Paul C. Tang

Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption

Recently there has been a remarkable upsurge in activity surrounding the adoption of personal health record (PHR) systems for patients and consumers. The biomedical literature does not yet adequately describe the potential capabilities and utility of PHR systems. In addition, the lack of a proven business case for widespread deployment hinders PHR adoption. In a 2005 working symposium, the American Medical Informatics Associations College of Medical Informatics discussed the issues surrounding personal health record systems and developed recommendations for PHR-promoting activities. Personal health record systems are more than just static repositories for patient data; they combine data, knowledge, and software tools, which help patients to become active participants in their own care. When PHRs are integrated with electronic health record systems, they provide greater benefits than would stand-alone systems for consumers. This paper summarizes the College Symposium discussions on PHR systems and provides definitions, system characteristics, technical architectures, benefits, barriers to adoption, and strategies for increasing adoption.

Early Experiences with Personal Health Records

Over the past year, several payers, employers, and commercial vendors have announced personal health record projects. Few of these are widely deployed and few are fully integrated into ambulatory or hospital-based electronic record systems. The earliest adopters of personal health records have many lessons learned that can inform these new initiatives. We present three case studies--MyChart at Palo Alto Medical Foundation, PatientSite at Beth Israel Deaconess Medical Center, and Indivo at Childrens Hospital Boston. We describe our implementation challenges from 1999 to 2007 and postulate the evolving challenges we will face over the next five years.

The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters

OBJECTIVE To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING General internal medicine practice at an academic medical center. PARTICIPANTS Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patients agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patients life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

Comparison of Methodologies for Calculating Quality Measures Based on Administrative Data versus Clinical Data from an Electronic Health Record System: Implications for Performance Measures

New reimbursement policies and pay-for-performance programs to reward providers for producing better outcomes are proliferating. Although electronic health record (EHR) systems could provide essential clinical data upon which to base quality measures, most metrics in use were derived from administrative claims data. We compared commonly used quality measures calculated from administrative data to those derived from clinical data in an EHR based on a random sample of 125 charts of Medicare patients with diabetes. Using standard definitions based on administrative data (which require two visits with an encounter diagnosis of diabetes during the measurement period), only 75% of diabetics determined by manually reviewing the EHR (the gold standard) were identified. In contrast, 97% of diabetics were identified using coded information in the EHR. The discrepancies in identified patients resulted in statistically significant differences in the quality measures for frequency of HbA1c testing, control of blood pressure, frequency of testing for urine protein, and frequency of eye exams for diabetic patients. New development of standardized quality measures should shift from claims-based measures to clinically based measures that can be derived from coded information in an EHR. Using data from EHRs will also leverage their clinical content without adding burden to the care process.

Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions.

OBJECTIVE To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions. DESIGN A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record. MEASUREMENTS Completeness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress notes diagnostic and treatment plans, and appropriateness of documented clinical decisions. RESULTS The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records. CONCLUSIONS Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes.

The Use of Electronic Medical Records

OBJECTIVE To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING General internal medicine practice at an academic medical center. PARTICIPANTS Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patients agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patients life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

Major issues in user interface design for health professional workstations: summary and recommendations

Lack of good user interfaces has been a major impediment to the acceptance and routine use of health-care professional workstations. Health-care providers, and the environment in which they practice, place strenuous demands on the interface. User interfaces must be designed with greater consideration of the requirements, cognitive capabilities, and limitations of the end-user. The challenge of gaining better acceptance and achieving widespread use of clinical information systems will be accentuated as the variety and complexity of multi-media presentation increases. Better understanding of issues related to cognitive processes involved in human-computer interactions is needed in order to design interfaces that are more intuitive and more acceptable to health-care professionals. Critical areas which deserve immediate attention include: improvement of pen-based technology, development of knowledge-based techniques that support contextual presentation, and development of new strategies and metrics to evaluate user interfaces. Only with deliberate attention to the user interface, can we improve the ways in which information technology contributes to the efficiency and effectiveness of health-care providers.

Report of the AMIA EHR 2020 task force on the status and future direction of EHRs

Over the last 5 years, stimulated by the changing healthcare environment and the Health Information Technology for Economic and Clinical Health (HITECH) Meaningful Use (MU) Electronic Health Record (EHR) Incentive program, EHR adoption has increased remarkably, and there is early evidence that such adoption has resulted in healthcare safety and quality benefits.1,2 However, with this broad adoption, many clinicians are voicing concerns that EHR use has had unintended clinical consequences, including reduced time for patient-clinician interaction,3 new and burdensome data entry tasks being transferred to front-line clinicians,4,5 and lengthened clinician workdays.6–8 Additionally, interoperability between different EHR systems has languished despite large efforts towards that goal.9,10 These challenges are contributing to physicians’ decreased satisfaction with their work lives.11–13 In professional journals,14 press reports,15–17 on wards, and in clinics, we have heard of the difficulties that the transition from paper records to EHRs has created.18 As a result, clinicians are seeking help to get through their work days, which often extend into evenings devoted to writing notes. Examples of comments we have received from clinicians and patients include: “Computers always make things faster and cheaper. Not this time,” and “My doctor pays more attention to the computer than to me.” Ultimately the healthcare systems goal is to create a robust, integrated, and interoperable healthcare system that includes patients, physician practices, public health, population management, and support for clinical and basic sciences research. This ecosystem has been referred to as the “learning health system.”19 EHRs are an important part of the learning health system, along with many other clinical systems, but future ways in which information is transformed into knowledge will likely require all parts of the system working together. Potentially every patient encounter could present an …

AMIA Advocates National Health Information System in Fight Against National Health Threats

To protect public health and national safety, AMIA recommends that the federal government dedicate technologic resources and medical informatics expertise to create a national health information infrastructure (NHII). An NHII provides the underlying information utility that connects local health providers and health officials through high-speed networks to national data systems necessary to detect and track global threats to public health. AMIA strongly recommends the accelerated development and wide-scale deployment of electronic public health surveillance systems, computer-based patient records, and disaster-response information technologies. Such efforts hold the greatest potential to protect our citizens from disaster and to deliver the best health care if disaster strikes.

Computer-Based Patient-Record Systems

The preceding chapters introduced the conceptual basis for the field of medical informatics, including the use of patient data in clinical practice and research. We now focus attention on the patient record, commonly referred to as the patient’s chart or medical record. The patient record is an amalgam of all the data acquired and created during a patient’s course through the healthcare system. The use of medical data was covered extensively in Chapter 2. We also discussed the limitations of the paper record in serving the many users of patient information. In this chapter, we examine the definition and use of computer-based patient-record systems, discuss their potential benefits and costs, and describe the remaining challenges to address in their dissemination.