GeriTech

In Search of Technology that Improves Geriatric Care

health information exchange

The pain of processing past records

A few months ago I wrote a post about the 159 page digital fax that I received, containing records for a patient’s recent lengthy hospitalization.

I’ve now discovered something even more time-consuming and annoying: a 202 page paper record mailed to me by a major medical system. (I won’t name names right now; suffice to say this system uses EPIC, as do many big medical systems these days.)

Sigh.

And this isn’t even the patient’s entire record. This is just the last two years, per my request; I’d thought this would probably give me enough information to meaningfully assist the patient and his family with the geriatrics issues.

In truth, I’m not surprised at the volume of this record, although I *am* surprised that the health center sent me a massive printout instead of sending me a CD.

Today I share some details, in hopes that it’s helpful to illustrate the state of health information exchange today, and what many primary care doctors have to deal with when they take on a new complex patient.

My workflow for a 200 page set of paper medical records

As Robert Rowley points out in a recent blog post, a modern “paperless” practice is in fact not so paperless.

At my old clinic, where we were still dealing with paper charts, this monster stack of records would have ended up in my box, where the medical records staff would expect me to go through it and indicate which parts to keep. (Guess what kind of chore tends to linger in the PCP’s box for days to weeks?) Then someone would have to punch holes in it and file it into the chart.

Now that I have my 21st century tech-equipped micropractice, here’s what I had to do:

  • Scan all the sheets into my computer and convert to PDF. I use Adobe Acrobat for this. Fortunately, I upgraded my printer-scanner a few months ago, and it scans pages through the document feeder pretty quickly. Still, the feeder can only hold about 80 pages, so this meant three big scanning runs. I did other administrative work while this was going on.
  • Combine the new PDFs into one single file and run OCR (optical character recognition). Sure, there are dozens of small items in there, but it would be too time consuming to create a multitude of small files (even though that’s often useful in the long run). Instead, I make a mega records file and run OCR, hoping that I’ll later be able to search the darn file for the particular info I need.
  • Shred the paper record. God forbid this brick of paper fall into the the wrong hands, or onto the toes of the person with the wrong hands. It must be shredded. (Same goes for those lab report copies that I get via snail mail, even though the info was already faxed to me.) Unfortunately for me, the shredder in my home office does not do 80 pages at a time; it can only manage 12-13 pages. So shredding the record is not a trivial step. I think about trees as I watch reams of paper get munched into little bits. Since this activity, unlike most of my clinical work, does not require much mental or emotional attention, I wonder if this counts as a moment of cognitive restoration. (It might, except I’m a little annoyed at having to do this in the first place.)
  • Read through the record & take notes on the key findings. This part took about an hour. This patient has had many many encounters over the past two years, as well as a few hospitalizations. The records, of course, came with no table of contents or summary of what was inside. They were, however, in chronological order. Interestingly, many pages contained completely useless (to me) lists of what a given clinician had ordered. Please. I don’t need documentation of the orders, I just need the results. (You can leave it to me to infer that the tests were ordered.)
  • Share the records file with the patient via the my EMR’s portal system. In this case, the sharing is effectively with the patient’s adult child since this very elderly patient has poor memory and can no longer manage his healthcare. Although I haven’t been asked to take this step, I tend to share most documents that I file in patients’ charts. (Why don’t I share everything? Because it’s an extra step, because those steps add up timewise, and because I have to remember to do it.)

We should make health record reviewing and sharing easier

I don’t think anyone seriously disputes this, but I do wonder when it will materially become easier, and whether there aren’t a few small steps that the big players could take to make this situation more manageable for docs like me.

In general, the obtaining and reviewing of records remains a pain because to date most healthcare providers haven’t felt very motivated to make it easy for others to view their work, whether those others are clinicians outside their health system, or patients themselves. There are also legitimate concerns about protecting patient privacy and sensitive health information.

Once information is actually pried out of a health provider’s system, one is left with significant issues related to organization and usability. So the next step beyond sharing the information would be to make it easy for others to organize and act on the information.

For information released to patients and caregivers, this means the data needs to be presented in language suitable for the lay public, and not solely organized according to the conventions of those with clinical training. For information released to other clinicians, the data would ideally come ready to easily import into other EMRs.

This is, I hear, could eventually be achieved via things like SNOMED and HL7. Then again, I’ve been hearing about these standards for years and somehow my clinical experience remains dominated by reams of printed pages coming to me by fax and by mail.

Is there any relief on the horizon for the average clinician?

Ideas for better health information retrieval

Let me start by saying that I am absolutely lacking expertise in this arena. Still, I’m going to float a few ideas:

  • Digitize the information request process; make it more transparent and followable. Right now, for either an outside clinician or a patient to request information, you need to fax a release of information to a provider’s medical records office. Once you fax, you have no idea whether they received it, unless you call. Furthermore, some medical records departments answer their phone, but many do not. This is a major drag for medical assistants all through the country, and for those clinicians who practice entirely solo as I do. If we could just submit requests electronically and follow the progress online (why can’t one check the status online?), this would make life easier, and would make it easier to track and improve the health records request process.
  • If a medical center must send printed copies of the record, include a table of contents. Obviously I’d prefer to receive information in a digital format that is searchable and easier to organize, but if you must send me a fax or mail package, can I please have a table of contents?
  • Let patients download ALL their information to a third party personal health record of their choice. I’m hoping for a combo of OpenNotes and redesigned Blue Button output, going into a personal health record. And then of course the PHR needs to facilitate sharing data with clinicians of choice. This at least would make it easier for me to access the needed info. (Plus there are many other benefits to patients having copies of their medical records; too many to list in this post.)
  • Persuade EPIC to improve their records output options. Beyond a table of contents, EPIC should provide the records organized by type: primary care clinic notes, specialty notes, ED notes, hospitalizations, labs, radiology. Actually, better yet would be to get the records digitally and have the option of sorting by date versus by type. Maybe EPIC records could come on a CD that not only contains the data, but also executes a little viewing program. (I have received medical records CDs with dozens of PDFs, and it is not fun.)
  • Let outside doctors riffle through a medical system’s records directly, once patient permission has been given. This one, I admit, is very unlikely to happen. Security concerns and all that. But wow, it would be great, although I’d still need an Evernote-style clipper or other tool to snip out the info of interest and add to my own EMR.

Summing it up

The process of obtaining and reviewing medical records from another healthcare system remains slow and painfully inefficient, especially when records are delivered as monster stack of printed paper. It’s ironic that in this digital age we persist in printing out digital files, mailing/faxing them, and then need to re-digitize and upload to a new EMR. It’s also a lot of time and effort for primary care doctors or consultants like myself, who need to review a complex patient’s past medical history.

At the very least, it would be terrific to digitize the request process, rather than having to fax into the ether and wonder what is going on with the request. EPIC and other EMR systems could also do a better job of providing data to outside providers in a format that is better organized (start with a table of contents), and easier to import into a new EMR.

I’d love to see patients gain the right to download all their medical data to their own personal health records, and then be able to share with other clinicians such as myself. 

Improving health information exchange from hospitals to outpatient

In my last post, I described why it took me almost two hours to sort through the recent hospital records of an elderly patient. The records had arrived in my digital fax queue as a PDF with 159 pages of images of text.

It seems a bit nutty, in this digital age, that so much of medicine is still being done through paper and faxes, but there it is. Most hospitals have EMR systems, but if a clinician who’s not within the hospital system needs medical information, that information usually gets printed and faxed. (At my previous job, I used to get CDs with PDFs from Kaiser. Better in some ways, but still relatively slow to work through.)

What might work better? The most popular plan I hear to solve the problem of independent clinicians accessing hospital records is to create Health Information Exchanges (HIEs).

I really don’t know what to think of HIEs, especially since I haven’t yet had the chance to use one.  They seem to be slow to set up — the Bay Area has been working on one for a while — and it’s unclear how well they will smooth the workflow of independent outpatient doctors.

Health Information Exchange features we need

Let’s assume the HIEs will eventually arrive. How should they function, to allow outpatient clinicians to get needed information in an easy and low-hassle manner? The best-case scenario I can envision with a HIE would be a online system that I could easily log into, and that would allow me to do the following:

  • Allow me to search through records to find specific items related to my patient.  I can’t emphasize search enough. Browsing seems to be the main EMR paradigm. It’s slow and a pain and increasingly divorced from our experiences with consumer software, where using the search function rules (and delivers). As clinicians, we shouldn’t be trying to figure out which section of some other medical center’s EMR contains pulmonary function tests; we should just be able to search for it.
  • Make it easy to copy certain records to my own EMR. The ideal would be to easily tag items that you want to copy, and then have them transfer to your own EMR with useful titles included. (Of course, if the data I get is searchable and my own EMR has a good search function, the titles become less necessary.) An alternative would be for providers to be able to use something similar to the EverNote web clipper tool, where you highlight what you want and it gets easily transferred.
  • Push or pull certain commonly requested groups of records on request. Just as most labs have created groups of commonly ordered labs (CBC, comprehensive metabolic panel, etc), you could create groups of commonly requested records for certain purposes. For example, when I need to review records from a hospitalization, I want to see the Admission H&P, the discharge summary, all radiology (except chest xrays; just one of those please) and studies, and the last available lab values. (I don’t need every CBC drawn in the hospital, just the last one.) Ideally providers could customize the groupings that they wanted. The consumer version of this is creating a search/query, and easily being able to save/reuse it.
  • Lets the patient directly give me permission to access his/her records. Whether
    or not the patient gets direct access to all his or her hospital
    records, wouldn’t it be great if the patient could directly and easily
    give permission for certain clinicians to gain access? Would speed
    things up immensely, and make it easier for patients to make sure their
    care is coordinated. 


What’s the best path forward for information sharing and care coordination?

I admit I’ll be surprised — stunned, really — if the HIE, whenever it finally arrives to the hospitals near me, has many of the above features. An HIE is after all enterprise software, purchased not by the daily users, but by administrators or better yet, groups of stakeholders.

Are there alternatives? Some EMR companies, like Practice Fusion, are spearheading a move towards peer-to-peer sharing of medical information. This is a promising idea, but doesn’t help when one is trying to extract information from a hospital.

Another option: that health information sharing among clinicians will be driven by the patient’s control over his or her medical records. Certainly could happen, since connectivity with patients may happen a lot faster than PCP connectivity with hospitals.

Personally I’d welcome this, as I’d like to see patients get to gatekeep most of their medical data, including laboratory data. But I don’t know how close we are to patients getting access to their raw hospital data (and am skeptical that the Blue Button output would cut it, when it comes to clinicians getting the needed info to coordinate care). OpenNotes is a promising start but was just for the outpatient setting — and the patients were mainly in their mid 50s with relatively few medical encounters.

Will patients soon be able to download meaningful hospital data into their personal health records (PHRs) and share with clinicians of their choosing? Only if they demand it.

In a nutshell:

Health information exchanges (HIEs) are projected to eventually allow outside PCPs to access hospital records. Features I hope they’ll include are capacity to easily search and copy the information. Bonus if patients end up able to directly give other clinicians permission to access their medical information.

For more information: in doing a little brief research related to this post, I came across a few good resources for those who want to learn more about HIEs. The National eHealth Collaborative has a report on “Secrets of HIE Success,” which offers insights into how some HIEs have come into being.

But far more interesting and informative to me is Robert Rowley‘s series of blog posts on HIPAA and HIE: Part 1, part 2, part 3, and part 4. Love it when articulate primary care docs write about healthcare.

Clinicians and others, have you had good experiences with HIEs yet?