Guest Author - A Healthcare Worker on the Electronic Record

Guest Author- A Healthcare Worker on Electronic Health Information
I have been working in the healthcare industry for the last 9.5 years. The last 4 years I have worked in health information management. I have worked with the transition of the hospital’s paper record to an electronic system. Currently, the new patient records are 90% electronic. But old records are still paper and are currently being scanned into an electronic format.
First, I would like to define terms regarding electronic records. EMR – The Electronic Medical Record is a record of a patient’s visit. It is a computerized legal clinical record of the medical care delivered by the hospital, doctor, and any other services on a particular date.
The Electronic Health Record (EHR) encompasses a broader range of health-related data. It contains patient input and access spanning episodes of care across multiple organizations. The data can be used to look at health care issues for a community, region, or state.
Second, there are two current initiatives driving the electronic records program; the federal stimulus initiative for electronic records by 2014 and Wisconsin Governor Jim Doyle’s initiative to have electronic records by 2012.
More information on these two initiatives can be found at: Wisconsin.gov/ehealth/EHR/index.htm and ehealthboard.dhfs.wisconsin.gov.
Third, I would like to share some of the problems that the medium size hospital I work for has encountered. The first version of the “electronic record” went live in July of 2009.
The first problem we encountered was the idea of what an electronic record (for our hospital) was. Physicians and outside health care providers assumed that the whole record was electronic. Along with this assumption was the idea that the record would be available immediately. To appreciate this dilemma let me outline the record keeping forms that our hospital supports for medical records. From the 1940’s through 1950’s the records are on reel-to-reel tapes. From the middle 1950’s to 1995 the records are on microfiche. From 1996 to 2003 the records are on CD. Records from 2004 to 2007 are paper and currently being put on CD or being scanned. Records from 2007 to current are almost completely electronic. Currents records are further broken down by dictated/transcribed, point of service, and scanned portions.
The second problem was training staff to access a record. All new records are scanned into an electronic format as soon as possible which makes the record available quickly and to all departments and clinics within our campus. However, now staff, nurses, and physicians have access to medical records. These personnel had to be retrained on how to encompass this into their daily routines and workloads. There was a lot of reluctance on the part of this group of individuals, who main goal is patient care, to now be an active part of the patient’s record retrieving process. It is still difficult for some clinicians to change the idea of a patient visit . Now the visit has been adjusted to include viewing records either with the patient or before anyone sees the patient and also includes dealing with the records when the visit is over. Traditionally, some of this work was done by other areas of the organization.
The third problem is use of the electronic record. HIPPA has many standards for protection of patient information. As this information becomes more accessible, it has to also become more trackable. Currently, we cannot release records in certain formats because the organization cannot guarantee the security of the format. (Such as email) Therefore, it limits the use of information for outside agencies such as pharmacies, labs, and offsite research institutions. In my opinion, this will be one of the most difficult problems to surpass to put together the EHR, as organizations struggle with keeping patient information confidential and secure, yet available.
The electronic record has streamlined our billing and coding processes. It has made accessing a patient’s record quicker and allows a greater continuity of care in our organization.
Given the struggles still to come with electronic records, I feel that it would be of great benefit to the patients and health care providers to have access to health information as quickly and securely as possible no matter where the patient is.