So, every
once in awhile, I move away from posts that are extremely personal, emotional,
and philosophical, to talk about the more practical aspects of being a patient,
with some old-fashioned research thrown in for good measure.
Electronic Medical Records
Recently,
the hospital that my rheum and other specialists are at, and the student clinic
where my primary care doctor is, moved to an electronic medical records system.
At your
first appointment after the system was instituted, you received an access code,
which allowed you to go online and access your medical records. You don’t have to, but for someone like me
who is chronically ill, the possibility of having my medical information at my
fingertips was very appealing. So I
signed up pretty much right away.
Until I
discovered that there was an IPhone App I could download, I did not realize
that the system I was using is actually of the “Vendor Created, System Hosted”
variety (Halamka, et al. 2008). This
means that a third party created the system and the health system I belong to
hosts it.
In other
words, Epic Systems, a company out of Wisconsin, created an electronic records
system, known as MyChart. This system
has been around since the late 1990s. Along with Halamka, et al. (2008),
Hassol, et al. (2004) and Serrato, Retecki, and Schmidt (2007) look
specifically at the MyChart system.
Through
the patient portal online, you can do a variety of things: request and cancel
appointments, request prescription renewals, review health history, view
immunization records, view test results, send messages to your healthcare team,
and pay bills online.
Here are
some of my observations thus far:
Likes:
-
You
can create tables that compare past test results, which is useful to monitor
certain levels.
-
I
can e-mail my doctors’ offices, schedule appointments, cancel appointments, etc.
-
I
get an automated e-mail when new results, messages, appointments, are posted.
-
Unlike
before, both the hospital and the student health center can see records. Before, only one could see all records and
the other could not, which made things very tricky when you have a primary care
doctor at one and all your specialists at the other. This was a serious flaw in the old system,
which I am grateful has been fixed.
-
Presumably
no more having to pay money to get your hands on your medical records and test
results.
Dislikes:
-
I
can only see my records/history from AFTER the system went into effect. Presumably, the interface that my doctors use
allows them to see the entire health record, not just since the implementation
of the new system, but I am not certain of this, since I have never seen the
system from the other side.
-
No
one, in terms of doctors, knows how to use the system, which has increased the
time of clinic visits by a significant degree.
It was instituted in the summer and there is still a steep learning
curve, which I know has also been frustrating for the clinicians.
-
If
there was some potentially devastating test result, would it get posted to the
health record that the patient could interface with? Or would it not be released until the doctor
delivered the news to the patient?
-
I
don’t kn0w what every test means. I know
certain levels and things like that, but not every test.
-
One
of my medications is not commercially available in the United States, and
therefore, was not in the database. I
was told the system would not allow the doctor to enter a medication not already
in the system. This seems like a huge
liability, especially as far as drug interactions go.
-
There
are some inconsistencies. For one thing,
the prescribing doctor on most of my medications is incorrect. But there is no way to change things. While you can interface with the medical
record, as the patient, to my knowledge, you cannot manipulate it, even when
you find things that are incorrect.
In their
study, Hassol, et al. (2004) found that a third of people felt that their
medical record and information was not complete. Further, there was a distinct inability to
understand tests results, especially abnormal ones. Further, Hassol, et al. (2004) confirm my
worst fears that patients can see any and all test results, even ones that are
potentially devastating, before their doctor has had a chance to contact them
about them directly.
One would
hope that one benefit of having access to an electronic records system is that
there would be greater coordination of care across specialists for the same
patient. However, this has been
identified as one area that is lacking (O’Malley, et al. 2009).
This is
something I have noticed generally about my care, and something that I hoped
would be improved by this system. As I
suggested, now all of my doctors in the same health system have access to my
records, however, whether doctors put that information to good use is up to
them. Additionally, when I saw my PCP
last week, she was very frustrated because there has been a variety of contacts
(via phone and e-mail and through the portal) made between me and various
doctors’ offices in the past month, and my PCP was having difficulty finding
the last note she had made in my record when I saw her a month ago.
Negatives
on a broader scope include electronic medical records widening the healthcare
disparity based on race, as whites are much more likely to utilize these
systems than are blacks and other minorities (Goel, et al. 2011; Roblin, et al.
2009). Additionally, there are various
privacy concerns due to the potential negative effects of the wrong people
gaining access to electronic record information (Li, et al. 2011).
I have to
say that I like the ability to e-mail questions, refill requests, and requests
for making and canceling appointments online.
It saves me the hassle of going through my phone to find the doctor’s
office number, of which I have many, and waiting on hold on the phone to talk
to a person. However, when doing things
via the portal, this then puts the onus on the doctor’s office to contact the
patient in regard to whatever message or request they have sent, rather than it
being the patient’s responsibility.
It may or
may not be surprising then that Hassol, et al. (2004) found that patients
preferred online communication the best, while doctors preferred telephone and
in-person communication in preference to online.
E-Prescribing
Even before the adoption of the electronic records system was instituted in my health system, prescriptions went paperless. Prescriptions are all electronic, so not only does the patient not have a paper copy of the prescription, but if there is an error, the patient won’t necessarily be able to catch it, because they don’t really get the opportunity to view the prescription that gets put into the system by the clinician.
Even before the adoption of the electronic records system was instituted in my health system, prescriptions went paperless. Prescriptions are all electronic, so not only does the patient not have a paper copy of the prescription, but if there is an error, the patient won’t necessarily be able to catch it, because they don’t really get the opportunity to view the prescription that gets put into the system by the clinician.
I have had
varying issues with this, as well:
-
My
original Humira dose was totally wrong.
It somehow got listed as being taken twice a week instead of twice a
month, necessitating the pharmacy to call my doctor to correct the error.
-
The
prescription gets sent to the wrong pharmacy.
This has happened almost every time, and has involved me needing to
contact the doctors’ offices to get the prescriptions re-submitted to the
correct pharmacy. Unfortunately, the way
my prescription insurance works, I can’t get all of my prescriptions from the
same pharmacy. The “normal” ones I get
at CVS, the Quinacrine I have to get from a specialty pharmacy that compounds,
and certain other special prescriptions I have to get from the hospital pharmacy. This system might be ideal for patients who
are able to use one pharmacy for all their medications, but it seems to me that
if you use more than one, it really complicates things.
-
It
defaults. So for the Humira, when I was
trying to get the pre-filled syringe instead of the pen, it automatically
selects the pen and the nurse or clinician had to notice this and change it,
which didn’t happen, again necessitating contacting the doctor’s office
multiple times to make the change.
I am not sure
of the specific E-Prescribing system that is used by my healthcare providers,
but whichever one it is, I have noted above the various problems that I have
experienced.
While some
have suggested greater efficiency with E-Prescribing (Agarwal, et al. 2010; Grossman,
et al. 2012), E-Prescribing actually tends to take doctors longer than simply
handwriting them (Lapane, et al. 2011), and can increase, rather than decrease,
the amount of errors made that can have adverse consequences on patients
(Palchuk, et al. 2010).
The thing
I really don’t like about this system, with all of its flaws, is that there is
no way to get a paper prescription. Even
when the prescription keeps getting messed up.
And there is no way to see this, because you never see what the physician
is putting into the system. I’m all for
technology, but to be so technologically dependent, even when there are clear
errors, is just plain annoying.
A lot of
problems in E-Prescribing occur when there is a lack of technical support
(Crosson, et al. 2011), suggesting that adequate training of healthcare workers
is needed, and adequate support needs to be provided when problems occur.
I’m not
trying to be a Negative Nancy here, but of course, all of this presupposes that
the patient has adequate internet access and is technologically savvy enough to
use the systems. And the doctors have to
be technically savvy, as well, which may make it difficult to learn a totally
new system while having a regular caseload of patients.
If your
healthcare providers haven’t hopped on the electronic health bandwagon yet, it
is only a matter of time. But given all
of the issues that I and previous research has noted, the bottom line is that
these systems are only as good as the people that created them and the doctors
and other medical personnel that use them.
These are
screenshots from my IPhone of the sign-in screen to my health system-specific
portal (left) and the actual interface of the MyChart capabilities
(right).
These
systems look quite different between the IPhone interface and the PC interface,
so I have also included screenshots of the sign-in screen (top) and interface (bottom)
as they appear on my PC. Without showing
too much of my personal health information, I wanted you to see all the various
things you can do with the portal.
* I’ve
excluded from analysis articles that come out of the UK and Canada, as their
healthcare systems, as they currently stand, are different from ours.
**For this
I looked specifically at research related to electronic health records and E-Prescribing,
rather than health informatics, in general, for which there is a large
literature.
References
Adler,
K.G. 2009. “E-Prescribing: Why the Fuss?” Family
Practice Management (January/February) 2009: 22-27.
Agarwal,
R, C.M. Angst, C.M. DesRoches, and M.A. Fischer. 2010. “Technological
Viewpoints (Frames) About Electronic Prescribing in Physician Practices.” Journal of the American
Medical Informatics Association 17: 425-431.
Crosson,
J.C., R.S. Etz, S. Wu, S.G. Straus, D. Eisenman, and D.S. Bell. 2011.
“Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care
Practices.” Annals of Family Medicine 9
(5): 392-397.
Goel,
M.S., T.L Brown, A. Williams, R. Hasnain-Wynia, J.A. Thompson, and D.W. Baker.
2011. “Disparities in Enrollment and Use of an Electronic Patient Portal.” Journal of General Internal Medicine 26
(10): 1112-1116.
Grossman,
J.M., D.A. Cross, E.R. Boukus, and G.R. Cohen. 2012. “Transmitting and
Processing Electronic Prescriptions: Experiences of Physician Practices and
Pharmacies.” Journal of the American Medical Informatics Association 19 (1): 353-359.
Halamka,
J.D., K.D. Mandl, and P.C. Tang. 2008. “Early Experiences with Personal Health
Records.” Journal
of the American Medical Informatics Association 15 (1): 1-7.
Hassol, A., J.M.
Walker, D. Kidder, K. Rokita, D. Young, S. Pierdon, D. Deitz, S. Kuck, and E.
Ortiz . 2004. “Patient Experiences and Attitudes about Access to a Patient
Electronic Heath Care Record and Linked Web Messaging.” Journal of the American
Medical Informatics Association 11 (6):
505-513.
Lapane, K.L., R.K.
Rosen, and C. Dube. 2011. “Perceptions of E-Prescribing Efficiencies and
Inefficiencies in Ambulatory Care.” International
Journal of Medical Informatics 80: 39-46.
Li, F., X. Zou, P.
Liu, and J.Y. Chen. 2011. “New Threats to Health Data Privacy.” BMC Bioinformatics 12: 1-7.
O’Malley, A.S., J.M.
Grossman, G.R. Cohen, N.M. Kemper, and H.H. Pham. 2009. “Are Electronic Medical
Records Helpful for Care Coordination? Experiences of Physician Practices.” Journal of General Internal Medicine 25
(3): 177-185.
Palchuk, M.B., E.A.
Fang, J.M. Cygielnik, M. Labreche, M. Shubina, H.Z. Ramelson, C. Hamann, C.
Broverman, J.S. Einbinder, and A. Turchin. 2010. “An Unintended Consequence of
Electronic Prescriptions: Prevalence and Impact of Internal Discrepancies. Journal of the American Medical Informatics
Association 17: 472-476.
Roblin, D.W., T.K.
Houston, J.J. Allison, P.J. Joski, and E.R. Becker. 2009. “Disparities in Use
of a Personal Health Record in a Managed Care Organization.” Journal of the American
Medical Informatics Association 16 (5):
683-689.
Serrato, C.A., S.
Retecki, and D.E. Schmidt. 2007. “MyChart – A New Mode of Care Delivery: 2005 Personal
Health Link Research Report.” The
Permanente Journal 11 (2): 14-20.