How Structured Medical Data Helps You and Your Patients

The Robert Wood Johnson Foundation recently reported the current adoption rate of electronic health records by physician practices stands at just under 40%. Hospitals are slightly higher, at 44%. This represents a significant gain – nearly triple the rate in 2010 when incentive funds from the U.S. government were first discussed.

While doctors and healthcare organizations are diligently working to receive their portion of Meaningful Use Stage 1 and Stage 2 funds, surveys indicate progress hasn’t always been blissful. Change is difficult. Only 5.1% of hospitals have successfully attested to Stage 2 so far. The report includes a number of barriers keeping this number low

One of those barriers, a core component of Stage 2, is to provide patients the ability to view online, download and transmit their health information. Encouraging patients to participate in their own care is an important tenet for the future of healthcare. This concept isn’t new – a patient’s right to request and receive medical data from his or her paper-based medical record has long been available. Personal Health Records in the form of “untethered” USB drives and tethered patient portals have also been around for a number of years but with very low adoption (remember Google Health?).

There are a few beacons of hope: Kaiser Permanente’s is available to over 9 million patients to access their health records, including 68 million lab results in 2011 alone! In 2010, President Obama announced Blue Button, another tool that would allow veterans interacting with the VA and Medicare beneficiaries to access data in their respective EHR systems.

The tide is turning – slowly. The American Health Information Management Association (AHIMA) is waging a public information campaign called MyPHR. The site provides data justifying why implementing PHR tools is valuable for all stakeholders and explains exactly what data a person should carry with them in case of emergency and the information that needs to be provided when checking in with a specialist. That list should include:

  • Patient demographic information
  • Medication information
  • Allergies
  • Laboratory results
  • Summary of physician visits
  • Diagnoses
  • Doctors' notesimages (X-rays, MRIs, etc.)
  • Family health history

According to MU rules, patients can request their records be provided on paper or electronically, via the web. For many practices, meeting this requirement will not be a significant issue going forward because much of the current medical data will be available in electronic format in the EMR.

But what about historical patient medical data in the paper-based records? Meeting this requirement in a timely manner if most of the record is still in paper form presents an added burden.

Hiring a scanning service bureau to scan and index entire wall(s) of patient folders and files is costly, disruptive and potentially introduces chain of custody HIPAA issues. Because of these negatives, most providers pull and scan patient data in advance of an encounter so records for all active patients will be available in the EMR over time. Both provide a more comprehensive electronic record and free up costly square footage that could be retrofitted to additional exam rooms or office space. Electronic records storage with backup also provides the practice with disaster recovery in the event of fire or flood. This protects the patient’s history as well.

Once the records are imaged and made part of the EMR, they’re available on the provider’s desktop, laptop or tablet for reference when meeting with the patient, and for inclusion in a web-based portal – the Personal Health Record. As shown at Kaiser Permanente, reporting lab results to a patient is more easily fulfilled when the paper record becomes part of the electronic record.

Above all, patients can download and print out current medication lists, allergies, family health history and other key medical data that will serve them well while traveling, seeing other providers or evaluating health decisions. Now, not only does the provider have access to patient data at the point of care, the patient is empowered to become an active participant in the healthcare process, reducing costs and driving better health and wellness outcomes - the ultimate aim of meaningful use.

about the author: Ellen Bzomowski

With 20 years of experience in data capture and voice recognition, Ellen’s experience has focused on achieving higher efficiency and automation in getting data where it will be most useful to an organization. At Extract Systems, she continues to focus on the same ideas and works to get the word out about how Extract Systems’ advanced data capture and redaction solutions make more data valuable and accessible, while securing anything that is private. She holds an MBA from Northeastern University and lives and works in Boston.