as opposed to a checkbox or drop-down list, then decision-support won’t work.  Scanned documents, for example, can’t be “read” by the LMR which is why we prefer to use inhouse testing facilities that are electronically interfaced.  And if the LMR can’t accurately assign patients to individual physicians (remember most patients see multiple physicians and many insurances don’t require patients to have a PCP), then population management becomes difficult.  We hope as we integrate more information into the LMR and physicians rely on it more, the scope and depth of decision support can increase to truly transform and improve patient care.