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Electronic health records are changing discharge planning in unexpected ways
Expect big push to expand IT reach
Special Report: Information technology changes DP
[Editor's note: In this issue of Discharge Planning Advisor, there is a special report on health care information technology and how it is changing discharge planning, as well as transforming the entire health care system. In this issue, the cover story is about this transformation and its future. This issue also contains a story about how an Australian health system has used electronic discharge summaries as a building block. In the July issue, there will be additional stories about electronic health records and how IT leaders have handled the transition.]
Information technology's toehold in U.S. hospitals and health care organizations likely will expand considerably in the coming decade as hospital systems and medical clinics receive federal stimulus package funds to make investments in electronic medical records (EMRs) and other new technology.
President Barack Obama signed the American Recovery and Reinvestment Act on Feb. 17, 2009, providing $1.5 billion to health centers for the acquisition of health information technology (IT) systems, as well as for other infrastructure improvements.
As hospital systems expand their use of IT, there will be some expected and unanticipated benefits to the discharge process, experts say.
"An electronic medical record allows us to create systems where we can integrate the bedside nurse, care coordinator, and discharge planner and give them all low barriers to access information and to break down silos between those groups," says Russ Cucina, MD, MS, an associate medical director of information technology and an assistant professor of hospital medicine at the University of California - San Francisco (UCSF) and UCSF Medical Center in San Francisco.
"That goes a long way to improving both the quality of discharge planning and the discharge process," Cucina says.
This change, which might occur fairly rapidly, also could result in some major growing pains as institutions rush into buying new technology without thoroughly assessing their system's capacity for absorbing it.
"I do think that as enthusiastic as I am to see the government providing the stimulus funds, I have to say that I have concerns about both the completeness of the existing hospital information systems available for purchase and the preparedness of many hospitals to implement such a system," Cucina says.
"So, while it's wonderful we will see lots of money for purchases, I hope hospitals don't underestimate the challenges," he adds. "The money could be wasted if they do."
Another challenge will be to use the new IT in a way that everyone agrees will be very important to improving our nation's health care system and in building IT links between hospitals and other providers, experts say.
From a discharge planning perspective, it will be ideal to have an EMR that can send e-mails and medical information about patients to community physicians, pharmacies, and other providers.
But this level of integration may take years perhaps decades to be realized.
"Right now, the electronic records are used in about 4% of physician offices across the country," says Donald Balfour, MD, president and medical director of Sharp Rees-Stealy Medical Group in San Diego.
The chief obstacle is cost, but the stimulus package could overcome that one, he notes.
"Because of the cost, physicians are reluctant to use information technology," Balfour says. "The whole purpose of the stimulus package is to give money to physicians so they could make purchases themselves."
But then it's up to the hospitals and physicians to connect their electronic networks. This also is an expensive and time-consuming task that might only be possible to accomplish if hospitals are permitted to help smaller physician practices with the transition to the electronic age, Balfour explains.
"We've been trying to loosen the [inducement] laws so hospitals can help physicians by putting a computer in their offices," Balfour says. "But right now that's considered inducement."
Hospitals are further along in implementing information technology, although it's the rare hospital that has a completely electronic medical record system.
The American Society of Health-System Pharmacists (ASHP) published results in December 2008, of a national survey on informatics in hospitals. The survey found that 42.9% of hospitals had one or more parts of a medical record in electronic form, but that only 5.9% of all hospitals had a complete EMR system.1
"Overall, even smaller hospitals are implementing forms of technology," says Karl F. Gumpper, BSPharm, BCNSP, BCPS, FASHP, a co-author of the ASHP survey study and director of the section of ASHP's pharmacy informatics and technology.
"When you look at the different choices and different programs for implementing [EMR], a lot of it depends on the size of the hospital, what its structures are like, and whether it's a for-profit or not-for-profit hospital," Gumpper says.
The ASHP informatics survey also found that of the hospitals that used some part of an EMR, only 53.2% allowed all health care providers in the hospital to have access to the electronic records.1
Nurses, pharmacists, and physicians were routinely given access, but mid-level practitioners were not granted access at a number of hospitals.1
U.S. hospitals might learn how to achieve success in transitioning to EMRs by studying the way IT transitions were handled in other countries.
For instance, primary care physicians in the United Kingdom have been using EMRs since the late '80s, says Richard Tanner, MD, a professor of medicine at the University of Pennsylvania School of Medicine in Philadelphia. Tanner has published studies that used the UK electronic medical record database.
"You'd have thought it was the National Health Service who forced them to do it, but that wasn't the case," Tanner says. "They started using EMRs on their own, because they found it was more efficient for them to use EMRs, so it was a provider-generated phenomenon."
As physicians transitioned to IT, a consensus began to develop around the idea of creating a national database that could be used for research purposes, as well as for more effective care transitions, he adds.
The National Health System requires that all medical providers report patient data directly to the primary care doctor, so the health record captures all major health events that occur in the patient's life, Tanner says.
Australia is another country where EMRs are more widely used by medical providers.
In Australia, general practitioners are the leaders in moving the industry to information technology, says Melanie Jane Alderton, Bapp Sci Hons, health information manager of medical records for Balmain Hospital in Balmain, New South Wales, Australia.
Hospitals are moving more slowly in adapting IT links to other providers, mostly because of data security and privacy issues, Alderton notes.
One obstacle to global EMRs that health care IT leaders have been addressing in the United States involves standardization of terminology.
There is a variety of health IT vendors in the United States, and each health provider might adopt and adapt IT to fit its own culture. So even within a health system, there will be one type of IT for the pharmacy department and another for physicians and another for radiology, etc.
But for these various electronic systems to communicate with one another, there need to be standard definitions, says Jane Brokel, PhD, RN, an assistant professor at the University of Iowa's College of Nursing in Iowa City, IA. Brokel co-authored a recent study about how a large Catholic health care system redesigned its care processes using an electronic health record.
"We utilized a lot of the standardized nomenclatures that have been adopted to meet the Health Information Technologies Standards Panel (HITSP) federally," Brokel says.
HITSP is funded by the U.S. Department of Health and Human Services (HHS) and is sponsored by the American National Standards Institute (ANSI). Its purpose is to develop a set of standards that will enable and support interoperability among health care software applications as they interact in a national health information network.
"Adoption of standardized nomenclatures and terminologies has to be agreed upon," Brokel says. "Free texting is not easily exchanged with the health information exchange infrastructure being put in place."
1. Pedersen CA, Gumpper KF,. ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in U.S. hospitals - 2007. Am J Health-Syst Pharm. 2008;65:2244-2264.
For more information, contact:
Melanie J. Alderton, Bapp Sci Hons, Health Information Manager, Medical Records, Balmain Hospital, Balmain, New South Wales, Australia. E-mail: firstname.lastname@example.org.
Donald Balfour, MD, President and Medical Director, Sharp Rees-Stealy Medical Group, 2001 Fourth Ave., San Diego, CA 92101. Telephone: (619) 446-1530. E-mail: Donald.Balfour@sharp.com.
Jane Brokel, PhD, RN, Assistant Professor, University of Iowa, College of Nursing, 482 NB, 50 Newton Road, Iowa City, IA 52242. E-mail: email@example.com. Telephone: (319) 335-7111.
Russ Cucina, MD, MS, Associate Medical Director of Information Technology and Assistant Professor of Hospital Medicine, University of California - San Francisco, UCSF Medical Center, UCSF Box 0131, San Francisco, CA 94107. E-mail: firstname.lastname@example.org.
Karl F. Gumpper, BSPharm, BCNSP, BCPS, FASHP, Director, Section of Pharmacy Informatics and Technology, American Society of Health-System Pharmacists, 7272 Wisconsin Ave., Bethesda, MD 20814. E-mail: email@example.com.
Richard Tannen, MD, Professor of Medicine, University of Pennsylvania School of Medicine, 295 John Morgan Bldg., 36th and Hamilton Walk, Philadelphia, PA 19104. E-mail: firstname.lastname@example.org.