Document outline and procedural instructions

¶ … Pulse of Electronic Medical Records

Taking the Pulse

Dr. Cara is treating a patient for congestive heart failure in the hospital emergency room. The elderly female patient has made multiple trips to the ER the last four months after suffering chest pains, palpitations and other health scares.

Before ending her 12-hour shift, Dr. Cara writes instructions on the patient's medical chart. Under the column that reads "medications," she writes "now nec,," an abbreviation for "now necessary."

An hour later, the next attending ER physician reviews the chart -- and then, struggling for clarity, reads it several times again. Is that a "w" or a "t"? Is that word "now" or "not"? He cannot reach Dr. Cara by phone, but sees that she has been consulting with the patient's cardiologist. Assuming from this piece of information that the patient has been prescribed medication from the cardiologist, the physician reads Dr. Cara's note as "not nec.," or "not necessary."

His interpretation is as wrong as it can be.

Quality health care has been defined as "doing the right thing at the right time in the right way to the right person and having the best possible results" (Agency for Healthcare Research Quality, 2004). But this patient, and perhaps thousands like her across the United States every day, receive less than quality health care. In fact, errors like this one can, and have, cost patients their lives.

"Quality health care" can be measured by many yardsticks -- error reduction and patient safety among them. And it's long been assumed that these two crucial measures would be improved through the use of electronic medical records, or EMRs.

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But that's not exactly what A.S. Kazley and Y.A. Ozcan (2008) found in their study of hospitals' use of electronic medical records.

The study

Kazley's and Ozcan's study attempted to determine if EMRs are associated with higher quality care in treating three certain clinical conditions: acute myocardial infarcation, congestive heart failure and pneumonia. Their research questions were: Do hospitals with EMRs provide higher quality care? And in which conditions can EMRs affect quality?

The sample in the study included 4,605 nonfederal, acute care hospitals in the United States. Of these hospitals, 479 used fully automated EMR systems. However, the authors said they included "only" 2,969 hospitals in the quality analysis because of limitations in the reporting and validity of the quality measures." Of the 2,969 hospitals, 348 used EMRs in 2004.

In the end, they found little support for their hypothesis that hospitals with EMRs provide higher quality care in all areas. In fact, they found that higher quality care associated with EMR use in hospitals tends to be "sporadic."

"We find no consistent evidence that EMR use can increase care in any particular condition over another," they write.

Discussion

Even the authors express surprise at their findings, and it's easy to understand why. When viewed against the current backdrop of expectations consumers are placing on the medical field, no expectation appears unjustified or unreasonable.

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As Kovnar and Knickman (2011) point out, consumers may understand that safe, quality health care is not "automatic," but they still have high expectations of their physicians -- once they find one, that is. With the ability to scan Web sites, read physician profiles and study symptoms and even possible remedies before they walk into a physician's office, today's "educated" consumers may demand more of their treatment regimen and feel less tolerance for physicians' mistakes and missteps.

As the authors suggest, something is "wrong" with a medical system that leaves patients wondering about the status of a blood test when, alternatively, they can track the precise movement of a FedEx package across the country, each city along the way and at any time of the day or night.

But high hopes remain for EMRs, too. As Miller and Simm (2004) point out, EMRs are "predicted to make the processes of health care more standardized and automated through the presence of screen prompters, mandatory patient information fields to be entered and tools to catch prescription interactions or inappropriate diagnoses. These improved automated processes are expected to lead to fewer medical errors and oversights, thus improving health care quality outcomes."

Kazley and Ozcan rightly point out that EMRs could improve many of the flaws of paper medical records. After all, they are transportable, transferable, complete, automated, standardized and typed, as well as connected to standardized clinical pathways and other tools, which could reduce the number of medical errors while increasing communication and coordination between physicians (Fonkych & Taylor,

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2005). Because of these characteristics, EMRs have been predicted to increase the quality of health care services (Miller & Sim, 2004).

While no true researcher formulates a hypothesis and then contorts a research study's findings to support it, there is clearly a need for more research with regard to EMRs improving the quality of patient care. With nearly 900,000 physicians and DOs in the United States today, there is plenty of fodder, especially with regard to EMRs in use in private practices and ambulatory/surgical centers. And rather than drawing distinctions between medical conditions -- as Kazley and Ozcan did in their study -- future researchers might do well to study the difference that EMRs make between disciplines -- for example, in the offices of podiatrists and obstetricians.