Michele Kline, MSN, CNP, has a somewhat familiar story: As a family nurse practitioner at the Cleveland Clinic, she sees a lot of “snowbirds”—retired people who split their time between Ohio and Florida. Since they have two residences, these patients also get their health care in two different states.
There was a time when that situation was fraught with the potential for health issues to fall through the cracks, due to a lack of communication among health care providers. Thanks to electronic medical records (EMRs), Kline says she doesn’t miss a beat.
For example, when one of her patients underwent a heart scan while in Florida, Kline simply sent an e-mail to her counterpart there. With the click of a button, she was able to check the results. When her patient returned to Cleveland for the summer, they picked up where they left off, with no gaps in care.
Though the market for EMRs has grown steadily, many clinicians have been reluctant to adopt the necessary systems and procedures. But as major players launch patient-focused programs—the Cleveland Clinic helped Google Health test its own application, and Microsoft and WebMD are among other companies getting in on the action—health care providers may find themselves scrambling to meet demand.
Concerns About Privacy
The growing trend toward EMRs, or the personal health records that Google has launched, has sparked debate among patients and clinicians. Some tout the benefits of EMRs, such as improved coordination of care and reduced medical errors, while others criticize them as creating more hassles for health care providers. Critics also worry about privacy breaches, since services like Google Health are not subject to the protection provided by HIPAA (although companies have developed their own privacy guidelines, which are similar to the federal regulations).
In an editorial recently published in the New England Journal of Medicine (2008;358:1656-1658), two Massachusetts physicians, Pamela Hartzband, MD, and Jerome Groopman, MD, warned health care workers about the pitfalls of electronic records. Hartzband, an endocrinologist at Beth Israel Deaconess Medical Center in Boston, worries that clinicians might miss some important diagnostic clues if they no longer take a patient’s medical history by hand, with pen and paper.
“Talking to the patient independently may offer some new clues and symptoms,” Groopman explains. “But everybody is working under pressure, so they just copy and paste previous information without taking their own history.”
He also worries that placing a computer squarely between the provider and the patient will rob the health care setting of a valuable personal connection. “Patients feel their doctors are looking at the computer screen instead of actually talking with them,” says Groopman, a hematologist-oncologist at Beth Israel Deaconess.
Groopman also is unhappy with the number of computerized forms he is required to fill out for malpractice and insurance reasons—things that have very little to do with actually helping a patient feel better. Since his institution switched to EMRs, he says, he must stay late into the night doing extra paperwork.
Kline, 48, who has used EMRs during her entire 11-year career as a nurse practitioner, disagrees with Groopman’s assertion that computerized records slow down clinicians and create more work for them.
There is a learning curve, she says. But once you learn how to integrate an EMR system into your practice, it can make you much more efficient, Kline contends. Instead of spending the end of her day playing phone tag and fielding last-minute requests from patients, she calmly responds to their e-mails. In the end, using e-mail to communicate takes less time for both the clinician and the patient, Kline says.
Getting Patients Involved
Whether clinicians like it or not, experts say this trend is taking off, and it’s probably not going to disappear. The trick, according to C. Martin Harris, MD, Chief Information Officer at Cleveland Clinic, is to get a system that really works—for both patients and clinicians. In Cleveland, they use MyChart®, by Epic Systems Corporation. The hospital now has a total of 2.4 million patients using MyChart for everything from scheduling appointments and requesting prescription refills to receiving reminders about annual tests, such as mammograms.
At Cleveland Clinic, each exam room has a desktop computer for providers to use. Harris says the computers aren’t really barriers to care, because his staff has been specifically trained to avoid turning to the machine first. They still look the patient in the eye and make personal contact while doing a medical history, he explains. They just enter the data discreetly at another time, perhaps while the patient is changing into a gown or settling on the exam table.
Kline takes it a step further and actually tries to get her patients involved with using the computer. For example, she might turn the screen sideways so both she and the patients can look at it. She’ll show them a graph of their blood pressure or cholesterol before she discusses a change in medication with them. In one instance, a patient had a question about whether a certain blood pressure drug would be safe to take during pregnancy.
“I didn’t know the answer,” Kline admits. “So we turned to the computer and looked it up together.” That way, the patient was involved in her own health care decisions, and she didn’t have to wait until the next visit to get an answer.
Fine-Tuning the System
Kline says she uses the Cleveland Clinic’s MyChart system only with patients who tell her they are active computer users and check their e-mail every day. Kline relates that her group of “active computer users” includes patients in their 80s as well as those in their 20s. Senior citizens are some of the biggest fans of EMRs, she adds.
Besides knowing which patients might be comfortable with electronic records, Kline keeps tabs on whether her patients are receiving the information they need from the system. If she notices a patient’s MyChart data are not being viewed, she will print out the relevant pages and send them to the patient via “snail mail.” As a precaution, if she is sending lab results to a patient, Kline will request an automatic reply, which tells her the person received the information. If she doesn’t get a reply, she will personally follow up with a phone call.
Of course, there are certain times when e-mail communication is not appropriate, Kline says, and clinicians have to use their own discretion and common sense. For example, if a patient is diagnosed with a critical or terminal illness, a personal visit or phone call is the right way to go. Also, if there are time-sensitive test results, phone calls work better—an e-mail might get lost in the shuffle.
Overall, Kline is a fan of the EMR. She feels it has made life easier for her patients, and for her. But then, not all hospitals have worked out the bugs the way Cleveland Clinic has over the years.
Kline advises other clinicians to hang in there with it. “If you can be patient and embrace the learning curve,” she says, “this has the potential to add efficiency to your day.”