VA's experience illustrates virtues of electronic medical records

COLUMBIA — Laura Porter's test results were inconclusive.

A 49-year-old homemaker and Columbia resident, Porter had gone in for a routine mammogram, the results of which indicated a possible anomaly in her breast tissue.

Then Porter received the news that every person dreads when confronting the possibility of the big C: further tests were needed.

Ellis Fischel Cancer Center had no follow-up appointments available for three weeks, and the doctor thought that was too long to wait for answers, so Porter decided to visit another health care provider for her second round of testing. She would have the test done at Harris Breast Center at Boone Hospital Center.

When her name was called in the waiting room at Harris, the technician asked Porter for a copy of her mammogram from Ellis Fischel.

She didn't have one.

The technician led her into another waiting room, where she remained for more than an hour. Eventually, Porter was told there was no point in doing the second test without comparing the results from the first test.

"I asked the people at Harris: Could we not just call Ellis and ask them for that?" Porter said.

The answer was no. HIPAA law prohibits interchangeability with patient records, and because Porter hadn't previously signed a release granting them access, Harris Breast Center's hands were tied.

Availability of records varies

Porter — like many patients and health care providers — was stressed and inconvenienced by the inconsistency she encountered in the methods of medical record-keeping. Sometimes, the results are even worse:

• In Arizona, a pregnant woman had a CT scan performed on her abdomen, exposing her baby to radiation, after a nurse got her medical chart confused with another patient of the same name.
• A Rhode Island hospital was fined $150,000 and ordered to install video cameras in its operating rooms after having five instances of wrong-side surgery since 2007.
• Following Hurricane Katrina, New Orleans area medical patients, whose paper medical records were by and large destroyed in the storm, experienced life-threatening delays in diagnosis and treatment.

A shift toward wider use of electronic medical records has been a key component of the national health care debate. The American Recovery and Reinvestment Act of 2009 provides incentives to physicians and hospitals who use electronic records and health IT and use them not in a superficial way, but in a way that demonstrably improves patient care.

According to the Alliance for Health Reform, incentives will phase out after six years and penalties for nonadopters will begin. Although many health care providers recognize that electronic medical records would improve patient safety, some are balking at the cost of migrating to a new system, while other health practitioners are wary of learning and adopting a new technology.

Veterans Hospital an early adopter

To understand how electronic medical records affect patient safety, save money and help medical professionals work more quickly and efficiently, one need look no further than the Department of Veterans Affairs integrated health care system.

For more than 10 years, the VA has been storing patients' medical records online via a specifically tailored and sophisticated electronic record-keeping system. Physicians can view everything about a patient's medical history: medications, X-ray imaging, EKGs, blood work, advanced directives, screenings, upcoming tests, upcoming appointments, specialists' notes and lab results.

The Department of Defense has a similar record-keeping system in place for active duty military, and the two organizations share a goal of adopting a virtual electronic lifetime health record.

Lana Zerrer, director of primary care service line and acting chief of staff at the Harry S. Truman Memorial Veterans' Hospital, has worked for the VA for four years and previously worked for the Department of Defense.

Asked which organization's record-keeping system was better, Zerrer didn't hesitate: "The VA, without question."

Patient response has been similarly enthusiastic.

"You can actually show them how their labs have trended," Zerrer said. "You can graph their cholesterol and their weight loss right next to each other and show how well they're doing. They love that."

The potential snag is that occasionally over-attentiveness to the electronic record can make the patient feel he or she is secondary in importance to the computer screen.

During a consultation, "one thing we have to be very careful of is that we don't stare at the computer the whole time, but everything is on the computer," she said.

Zerrer said that VA hospital staff are sensitive to this complaint, and staffers receive training specifically to combat that possibility.

"Simply putting the patient's chair right next to the computer can help: look at the screen, look at the patient," Zerrer said.

Stephen Gaither, Veterans Hospital public affairs officer, said it wasn't such smooth sailing when the system was first implemented. He's been there since 1977, so he witnessed the transition.

"Like any new system, you had people resisting change and then you had champions, people saying we weren't going fast enough," he said.

The early developers and engineers rolled out the electronic records system gradually and from within, constantly tweaking the system based on feedback and recommendations from physicians and nurses. Hospital workers felt a great degree of investment in the final product because there was a lot of cooperation between the software developers and the health care providers.

"That helped with the buy-in," Gaither said, "because people didn't feel it was being pushed down from on top."

To listen to Zerrer and her colleagues, the advantages of an intuitive and comprehensive electronic records system are practically limitless for both patients and providers.

The system reminds the doctor to administer tests when they come due for a specific patient — tests like colonoscopies and mammograms, which might otherwise lag for a few months because of canceled appointments, a breakdown in the paper tracking system or simple human error. In this way, the record-keeping system acts as a safety net and plays what Gaither calls its most important role — protecting patient safety.

Patient safety is Lynn Parshall's primary focus. A nurse practitioner at the veterans hospital who specializes in mental health, Parshall began her career as nurse's aide in 1976 at Rusk Rehabilitation Center. When she took a job at the veterans hospital in 2001, she was floored by the refinement and sophistication of its electronic records system.

"And it's become more refined since then," Parshall said.

Over the course of her career, Parshall has seen a lot of changes in the health care industry. Even later into her career at Rusk, she did not have access to a computer, so she had to develop a paper tracking system for things such as medications and nursing home visits, which she found difficult to keep up with. Such a system is unnecessary at the veterans hospital, since the computer system reminds the provider about needed tests and flags potential problems such as medications that should not be taken at the same time.

Parshall ticks off a laundry list of the ways the electronic record trumps the paper record still in place at many medical practices:

• A practitioner can add signers (a specialist health provider, for instance) to a record when a test or new medication is ordered, establishing an automatic system of checks and balance.
• The computer reminds health practitioners when, for example, to do a foot exam on a diabetic, a procedure that Parshall says has dramatically reduced the number of amputations because it allows doctors to catch problems early.
• All of the patient's medications — prescribed by the VA or otherwise — are entered into the system, and doctors are notified if one medication is in conflict with another.
  
• Patients and providers benefit from receiving real-time test and lab results.
• When a patient travels, his or her entire record can be accessed from any VA hospital in the country.
  

Parshall likes that it's so easy to view the patient record in so many different ways; she said it makes it much easier to catch mistakes and much harder to overlook needed treatments.

"That is one of the things that comes out in our health care debate," Parshall said. "We're oriented towards illness, and we're oriented towards acuity, but we're still not very oriented towards prevention."

Pushing forward

Former Senate Majority Leader Tom Daschle, who was the keynote speaker at the seventh annual Missouri Health Policy Summit in October, was adamant about the need for change in electronic records and health information technology.

"We have a 21st century operating room, and we have a 19th century administrative room," Daschle said. "All one has to do is go through the clinics at many hospitals today and see those hallways and hallways of manila folders to know how 19th-century oriented we still are."

The Alliance for Health Reform said that as of early 2008, only 4 percent of physicians were using a fully functional electronic health records system. Obstacles remain, such as cost, the learning curve, ensuring that systems are interoperable and maintaining patient privacy.

Asked about the worry of some patients that their personal information might become compromised by being stored online, Daschle smiled.

"You could argue that those manila folders that sit in the hallways of most doctors' offices today don't allow for a lot of privacy either," he said.

Laura Porter has a different perspective on the patient privacy problem.

"The law that's designed to protect everyone's privacy has become a burden," she said, referring to the anxiety she suffered trying to work around the very privacy laws that were designed to protect her.

Porter's nurse at Harris said that if she would drive to Ellis Fischel and pick up her mammogram for comparison, they could still see her that day.

When she got to Ellis, "the very nice woman told me that if I filled out this form and signed it, I could get my records in 24 hours."

Porter pleaded her case and was able to leave Ellis Fischel with a CD of her mammogram slides. Then she headed back to Harris, where she waited again before having her second test, then awaited the arrival of the doctor who would analyze the results.

Five hours after she'd left for her initial appointment, Porter received her answer: no cancer.

Porter was frustrated by the experience, not merely on behalf of herself, but on behalf of the health care providers at both Harris and Ellis Fischel. She saw firsthand how privacy laws inhibiting free transfer of her electronic medical record affected her peace of mind and her nurses' and doctors' ability to do their jobs quickly and efficiently.

"It's a burden not only to the patient, but to the health care provider," Porter said. "The people at Ellis were very helpful, but I know that they can't stop and do that every day for everyone who needs medical records."