|Electronic Medical Records: Moving Jails Forward|
|By Darrelle Knight|
It is obvious that we live in the Age of Technology. Nevertheless, technology for health information has evolved slowly over the past three decades, compared to systems for other industries. The importance of consistent, assessable medical records continues to be a goal for the health care industry, in theory best accomplished through the use of an electronic medical records (EMR) system.
The usefulness of such a system has been emphasized in the political arena. Both of the 2008 presidential candidates talked about the importance of electronic medical records. John McCain praised the Cleveland Clinic’s electronic medical records system, nothing that “technologies like this could reduce errors, alert doctors to best practices and might even lower medical malpractice insurance premiums”(Vanac, 2008). As part of his initiative to reform health care, Barak Obama said his administration would invest $10 billion dollars over the next five years to help transition U.S. healthcare to a standards-based electronic health information system, which includes electronic health records (Obama, 2008).
Health information technology has also created new employment opportunities. As the United States moves forward to implement electronic medical records, the ever-evolving fields by health care and information technology are merging to offer exciting new jobs. According to the U.S. Department of Labor, employment of medical records and health information technicians is expected to increase 18% a year through 2016-faster than the growth for all other occupations-because of the rising number of medical tests, treatments, and procedures that will be increasingly scrutinized by health insurance companies, regulators, courts, and consumers (Bureau of Labor Statistics, 2008).
A benchmark study, conducted by researchers from the RAND Health Corporation and published in Health Affairs in 2005, is widely referred to within health economics literature to support the need for electronic medical records. Overall, the authors of the study found that EMRs could save money by reducing redundant care, speeding patient treatment, improving safety, and keeping patients healthier (RAND, 2005). In a separate study by RAND published in the same issue, authors stated that incentives from federal official could encourage medical providers to adopt more advanced drugs prescription systems (RAND, 2005).
In July 2008, the House of Representatives and Senate overrode President Bush’s veto of H.R. 6331: Medicare Improvement for Patients and Providers Act of 2008. This law will raise Medicare payments to physicians who “e-prescribe.” The increased payments will take effect in 2009 and taper off until 2013. It will also enforce Medicare payment penalties beginning 2012 for physicians who do not e-prescribe (Dunham, 2008).
Through the Medicare Modernization Act of 2003, Congress mandated the Institute of Medicine “to carry out a comprehensive study of drug safety and quality issues in order to provide a blueprint for system-wide change.” The study, released July 2006, revealed that at least 1.5 million preventable, adverse drug events occur in the United States each year (IOM, 2006).
The overwhelming number of documented medical errors are from hospitals and other inpatient settings, not necessarily because the make more mistakes but because their errors are easier to track. It is considerably more difficult to conduct such studies in outpatient centers. In one a notable study, researchers reviewed death certificates over a 10-year span and concluded that the number of deaths because of medication errors increased 2.57-fold from 1983 to 1993. The number of deaths resulting from outpatient mistakes increased 8.48-fold (Phillips, 1998).
Illegible handwriting is one of the most common problems pharmacists encounter. Physicians’ handwriting is often a source of laughter; however, statistics reveal no humor in prescriptions and other physicians’ orders that are sloppily written. In 200, the increasing number of medication errors prompted the Institute for Safe Medication Practices to encourage the elimination of handwritten prescriptions within three years. Eight years, later, the organization continues to push for electronic prescribing.
According to the Institute for Safe Medication Practices, pharmacists make more than 150 million calls a year to physicians to clarify prescriptions (ISMP, 2000). This is a time-consuming process that takes physicians away from their patients and delays the moment at which patients receive medications. Illegible handwriting can also lead to obvious mistakes, such as patient receiving an incorrect dose or dosing frequency.
Every medical error can be potentially fatal and create expenses that may be preventable. With EMRs, health care providers use centralized patient information. The fact that most electronic software allows providers to access information onsite or from remote locations enables these providers to make improved health care decisions (Haas 2007). And because physicians, and other allied healthcare professionals can access the same information, they can better communicate among each other to optimize patient care. Streamlining such information also leads to more efficient care, cost containment, and a possible reduction in liability.
Advertisements for attorneys representing clients who have had adverse reactions to medications or have been harmed by medication errors have become just as prevalent as commercials for cars. Reducing liability is always a concern in health care systems, but correctional facilities must be particularly vigilant about this because they have a particularly high risk for litigation. Each patient in a correctional institution is already linked to an attorney.
Failure to document can be the deciding factor in a lawsuit, and lost documents can be particularly detrimental. Every day, hundreds of health care workers simply place lab orders, results, and other important health information in patients’ charts without securing them. This practice increases the risk of putting the information in the wrong patient’s chart, of orders falling out of the chart, or of orders being overlooked. EMRs ensure that patients’ information is centrally located and readily accessible.
Physicians often write orders requesting that patient charts be “thinned.” The electronic system stores all of the patients’ data on servers, therefore, eliminating the tedious and time-consuming task of rummaging through binders several inches thick to find one document. This system not only gives health care workers an opportunity to provide continuum of care, it may also be instrumental in preventing a case from ever reaching litigation.
In any health care organization, the pharmacy plays a large role in controlling costs, directly, and indirectly. For the purpose of this article, direct costs will be described in terms of concrete costs a facility spends on drug purchasing. These costs are fully quantitative, tangible costs that directly affect budget control. Indirect costs will be described as qualitative, intangible costs that can be prevented by pharmaceutical staff and other health care personnel.
A formulary is one of an organization’s most helpful tools for controlling costs. Using generic drugs is an obvious way to cut costs, though some medications that lie outside of the formulary will always be required. Careful consideration must be taken during the compilation of a formulary. Size, drug variations, new drugs entering the market, and therapeutic substitutions must all be considered, but in such a way that does not interfere with health care practitioners’ medical judgments. Formularies often vary widely, according to the type of services an organization offers. They are meant to ensure excellent patient care while maximizing an organization’s budget. A drug database loaded with restrictions on nonformulary options can remind physicians to try formulary options before moving on to nonformulary drugs that are often more costly.
Pharmaceutical staff can help facilities avoid costs and improve care by reviewing patient profiles. No reliable indicators exist for predicting which patients will have an adverse drug reaction or what their severity will be, but preventative measures can help reduce the likelihood of such events. All medications have side effects and the potential to cause adverse reactions; however, certain therapeutic classes of drugs command more attention.
In 2003, Wenchen Wu and Nicholas Pantaleo published data they collected on outpatient adverse drug reactions that required hospitalization. They found that the average length of stay for these patients was about 8 to 10 days and that the average charge per patient was $9, 941, with room and board accounting for 50% of the total charges. It is also interesting to note that 45% of the patients were 75 years or older. Of the 24 therapeutic classes involved, seven accounted for over 80% of the reported adverse drug reactions.
The Agency for Healthcare Research and Quality (AHRQ) summarized data from several studies on adverse reactions and ways to reduce the associated hospital costs. The AHRQ found several target classes were often involved in adverse reactions: antibiotics, analgesics, electrolyte concentrates, cardiovascular drugs, sedatives, antineoplastics, and anticoagulants. The agency also identified several common, preventable medical errors. Illegible orders, duplicate therapy, drug-drug interactions, and inadequate monitoring respectively accounted for 6%, 5%, 3-5%, and 1% of medical errors (AHRQ, 2001).
According to the AHRQ, one hospital estimated that it could reduce its costs by $270,000 by relying on pharmacists to assist physicians with prescribing and by educating other health care providers on medication use and safety (AHRQ, 2001). An integrated computer system that connects pharmaceutical, lab, and other patient information completes the continuum of health care and maximizes efficiency of the organization’s personnel. An AHRQ-funded study at the LDS Hospital in Salt Lake City found that when pharmacists notified physicians of patient allergies, the physician changed to a different drug 99% of the time. This monitoring resulted in only eight Adverse drug events (ADEs) from allergic reactions. The study also suggests that pharmacists can help prevent ADEs from excessive or incorrect doses by monitoring patient doses and drug levels (AHRQ, 2001).
Observation of Private Data
Data collected from a private organization that provides health care to correctional facilities nationwide suggests that monitoring by pharmaceutical staff and restrictions to formulary drugs helped a facility with an average daily population of 3,300 reduce its total drug costs by over $219,000 from October 2005 to September 2008. Pharmaceutical staff reduced the cost of nonformulary drugs, which were 29.8% of the total cost in 2005, to 18% by 2008. this saved the facility $226,888 in nonformulary drugs over the three-year period.
From a remote location, pharmacists with this health care organization examined all the facility’s pharmaceutical records electronically. They examined the profiles of all inmates who reported a list of medications during the booking process. Whenever a profile was modified (e.g., a new medication is added), the change was transmitted to the pharmacist queue, which was reviews for duplicate therapies, allergies, drug interactions, dosing irregularities, and adherence to the formulary standards approved by the facility’s Pharmacy and Therapeutics Committee. Pharmacists also monitored for medications that are just as effective when they are given twice daily as when they are three times daily and for extended release dosing or patches that can be used instead of immediate-release closing. The organization’s pharmacists reviewed an average of 4,700 profiles and make an average of 95 recommendations each month for this facility.
Because the recommendations by pharmacists like those in this study are not part of inmates’ medical record, physicians readily accept them. At one facility, the average charge per patient hospitalized with an ADE was $9, 491 (Wu, 2003). If 10 of the pharmacists’ recommendations were accepted by the physician at this facility-and prevented an inmate’s subsequent hospital admission-the facility could save over $90,000 a month in averted costs. Of course, this is not a concrete estimate because each patient and outcome is highly variable. This estimate also excludes the costs associated with possible legal liabilities that can result from ADEs.
National Commission on Correctional Health Care (NCCHC) Standards
The NCCHC has promulgated several standards for health records. Among the essential ones are standards for their recording, format, and confidentiality. Access to custody information and management of health records are among the standards NCCHC categorizes as important. As the world moves forward with the speed of technology, health care must move along with it. EMRs are not only helpful for streamlining health care, they support a “green” initiative, because less paper means less waste.
The NCCHC has a minimum of compliance indicators that each inmate’s health record must meet. Identifying information, laboratory reports, medical administration records, medical diagnoses, consent and refusal forms, and known allergies are just a few of them (NCCHC, 2008). If each medical discipline’s records are kept separate (e.g., mental and dental records), a process must ensure collaborative care. Pertinent patient information must be accessible to each health care giver caring for the inmate. With EMRs a provider (or designee) can enter medication orders, progress notes, lab reports, and other pertinent information at the point of care, creating a collective record that ensures improved patient care and that is preferred by NCCHC. Caregivers can also have immediate access to information, without transferring charts to several locations and risking losing orders. EMRs should be restricted so two users cannot enter orders at once, but they should allow several users to view pertinent information simultaneously.
The NCCHC accepts electronic signatures for documentation. It also recommends that all health records be standardized to fit a homogenous structure. All staff must be trained to provide records in this form, and this training can be time consuming and costly as new employees are hired. EMRs are typically loaded into a database and structured so that all orders follow the same format.
Another optional recommendation from the NCCHC is to place an inmate’s problem list at the beginning of his or her chart. EMRs allow prominent information to be put in clear, organized displays. Dashboards, tabs, drop-down lists are just a few methods navigation through an electronic chart. It is also simple to track inmate’s transfers throughout the facilities and to court by a few simple clicks.
The US Department of Health and Human Services created the Privacy Rule to establish the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as a requirement to protect patient medical information while allowing flexibility in transmitting it. Repercussions for noncompliance with HIPAA regulations may include civil monetary penalties and criminal penalties. The NCCHC requires complete compliance with HIPAA regulations because this is an essential standard.
The NCCHC suggests that health care providers use passwords to protect inmates’ medical records because passwords allow more thorough monitoring and control. Facilities must also prove that staff members have been educated about maintaining inmates’ confidentiality (NCCHC, 2004). Records of this education can be easily accessed if the facility’s software is programmed to instantly construct a database based on the as staff’s electronic signature as they complete HIPAA education requirements.
Because hard copies of inmates’ health records may be accessed by unauthorized personnel, failing to secure these records may violate federal laws protecting patients’ rights. Therefore, medical records must be maintained under secure conditions and kept separate from inmates’ correctional records. This can be accomplished by using only one software program to assign user privileges and limiting access to those privileges. Using a single program can avoid the training, costs, and maintenance associated with using several such systems within a facility. It can also benefit health care professionals who must access search inmates’ arrest and custody records for information about their violent behaviors, drug and alcohol abuse at time of their arrest, and mental conditions.
Another standard characterized as important by the NCCHC is the Management of Health Records, which indicates that health records and summaries may accompany inmates when they transfer to other correctional facilities. Record retention must be followed according to the jurisdiction’s legal requirements, and reactivated records must be provided in a timely manner when a health care provider requests them (NCCHC, 2004).
The NCCHC recognizes that readily accessible health records from collaborative clinicians improve patient outcomes. If an inmate returns to a given correctional system, timely reactivation of his or her previous medical records can give clinicians a comprehensive account of the patients’ previous problem list. The NCCHC also suggests that patients with knows critical or chronic conditions be flagged to expedite their immediate referral to a health care provider (NCCHC, 2004). This can be accomplished with EMRs by sending profiles of these patients directly to a “critical queue” that immediately prompts health care staff that the inmates need urgent care.
The NCCHCs 2008 Standards for Health Services addresses 20 significant changes pertaining to health care; however, only four are paraphrased in this article. Standard B-02 is intended to motivate facilities to implement systems that improve clinical outcomes. Systems that refer inmates requiring immediate attention to clinicians, the prevention of medication errors, and error-reporting mechanisms are examples.
Standard B-04 is considered a significant charge. It allows two options for conforming to health assessments of inmates. The first is to perform a health assessment on all inmates. The second allows the responsible health authority to perform individual health assessments on inmates when there is a clinical indication. These options are available for sites with 24/7 onsite health staff. Clinical indications can be discovered during intake screening or as clinical changes develop during the inmate’s tenure in custody.
Standard E-12 addresses continuity of care during incarceration and includes periodic screenings, clinical chart reviews as a requirement, and episodic illness. Standard G-01 requires comprehensive treatment for patients who need chronic care. These requirements should be in accordance with nationally and clinically accepted guidelines for treating condition and preventing further complications. Conditions include diabetes, hypertension, HIV, epileptic disorders, and mental illness.
The transition of all of the aforementioned changes to standards can be implemented with EMRs. Paper charts can make the transition process for the required changes cumbersome and tedious. Electronic systems can reduce human error by preventing medication errors. For example, hard copy of inmates’ appointments for medical attention can be carelessly misplaced-EMRs reduce this possibility by adding the appointment date to the clinicians’ calendars and queues for scheduled dates. They can also flag patients with chronic conditions and those who need health assessments. Once those patients are categorized by condition, it is simple to track data within the facility and contribute to community health statistics as inmates are released.
Overall EMRS should be simple to use, unified, uniform, and easily accessible by authorized personnel. They should produce hard copies upon request. In case of power or system failure, a backup source in a remote location should provide health records in a timely manner. EMRs also give medical staff prompt access to previous booking records so they can have a complete picture of inmates’ previous conditions and medications. The software should also be designed to reduce human error and enhance clinical outcomes.
There is limited research or subsequent data suggesting that computerized medical records would be beneficial within correctional facilities. Most of the literature reviewed for the purpose of this article was based on data collected from hospitals, large health care facilities, and physicians’ offices. It should be noted that it is not the author’s intent to insinuate that any of the benefits mentioned within the course of this article will be realized by correctional facilities providing health care to inmates. Rather, this represents the author’s attempt to open discussion about possible advantages and rewarding outcomes that could result from correctional facilities implementing an EMR system.
Editors Note: The above article has been reprinted with permission and previously appeared in the [May/June 2009 CORRECTIONAL HEALTH CARE REPORT]
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