Electronic records can streamline patient care

The patient says he has been suffering from more asthma attacks, so a natural question is: Has he been faithfully taking his daily medicine?

In another era, physicians would have to rely solely on the patient or the parent for that kind of information. Increasingly, these days they also can see on a computer screen if the pharmacy has provided a refill.

That is the promise behind electronic medical records, which are becoming the norm in hospitals nationwide at the urging of the federal government. Critics warn that these systems can drive up costs and deprive doctors of time that would be better spent listening to patients, among other drawbacks. But in the best of worlds the idea is to bring about a coordinated, efficient approach among the many professionals whose job it is to make sick patients healthy.

Electronic records were a focus at the recent annual conference held by ECRI Institute, a nonprofit in Plymouth Meeting that studies health-care quality and patient safety. Among the participants was Nemours/Alfred I. duPont Hospital for Children in Wilmington, which reported that its electronic records system had helped cut readmission rates by half for patients with asthma and sickle-cell anemia.

Those figures are based on the number of patients who get readmitted within 30 days of discharge from the hospital, a standard industry measure of whether hospitals are providing proper follow-up.

But that yardstick is not good enough, said Stephen T. Lawless, vice president for quality and safety at the Nemours health system.

"Our goal is no longer 30-day readmissions," Lawless said at the conference, held in Washington. "It's readmissions over the next year."

Other participants reporting success with electronic records included the Veterans Health Administration and Kaiser Permanente, a large insurer and health system based in California.

Typically, such systems allow all clinicians to see specifics on a patient's symptoms, medicines, lab results, and treatments. In the case of an asthma patient, the records provide a clear picture if a patient is headed for trouble - say, if they are experiencing sinus infections, or seeking frequent prescription refills, said Bill Houston, a physician at a Nemours pediatrics practice in Wilmington.

Nemours added a new wrinkle in the last year, making a patient's records visible to the school nurse, if the family agrees.

The year before that, the health system also started allowing families to log on and see a version of the child's records. In 2010, the Nemours system received a national award from HIMSS, a Chicago-based nonprofit that advocates the use of health information technology.

Other ways that such systems can improve care is to make sure patients schedule their appointments. For example, a primary-care doctor can sign up a woman for a mammogram on the spot, said Jeffrey C. Lerner, ECRI's chief executive officer.

"It's this kind of ecology where things are interconnected and work together," Lerner said.

Critics note that hospitals have billed Medicare for more services upon adopting electronic-records systems.

That does not necessarily mean something is amiss, said David W. West, medical director of health informatics at Nemours. It can simply mean the hospital is now getting paid for services that were not always billed in the past because of incomplete documentation.

At Nemours, for example, this happened with respiratory therapy, which requires therapists to travel from room to room managing ventilators and conducting breathing treatments. Therapists used to document such services twice - once for clinical purposes, and then again for billing, after they returned to the office.

Sometimes they would forget to post charges for billing, but now they can't, because it's all part of the same process, West said.

Not everyone is convinced.

"It's a little hard to believe that all of that is just better documentation of things we already were doing," said Leora Horwitz, an assistant professor at Yale School of Medicine.

Writing in a recent column for the New York Times, Horwitz said electronic records were a necessary and valuable tool but only with proper implementation.

Among the problems she has seen are that records have mushroomed in size, to the point where important details can get lost. She and others also have warned of improper cutting and pasting, meaning a doctor has repasted notes without reexamining a patient.

Lawless said Nemours has an answer for that. The health system's software flags any text that has been pasted.