The importance of health information
This is a follow on the last post on health information. I actually started this one before I got the question, so maybe this is a prequel blog post…?
I have been thinking about the challenges that are going to face us in Canada as we move forward and start interconnecting EMRs (Electronic Medical Records) and sharing data. I am wondering:
What happens to health information when the EMRs of today are no longer “islands”(1) unto themselves?
Right now many EMRs are being used in relative digital isolation. Often EMRs have a laboratory results feed in to the practice, but very little comes out of the practice in digital form. Printing of referral letters and consult letters and patient summaries and prescriptions is the norm.
Many clinicians, from what I have observed, still think of their EMRs as “EPRs” – Electronic Paper Records. They use them as legible, remotely accessible paper charts and work around limitations as they would in paper. For example:
- Prescription writer or lab form is too complex?
No problem, write it in free text and use the paper forms still in your office. - EMR have a problem with not putting significant past medical and surgical history on your referral note?
No problem, just put it in the problem list. The problem list prints on the referral note automatically. - Not able to code procedures correctly (because you are using the problem list as in #2)?
No problem, do not worry about the code, just pick something close and edit the display name so it is accurate to what you are trying to say. - Do not have a place to document housing issues? No problem, just create a new data element in the problem table for “unstable huosing – living under Main St Brige”(2)
- Problem list not specific enough for you?
No problem, create a new value in your code set that is more specific. - Difficult to write that complex dosing regime of one pill twice a day and two pills at night?
No problem, put anything in the main field but make sure you use the comments field to say what you really want, the pharmacist will figure it out when she reads the printed prescription. - Want to speed up your new patient visit? No problem, the EMR makes it easy to make your own templates. Just make a new template with tick boxes for “All immunizations up to date”, “NKDA” and others. OR you can just make a text macro that gives you a nicely formatted few paragraphs that you can edit only where you need to.
You can see where things are going, right? All of those are real examples and all of these are uniquely solved in each practice. Oftentimes they are uniquely solved many different ways in one practice.
Now fast forward a few years and start linking up EMRs, through Infoway’s EHR or through a standardized referral system or even through a custom interface from the vendor (it doesn’t really matter) and what happens?
As patients move around, EMR data in each practice becomes a mosaic. Local fixes are copied from one system to another. Each one different, just like the old paper charts. Specialists will have a worse time of it as they will be getting referrals from many sources, each one customized.
Clinical decision support will fall apart — how many people are missing their H1N1 vaccination? Don’t know, some of these records are using this field “immsuptodate” and others code it in the problem list as “053, injection, other” with a display name of “H1N1″, another few have this field called “immunizations_UTD_2009″…
The default approach would be to leave free text alone and only consider coded values, but this does not help when clinicians have co-opted terms for their own use.
This scares me. I do not think we have thought deeply enough yet on how to manage this issue. 
It is going to be a huge clean up activity to get existing information standards compliant. To be fair to the EMR vendors and clinicians, there is not a supported “right” way to store health information in EMRs yet. We have some standards in Canada, but the bulk of the clinical information has been recorded without those standards in mind. The local “work arounds” were/are required to get the job of providing care done.
What tools should we start seriously considering in order to improve our health information as it moves off the isolated islands? Maybe we just need more duct tape?
Harmonizing our standards and redesigning EMRs to be standards compliant are only part of the process.
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1. This is a popular term here in BC and likely elsewhere – a standalone EMR with few electronic connections to the outside world would be an island. Much of the data coming in and out is via paper (printing and scanning). It is an appropriate analogy as information is evolving more rapidly on islands.
2. Typos intentional to prove a point. Note also that there could be no code associated with this if the EMR allowed for codeless terms.
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