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,
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
I'll provide my biased opinions on 5 topics germane to collaborative
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
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
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
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
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
How have electronic records helped and hampered collaboration where you
Which EMR do you use, what are its strengths, weaknesses, and