Electronic Document Management Research Paper
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Free Research Paper on Electronic Document Management
The Internet has affected many industries around the globe, and its effects are ever growing. Medicine is no exception from this paradigm; various aspects of medical practice have been affected by the World Wide Web. One of the most heated issues in the medical field now is electronic document management; this issue has triggered an array of contradicting responses from various experts. Within the scope of this research, we will elaborate on the Electronic document management; in particular, we will discuss electronic document management as it related to one particular area of health – surgery. The advantages and drawbacks of electronic documents usage by surgeons will be analyzed, and the comparison with other methods of data storage drawn. The opinions of different surgeons will be discussed and analyzed; the potential solutions for electronic document management recommended. In this research, electronic documents will be referred to as “electronic health patient record”, “electronic medical records” and CPR – “computerized patient records”.
The first attempts to establish the electronic health patient record (EPHR or EMR) were initiated in the 1960s and continued into the 1970s and 1980s. In 1991, the Institute of Medicine published a paper titled “The Future Computer-Based Patient Record,” which declared the EPHR as an essential technological tool and also predicted the widespread use of computer-based patient records by 2002.
EPHR can be defined as a “unified, secure solution for a platform and institution independent longitudinal electronic health record.” (Clayton, p. 355) In other words, a record that would document all of the health care surgical interventions in a person’s life starting with neonatal events and ending with his or her post-mortem.
There are five distinct stages toward the development of the true EPHR. The first stage is the Automated Medical Record, which only about 5% of institutions and physicians’ practices have in place. (Graham, G., Nugent, L., Strouse, K, p. 20) This initial stage uses computers, but continues to rely on paper records as well for documentation. This is the first step toward the ultimate goal and is a necessary developmental stage.
The second stage is called the Computerized Medical Record (CMR) stage, which totally eliminates the need for paper. At this level, the data is scanned into the system, which preserves data integrity features. Some English and U.S. hospitals have entered this level with mixed success.
The third stage is the Electronic Medical Record (EMR), which would be a true enterprisewide application and would allow accessing of all patient information available within the enterprise. The EMR would allow the computer to record the complaints of the patient and would help in the diagnostic process as well as developing a plan of care and the placement of orders. This stage is provider-oriented.
The fourth stage is called the Electronic Patient Record and would be all that the third stage is, but also offer multi-provider links (community based, regional, national and international). This stage of development requires a unique national and international patient, provider and payer identification system as well as the infrastructure and technology for this interchange of information.
The fifth and ultimate stage is referred to as the Electronic Patient Health Record (EPHR) and is the goal of all of the other stages. The EPHR makes the patient the center of the process by involving him or her in all aspects of data entry, as well as through the inclusion of data, which is not necessarily health-related (such as the person’s banking information, etc.).
The creation of the electronic patient record or the electronic health record was a journey without a definite end and was not a question of finding the right vendor as much as it was catching sight of the vision. (Kalra, p. 141) The overall message is that the surgeon — or even the somewhat less-expensive but still costly nurse — should not be the ones to enter a lot of the information.
It was stated in numerous lectures that patients should enter much of their own data. The patient was deemed capable of being the best source of his or her history and chief medical complaint, at the very least. It is clear that the industry will receive encouragement as needed to continue to develop the electronic patient record.
The vendors and medical community are expected to progress along the continuum, but it also is certain that HIPAA will do much to move the effort of the EPHR forward. Vendors that already are moving with the direction offered by HIPAA are ahead of the game, while those that have waited to respond until the legislation is in place will be playing catch-up.
In spite of the emphasis of the HIPAA legislation, it is clear that the aspects that HIPAA addresses are necessary to the goal of the electronic patient and health records. Even at present stages of development, the electronic patient record could offer substantial benefits to all participants:
* On-line eligibility of patients.
* Co-pay determination.
* Pre-edit of transactions.
* Easy re-submission.
* Prompt payments.
* Electronic fund transfers.
* Reduction of retrospective denials. (Huff, p. 114)
One of the most interesting of the free-form, capture, transcribe, scan and store approaches towards electronic health patient record system was exhibited by Advanced Imaging Concepts in its Impact MD product. Its approach to automating patient care is to transparently automate the back office records storage of the physician’s practice, whether the doctors change their front-end practice method or not.
AIC and the companies that embed its products in theirs have done this quite well. The approach is simple: Give doctors what they want. As one doctor/user put it, “We don’t have to file papers; we don’t have to spend money on space to store paper charts anymore. We just scan it into the system and it’s there. It’s at our fingertips when we want it.” (Van Ginneken, p. 121)
The scanning approach to medical records storage and management, when well done, overcomes the fears of many doctors about EPHRs. It is cost-effective. It is controllable. It doesn’t require a lot of training and can be done with existing office staff. It does provide rapid access to patient records, and it can allow physicians to continue to work in the manner they are accustomed to (with paper) as they gradually adopt a direct, electronic methodology to collecting patient information.
The AIC approach accommodates early adopters of electronic records, as well as the late and reluctant adopters, who hold onto the paper record until they die, retire or feel uncomfortable being among the last adopters of a new paradigm. (Graham, G., Nugent, L., Strouse, K, p. 22) As such, AIC is a nearly perfect solution to half of the medical records problem in physician offices — it fixes the back-office records storage and retrieval problems.
But it ignores the other important part — mining the rich data content of patient medical records and using it to modify the paradigm of care delivered at the point of care. Yet it is these front office point-of-care encounters where medication errors are caught, where charting to support billing is needed, and generally where changes are needed to raise the bar, so that treating sickness can be transformed into “health” care. (Huff, p. 129)
To make this transformation the data resident in the patient’s chart, no matter how it is stored, managed and retrieved, is required, and that is the next challenge for systems like AIC’s and others that embrace the scanning approach. What remains for AIC and others is how to mine data contained in its optical images.
This will involve at least two steps: First, converting these images into a character-based, codifiable format, and second, indexing and cataloging such free-form data into medical concepts and frameworks that are unambiguously searchable. Neither of these tasks will be easy to solve. AIC seems poised to bite off the optical character recognition step next.
This step will add a step into the medical records back-office process, however, requiring more time that will in turn reduce the cost-effectiveness of the solution somewhat. Even when this has been successfully accomplished, the matter of resolving essentially free-form information into viable medical concepts will remain.
Scanning also has a place as an adjunct to the optimization of the surgeon practice front office. Card Scanning Solutions makes a contribution with its MedicScan products. This is a scanner and companion software that allows the practice to scan a patient’s insurance card and optimizes the process of getting it into the chart and making it accessible. (Van Ginneken, p. 140)
Once attached to the USB port of any Windows-compatible PC, the scanner senses the insertion of an insurance card, capturing the front and back sides of the card in a few seconds and converting it into a predefined, compressed image that is automatically routed to the windows desktop or to a patient’s record (optional software) for inclusion in the chart. Additional data can be annotated to this record to facilitate retrieval. This optimizes the initial capture of insurance information and facilitates expedited validation of that information on each subsequent patient visit.
Finally, to automate the completion of the patient form for each encounter, there are a variety of mechanisms, ranging from patient-carried, healthcare payer-issued ID cards to Internet-based patient medical demographics files that can be downloaded and merged onto the complaints visit form, eliminating the need for the patient to continually fill in things like their name, address, birthdate, insurance carrier, policy numbers, telephone numbers, etc.
At most the patient can edit this information retrieved from their ID cards or Internet demographic files, and simply check off the symptoms, presenting complaints or services scheduled, etc. (Kalra, p. 166) This expedites the time patients spend filling out forms and enhances their view of the efficiency of the physician practice.
However, neither of these mechanisms has yet been widely used in England, as they represent automation usually associated with the practice management systems, and many of these systems don’t accommodate either of these mechanisms, as they have not been widely used by payers or patients. This is an area of patient education and automation that would be an excellent topic for the patient and physician to discuss upon the first visit and adoption into the practice, or upon the conversion to automation upon a yearly visit thereafter.
To effectively retrieve medical information, one has to effectively store it in the first place. While that sounds simple enough, it is not — particularly in a multi-surgical practice setting. It is even more complicated if the practice is multi-specialty.
Human beings are by nature non-precise in their verbal (and written) expressions, particularly when they are in a hurry (as during a busy time in the office, seeing patients). As a result, variations in surgical terminology creep into the medical records. Add in an office nurse, used to using nursing terminology and there can be variations in free-form charting.
For example, one surgeon notes the patient has an elevated temperature, another that the patient has a fever and a third that the patient is febrile. The nurse may chart a complaint of “temp,” and the patient writes his systems as “I feel hot.” All of these descriptions ultimately must be reduced to one code and stored in the clinical knowledgebase documenting this patient encounter. (Huff, p. 144)
Only when these diverse descriptions are so resolved does it become easy to extract information from the clinical knowledgebase about all patients with the code for fever. If instead of being stored under one code, such observations are stored under several descriptors, then the caregiver must know and concatenate all synonyms for fever when querying the database longitudinally (across multiple patients) to correlate fever with some other medical condition of interest.
The same is true for immunizations, diagnosis, drugs administered and other data that a practice may wish to correlate. If the electronic system is rules-based to help the practice recognize and correct oversights such as immunizations, then the rules need to know which codes to look at and correlate to trigger the surgeon’s alert that some action or intervention is required for this patient, now — while he or she is in the office and available.
Use of PDAs (portable data assistants), such as the Palm Pilot or Compaq Ipaq, already had been adopted by 30% of surgeons in England. Another 23% were interested in adopting it in the near future, while 16% were not sure, and 31% had no plans to use PDAs. This probably splits along age-of-surgeon lines, as younger doctors entering practice already have been using PDAs in med schools and consider them a familiar tool to enter practice with. Younger surgeons may also be more inclined to adopt this technology than their older colleagues. (Huff, p. 170)
When you look at what surgeons use PDAs for, 84% use them to manage their personal schedules, while 68% use them to manage their professional schedule. 59% use PDAs for accessing drug information. As surgeons bring the PDA into their practices, 19% use it for online access, 17% for writing or entering clinical notes on patients. 8% are using it for mobile email access while 6% use it to transmit drug orders to pharmacies, and 2% use it to retrieve lab results.
These lower values of PDA use are more a function of missing office infrastructure and applications than the PDAs themselves. For example, regarding PDA use for electronic prescribing, 6% of surgeons surveyed currently do so, but another 28% are interested in doing it in the future. (Huff, p. 173)
Several factors are driving this interest. First, 65% of surgeons feel that electronic prescribing will help reduce the incidence of medical errors, while 58% feel it will help improve accuracy and legibility of orders. And 55% associate this with fewer callbacks from pharmacists. 53% feel this will reduce time and overhead, particularly as 50% associate a PDA as a tool to select common drugs prescribed from “pick” lists. Almost half (47%) say they want to be able to more readily verify the patient’s approved formulary coverage. All of these factors account for the interest in using PDAs for prescription ordering, refills and management. (Huff, p. 177)
Security is a critical requirement of CPR systems and depends on technology and user behavior. Systems must track when users log on and off the system, lock out attempted log-ons after failed attempts, require users to update their passwords on a regular basis, and be able to generate secondary records that exclude patient identifiers and contain only those data needed by nonclinical data users. (Baretto, 0. 144)
The ability to connect the computer systems within and beyond an institution is another essential component of CPR systems. For example, surgeons would be able to request laboratory tests, order prescriptions, refer patients for consultation, or admit patients to the local hospital from the CPR workstations in their offices.
Information would also flow into the CPR system from other sources. Laboratory test results, consultation notes, and discharge summaries would be sent electronically to the surgeon’s office and filed automatically in the patient’s record. (Huff, p. 117) Similarly, bills could be generated automatically at the end of each patient visit and sent electronically each day to third-party payers.
CPRs should offer surgeons assistance with routine tasks, thereby increasing the time surgeons and other health professionals can spend with patients. For example, users would be able to generate with the stroke of a key routine forms such as school or insurance examinations and patient instructions for a range of illnesses or treatments.
Perhaps the most significant feature of the CPR environment would be the availability of clinical decision supports. Repeated laboratory test results could easily be transformed into a graph, thus facilitating recognition of a pattern. Decision algorithms and clinical practice guidelines would be available to assist in diagnostic and treatment decisions.
“Access to current medical knowledge would be facilitated by linkage with MEDLINE and other literature and bibliographic data bases.” (Baretto, p. 182) On-line, clinical reminders would support preventive medicine by informing practitioners or patients of needed vaccinations or tests. Clinical alerts, identified by subroutines embedded in the computer’s program, would prompt practitioners if a patient’s lab results revealed a dangerous trend or if incompatible drugs were prescribed.
In addition to improving the quality of care by providing better information to physicians, CPRs should also contribute to the moderation of health care costs in several ways. Direct entry of laboratory test results should reduce the frequency of redundant testing that occurs when previous test results cannot be found. (Huff, p. 142) Productivity is likely to be enhanced as time need not be spent tracking down missing records or missing data or waiting for records that are in use elsewhere. Since data need be recorded only once in the computer record, redundant data entry can be eliminated.
Finally, CPR systems will support the advancement of medical knowledge by making improved patient care data available for clinical and health services research. (Van Ginneken 184) Data that are maintained in CPR systems are likely to be more easily and less expensively collected and aggregated since data will no longer need to be manually abstracted from records and entered into research data bases. And CPRs offer a means of bringing research results directly to surgeons.
Although health care lags behind other industries in applying computer technology for data storage and retrieval, some activity in this arena has begun. Automated patient records can be found in various stages of development in some health maintenance organizations, outpatient clinics, hospitals, and multihospital systems. (Baretto, p. 191)
In addition, some surgeons are using clinical decision support systems that provide guidance in areas such as general medical diagnosis, drug therapy decisions, and the management of chemotherapy for patients participating in formal clinical trials. But nothing currently in use possesses the scope and scale of the envisioned CPR.
“Developing a comprehensive CPR system represents a significant, but not insurmountable, technological challenge.” (Huff, p. 170) Progress is needed in four major areas: Facile user interfaces must be developed so that practitioners will not find it cumbersome to use CPRs; system security technology and protocols must be enhanced to protect the accuracy and confidentiality of patient data; local, regional, and national networking capabilities must be built so that linkages among CPR systems can be set and data standards must be established so that data can be shared between CPR systems and used for various purposes.
Equally important, though perhaps more difficult to overcome, are the nontechnological impediments to CPR development: the lack of a clearly articulated and widely agreed-upon definition of what a CPR is and what the performance expectations of its users are for vendors; high research and development costs and an uncertain market; an inadequate number of experts trained in medical informatics; the public’s concern about protecting confidentiality of patient data; the issue of patient data ownership; and ambiguity in and inconsistencies among state laws related to patient records. (Van Ginneken, p. 231)
Organized or overt resistance to CPRs is unlikely, but subtle resistance is likely on several fronts. Individuals who believe that their jobs are threatened by the change and health care workers who are reluctant to learn new skills may be unwilling participants. Among those who stand to benefit from CPR implementation, competing and sometimes conflicting interests must be addressed.
Vendors who must play a key role in the success of CPR development must strike a balance among cooperating to facilitate development, avoiding antitrust violations, and pursuing profits. Finally, “individual institutions may be hesitant to invest in a CPR system due to high costs and as yet unquantified benefits.” (Baretto, p. 212)
Overcoming these barriers will require coordination among the many organizations and individuals interested in CPRs and a decisionmaking process that will be accepted throughout the health care system. For this reason, the IOM patient record committee’s major recommendation was the establishment of a Computer-based Patient Record Institute (CPRI) to promote and facilitate development, implementation, and dissemination of the CPR.