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Collaboration in an EMR Environment

Posted By Randall Reitz, Sunday, January 31, 2010
Updated: Thursday, May 26, 2011

If you're reading this blog post, you probably already know that an EMR is an "Electronic Medical Record"--or a computer-based patient chart. Describing an EMR environment is a moving target because our current healthcare system boasts 400+ different EMRs and each brand is constantly upgrading with new components.

A number of articles have been written about the strengths/weaknesses of EMRs and the risks/rewards of EMR adoption (here, here, here). This blog post will focus specifically on considerations related to the practice of collaborative care. Like any technological advance, EMRs have a ripple effect in a collaborative environment.

In some ways, adding an EMR into a primary care setting is akin to adding a mental health specialist:

  • It enhances services available in the primary care setting,
  • It improves some aspects of communication while bogging down others,
  • It challenges our basic assumptions about healthcare practices and ethics.

I'll provide my biased opinions on 5 topics germane to collaborative care:

1) EMRs both facilitate and complicate collaboration. All EMRs include an email-like tasking function for communicating between officemates. For example, suppose a lab value arrives in the physician's inbox. She judges it as WNL and forwards it to her assistant with an automatic notation to call the patient and inform him that all is good. These 3 clicks provide the full documentation required for the lab, put in place all necessary follow-up, and avoid the need to walk down the hallway looking for her assistant. It also provides for an on-the-fly paper-trail that reduces the risk that the lab value will fall through the cracks.

The same is true for integrated behavioral services. I will frequently get lab values (i.e. positive urine drug screens, thyroid values, diabetes A1c levels) for shared patients. This will prompt discussion about the best way forward. This works well for simple discussions, but bogs down for complicated decision-making that requires a face-to-face discussion. Most commonly, these messages read "Here's patient X's drug screen, positive for methamphetamine, let's discuss when I see you in clinic."

The problem is that these tasking inboxes go viral. Physicians and counselors spend hours sequestered in their cubicle "working their box". Instead of meeting with patients or networking heart of the clinic, they grow pale and flaccid clicking away. They occasional flitter off to an exam room with laptop and Red Bull in tow. Once there, they occasionally distract their monitor gaze for some eye-to-eye contact.

Equally exhausting, most EMRs allow for remote access, so people can work their box from home. This allows providers to get home at a reasonable hour, but breaks down collaborative opportunities and further contaminates the home environment with professional duties. The communication solution provokes the next communication problem.

2) Large EMRs magnify the confidentiality bugaboo. The healthcare system in which I work is adopting the same EMR across dozens of hospitals and clinics. This will allow for a consistent EMR environment, ease of information sharing, and should reduce duplicative orders that result from missing information.

On the downside, EMRs are not generally geared for collaborative settings, which causes some confidentiality concerns. For example our EMR can be programmed to have a robust Social and Family History. It also places the SFHx in a prominent place on each patient's e-chart. The downside of this is that if I put any explicit information in the SFHx (i.e. sexual abuse history, sexual orientation, criminal history) it will show up prominently when this patient sees the nephrologist, urologist, or podiatrist. The patient will be unwittingly sharing information that was shared in confidence with me. As a result, we chose to scale back on what goes into the SFHx and reserve sensitive material for counselor notes. These are still available to the entire hospital system, but require additional digging.

Similarly, one of the great successes of my community is that our physicians and hospitals invested in a regional health information organization (RHIO). Through this meta-EMR, almost every prescription, lab value, hospital record, specialist note, and imaging report is accessible in every office at a moment's notice. For confidentiality purposes, the person accessing the record only needs to confirm that s/he has access privileges based on 1 of 4 criteria (i.e. "I'm the patient's physician" or "I'm providing continuity of care services"). They call this "breaking the glass box". The system is smart enough to track which people accessed which records and produces reports regarding red-flag behavior.

However, this service is far more ham-handed with records produced my mental health professionals. My records are completely sequestered within the system and I need to send them out to other professionals one-by-one. If I don't send them, no one knows that I even saw the patient. This approach has pros and cons. The major con is that it is antithetical to collaborative care to treat the records so disparately. The pro is that this stays truer to the original mental health ethics and HIPAA laws. As with the SFHx, there is a lot of information that patients don't want shared. At the end of the day, this is probably a good thing because a confidentiality breech in a completely wired community is far worse than faxing a record to the wrong office. In the wired scenario the entire healthcare community can be exposed to the breech.

3) EMRs include cool applications and more are on the way. For example, our EMR, eClincal Works, includes built-in Smart-Forms for patient screening. This includes a PHQ-2 that self-scores and automatically prompts a PHQ-9 for positives. The PHQ-9 also self-scores and produces explanatory text directly within the patient's note. Ideally, it would also track changes in PHQ scores like a lab value, but that functioning is not currently available. eCW also includes a built-it CAGE screen.

Many EMRs include handy applications for collaborative care friendly chronic disease management. This includes disease registries, referral tracking, and self-management goal functionality. According to presentations I've seen, the next generation of these registries will move beyond disease-centric and instead focus on overall health markers for a patient that transcend individual diseases.

Future EMRs will need to better reflect the synchronous nature of collaborative care. For example, it would be ideal to have a shared note for group medical appointments and joint appointments. Each of the collaborators would contribute to one note that would reflect the entirety of the episode. I have also yet to find a good genogram tool within an electronic medical or behavioral health record. I have seen a few stand-alone software packages that create static "snap-shot" genograms, but not anything that is integrated with the rest of the record or easily updatable.

4) EMRs can reinforce the Body/Mind split. Demon Descartes would have loved him some EMR. I have yet to find an EMR that meets the needs of both medical and mental health specialists equally well. The needs and documentation traditions are different enough that it is difficult to serve two masters. So, medical and mental health records have developed in size and sophistication in separate spheres. Despite the fact that FQHC's and Community Mental Health Centers will frequently work quite closely together, they almost always do so on separate and incompatible records. In the worst cases (like my current practice), the embedded mental health workers end-up doubling their paper burden by preparing individual notes for both systems.

I have colleagues from a behavioral office who are imbedded within a large primary care office. The well-intentioned medical office offered to share their EMR with the behaviorists, but the contract with the EMR company would not allow them access unless they were all purchasing licenses as part of one corporation. The end result is that the medical office will probably completely subsume the behavioral office. Were this to happen, it would probably be a noteworthy advance in for-profit collaborative care, but it is an example of the technology tail wagging the dog.

5) Need for quality standards. EMRs have been around long enough that medically-focused standards and comparisons are available. For example, AAFP's Family Practice Management journal will regularly produce a readership survey that compares user satisfaction along several criteria, including: ease of use for basic EMR functions, inter-operability, scalability, cost, technical support, etc. Similarly, professional and governmental organizations have recommended EMR standards that encourage software companies to produce EMRs that better meet user needs. The collaborative care constituency has not yet produced such standards. Perhaps this type of project could be commissioned by Families, Systems, and Health journal. The results could be crafted into a CFHA position statement.

In the absence of such an undertaking, please use the comment space below to add your own thoughts and experiences regarding collaboration in an EMR environment.

How have electronic records helped and hampered collaboration where you live?

Which EMR do you use, what are its strengths, weaknesses, and idiosyncrasies?

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