By Jeanie Davis
The problems of electronic medical records (EMRs) have been all too real during this pandemic.
Patients with life-threatening COVID-19 symptoms have gone to hospitals without family or friends. They may not recall critical details of their medical history, including medications.
“This is so common, and is especially problematic if the patient has chronic disease comorbidities that impact how well they do in treatment,” says Vivian Campagna, MSN, RN-BC, CCM, the chief industry relations officer for The Commission for Case Manager Certification.
EMR System Flaws and Interoperability
At the crux of this crisis is the patient’s EMR, which holds important details that help providers make treatment decisions. Too often in hospitals, healthcare providers cannot access all these records, which is frustrating for everyone.
When the Affordable Care Act became law in 2010, there were incentives to set up EMR systems to allow all providers across the country to access a patient’s medical records, all within Health Insurance Portability and Accountability Act (HIPAA) privacy rules. The goal was to enhance patient care with this access.
“Interoperability” was the concept born during this time. It describes an optimal system in which patient records are easily accessed — a “patients first” goal of the Centers for Medicare & Medicaid Services (CMS). As the country faced the pandemic, CMS issued an updated rule to break down barriers and improve access to health information.
“Certainly, it is inherent in the pandemic that the situation is more complicated because we don’t have true interoperability,” says Campagna. “Case managers have been resourceful in using FaceTime to connect with families to retrieve essential information. Hearing the family’s story and having that dialogue can be very helpful to the case manager. A video chat or a conference call is also valuable.”
However, true interoperability is needed. “We need medical information that follows us so there is continuity of care wherever we are,” she explains. “All the details the patient can’t remember will be readily available to facilitate treatment, leading to better patient outcomes.”
Major Concerns and Challenges
Turf battles among EMR vendors have proven to be the biggest challenge, industry experts say. As every EMR system is built to be unique, each system includes features that inherently prevent interaction with another vendor’s system.
While using the same EMR vendor generally will mitigate interoperability issues, there often are many custom or add-on features that may be in place with the same vendors. These still may prevent interoperability and block the flow of important health information to the point of care. A variety of EMR vendors make achieving the goal of interoperability (and liberating data) that much more difficult, says Campagna.
Health Information Exchanges have blossomed over the past decade to improve the EMR dilemma. To assess the progress, eHealth Initiative conducted its annual survey to determine the biggest challenges. The survey went to 199 data exchange initiatives and revealed the huge task of building IT connections between dozens of disparate systems. A total of 142 groups reported interoperability as a major concern, as it is both difficult and expensive. (More information is available at: https://www.beckershospitalreview.com/healthcare-information-technology/the-3-biggest-hie-challenges.html.)
Lack of Consistency a Problem
In the survey, health IT groups asked vendors for more standardized pricing and integration solutions. They also asked for more “plug-and-play” functions, as well as standards in data vocabulary and transport.
Inconsistency in identifying patients is a big issue, as EMRs may use patient name, date of birth, or Social Security number as their primary identifier. Without standardization, it creates havoc in sharing a patient’s records.
Many patient advocacy groups have asked for a national, unique patient identifier similar to Social Security number, which would be used throughout the person’s lifetime and at every point of care.
HIPAA called for the creation of a unique patient identifier. However, Sen. Rand Paul, R-KY, introduced legislation in 2019 to repeal this requirement. (More information is available at: https://www.fiercehealthcare.com/tech/sen-rand-paul-continues-fight-against-national-patient-identifier-introduces-bill-to-overturn.)
Without a unique patient identifier, there is no way to link any person’s health data into a comprehensive picture of their healthcare experiences, says Campagna. “This must occur before industrywide interoperability can become a reality.”
Another issue is lack of standards for sending, receiving, and managing health information creates difficulties at every step. Even getting a simple copy of a health record — or sharing it with another institution — is foiled by mismatched type fonts, data fields, and formats, Campagna says.
All this is proprietary for the vendors and means data must be “manipulated and sanitized” before it can be imported by another system, she explains.
Why Interoperability Is Critical
Interoperability is focused on providing an overall picture of the person’s medical condition. The goal is to reduce duplication of tests and treatments that increase medical costs, misuse resources, and can result in treatment delays.
The goal is also to improve continuity of care, giving every provider the same access to patient information, explains Campagna. This expedites patient care as the provider knows immediately what treatment is required at that point instead of having to backtrack.
One common issue: When a patient is traveling, they may not have medical information with them. If they are in another region of the United States or abroad, how quickly can a medical provider access their records? It should be automatically available, but we are not there yet, Campagna says.
Instead, a patient typically must undergo another test, but the doctor will have nothing to compare the results. Without a benchmark, it is not optimal medical care.
“If the EMR systems were interoperable, there would be continuity,” says Campagna. “If I had an MRI five years ago, it would be in the record for comparison with my new MRI. If I can’t remember where I had that previous MRI, we’ll have to start all over again. We won’t know if the problem is progressing or if I’m having complications from the original problem.”
With current electronic systems, there should be no waiting three weeks for a copy to arrive from the previous facility, she adds. “Unfortunately, we haven’t quite got to that point.”
“With hospitals partnering and forming large health systems, we do see EMRs available to hospitals, clinics and physician offices within that system,” Campagna says. “All these groups are able to talk to each other, but if you leave the system, you may be required to go ‘old school’ and bring a written report from your doctor’s office that has to be scanned.”
Interoperability will lead to improvements in healthcare, says Campagna, as it will encourage continuity of care. Any diagnosis or illness will be recorded so every doctor will know a patient’s history. There will be increased efficiency as they will not have to repeat tests.
What Case Managers Can Do
To ensure patients do not undergo unnecessary tests, case managers can go the extra step to track down the records, she advises. “That gives us the ability to be much more efficient and effective as we work with patients and helps us formulate treatment and discharge plans. When working with patients, with families, or reaching out to providers in the community, case managers are very good at getting what they need, acting as detectives to track down the information.”
Professional organizations and other healthcare organizations have consistently lobbied for interoperability.
“Case managers should be making their voices heard in their professional organizations to keep the momentum in pushing forward,” Campagna adds. “We all recognize that with interoperability, we will have an optimal system for health records.”