The Institute of Medicine's 18 month study on improving the patient record concluded that "healthcare practitioners should adopt the computer-based patient record as the standard for medical and all other records related to patient care." (Ball & Collen 1992) The importance of information systems has also been recognized by the Joint Commission on Accreditation of Healthcare Organizations. JCAHO has now included new Health Information Management Standards in the Accreditation Manual for Hospitals (JCAHO 1994).
Despite recent interest in the computer-based patient record (CPR) and the excellent work being done by the information system vendors, the fully integrated, totally electronic record has eluded the marketplace. Many vendors have developed excellent components that perform one or more clinical functions, e.g. treatment plans, assessments, but very few have the total package. As a consequence, it is still necessary to use a variety of technologies to automate the various components and functions of the clinical record keeping and management process. The three basic technologies used by CPR vendors include:
1. Data processing systems
2. Office systems
3. Electronic document imaging
Data Processing Applications:
The data processing methods employed by the CPR vendors are the traditional tools used by management information systems. A series of menus (or more recently icons) are used to navigate around a system leading to inquiry functions, data entry screens and reports. These formatted screens are used to capture numerical and text data on a client, which is fed into a client database.
Some of the fields or data elements are coded, e.g. sex, diagnosis, marital status, while other fields like name and address accommodate free form alphanumeric text. Some of the fields provide for the entry of longer narrative which is used for miscellaneous comments, progress notes, assessments, etc.
The advantage to the data processing approach is that it is typically designed to facilitate repetitive data entry and the coded fields encourage standardization of the data. The screens, fields and codes are structured such that data are entered consistently, which helps reduce variability, errors and data entry time. Moreover, coded fields reduce the record size and simplify the process of locating, processing and reporting on a group of records.
A database can easily be "filtered" to select only the record(s) desired, e.g. "Presenting problem = Marital Problems". The codes are also a convenient method of sorting data and can be used for totaling and subtotaling in a report. These data manipulation features are not typically available in documents or blocks of text prepared by a word or text processor.
The disadvantage to the data processing approach to automating clinical information is that it is less flexible than a word-processed document. What you gain in efficiency and organization you loose in flexibility. Consequently, with the advent of the personal computer, virtually every healthcare organization has implemented off-the-shelf office productivity software, e.g. word processing, spreadsheets.
Office Systems:
The office systems applications include word processing, spread sheets, database management systems, graphics, e-mail, scheduling, and communications to name a few. The list of commercially available office systems software for the PC seems to increase almost daily. Further, over the past few years many of the systems are being integrated with one another (word processing, spread sheets, database management, e-mail, fax, Internet, etc.). Some of the integrated office systems packages available on the market today include Microsoft's Office, Lotus' Smart Suite and Correll's Perfect Office. Of these products Office has the lion's share of the market.
These packages are being used effectively by healthcare organizations and vendors to "fill in the gaps" left by the traditional data processing systems. Some common examples include:
- The use of word processing templates and forms for treatment plans, assessments and progress notes
- The use of spreadsheets to calculate and track quality assurance activities and continuous quality improvement indicators
- The use of database management systems to track client activities, outcomes, client satisfaction, etc.
- The use of presentation graphics packages to illustrate the numerical data captured in the spreadsheets and database management systems
- The use of e-mail to communicate with other clinicians regarding cases and to exchange related documents
- The use of scheduling to create and coordinate appointments for sessions and meetings
More recently, these programs are also being integrated with other software referred to as GroupWare or workflow programs that coordinate the routing, sequencing, processing and reporting of documents.
The workflow "engines" are used to facilitate the accomplishment of specific tasks by a workgroup or individual. They typically use an e-mail system as the electronic backbone to transport these data. Scheduling software and workflow rule tables are used to define the sequence of the activities, completion dates and recipients. An example of workflow software is Lotus Notes. The third and last technology used by information system vendors to create a CPR is electronic document imaging.
Electronic Document Imaging:
Electronic document imaging employs a scanner to create a digital image of a document. The document is then indexed and linked with a particular patient. This process is typically used for both active charts as well as for archival purposes. In the active chart, imaging is most useful when documents are received as a "hard copy". The image can then be linked to information in the data processing system. With the exception of the automated indexing using OCR or bar codes, the data cannot be processed, but is simply captured in graphical form.
The advantage to this technology is that the scanned document is then available simultaneously to multiple individuals at different locations. Further, the original chart does not need to be removed from medical records. The document can then be viewed and even annotated without altering the original image. The disadvantage is that the data on the document is not generally available to the data processing or office systems. In some specialized scanning applications forms are created with readable zones and OCR software is used to input data, e.g. client satisfaction surveys.
Components of the Electronic Clinical Record:
Using these technologies, healthcare software vendors have developed a variety of clinical applications that fall into one of two categories:
1. Basic charting functions
2. Clinical management functions
The basic charting functions include those applications that are used to capture client-related information such as:
- Client registration
- Client database
- Assessments
- Treatment plans
- Progress notes
The clinical management functions generally relate to the applications that are employed to monitor and control the activities of the clinical staff during admission, discharge, transfer and the provision of care. They include:
- Utilization review
- Utilization management
- Quality assurance
- Continuous Quality Improvement
- Credentialing and privileging
The clinical applications in the first group are typically dedicated modules that are designed to perform specific tasks. In the better systems they are integrated with one another and other applications like scheduling and billing and accounts receivable. The client database is the repository for most of the client specific information, much of which is derived from the client registration process.
The clinical management applications are somewhat less well defined. Most systems do not have discrete modules specifically designed for these applications. Typically, these functions are performed through adding data elements to the patient database and with custom report generators. Some third party products are available but they have the disadvantage of lacking integration.
Confidentiality:
Existing privacy and confidentiality regulations do not adequately address how electronic medical record information should be handled among patients, providers, authorizers, government agencies and third party payers. A number of bills are pending in Congress that attempt to address this issue. It is of growing concern to advocates and to the federal government.
The federal Substance Abuse and Mental Health Services Administration's Office of Managed Care's "Partners in Planning" addresses confidentiality in its chapter Contracts-Rights:
"It is vitally important that MCOs have policies and procedures to ensure the confidentiality of alcohol, drug abuse and mental health records. Most states have laws requiring the confidentiality of these records, but these vary considerably from state to state. Federal law and regulations include strict requirements on the confidentiality of alcohol and drug addiction records. These rules severely limit when information about an individual who is receiving alcohol and/or drug addiction treatment can be disclosed. For example, the regulations stipulate that a general consent form is not sufficient to disclose alcohol or drug addiction records; a specific, detailed consent form must be used. Yet many MCOs are unfamiliar with the specific requirements of federal law and problems have arisen as a result.
You may wish to review the contract to determine:
1. Will the contract require the MCO to adhere to federal alcohol and drug addiction confidentiality law and regulations?
2. Will the contract require that the MCO adhere to all other federal and state laws with respect to the privacy of member records?
3. Will the contract require that the forms the MCO will use to get informed-consent from its members for sharing of their medical information be approved by the mental health and/or substance abuse agency and by consumers and their advocates?"
Some organizations determine levels of security and categories of information to aid the process of creating clear procedures for determining who can access what information.
Access to each category of information is based on need and defined by job title and function. A receptionist may only need to know the name of callers to an Access Center. A crisis supervisor may need much more clinical data. These employees should be required to sign confidentiality statements and should receive training in confidentiality. No other employees should have access to this information.
Additional recommendations include:
- Adopt the American Health Information Management
Association guidelines for release of information. An
acceptable authorization should:
- Be in writing or given via computer
- Be addressed to the healthcare provider
- Specifically identify the patient (full name, address, and date of birth)
- Identify the individual or entity authorized to receive the information
- Identify the health information authorized for disclosure
- Specify the reasons or purpose for the disclosure
- Specify the date, event, or condition upon which authorizations will expire unless revoked earlier
- Indicate that the authorization is subject to revocation by the patient or the patient's legal representative
- Be signed or authenticated by the patient or the patient's legal representative. (The legal representative must indicate his relationship to the patient.)
- Be dated sometime following the patient's admission or service encounter. Unless Connecticut regulations state otherwise, no more than six months should elapse between the date of signature on the authorization and the date the information is requested
- All of the above should be kept with the consumer's health record
- All users of any manual or computer system should sign statements acknowledging that clinical information is strictly confidential and that access codes, passwords, etc. are for their individual use only.
- Passwords, access codes, etc. should be changed as soon as any user leaves the organization.
- All staff and computer system users should complete an orientation and continuing education program regarding Member Rights and Confidentiality. Completion of the training should be documented in writing with a signed acknowledgment that the employee understands and will abide by the Policies and Procedures.
- Create a Member's Rights subcommittee of the Quality Assurance / Improvement SteerAddress access to privileged information by contractors and vendors.
- Contracts should require that the entity will abide
by the confidentiality policies and procedures of the
organization as well as federal and state laws. The
contract should also specify
- That the vendor will keep such information in strict confidence
- The information will only be used for it's intended purpose
- That it will only be used by employees who need access to such information in order to provide services under the contract and who have signed an agreement requiring employees to hold the information in confidence
- That the information will be returned in useable form upon request or at a specified time (e.g. end of contract).
About The Authors:
Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcs@eos.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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