Editor's Note: This week's blog post was originally published in KevinMD and was submitted to KevinMD by the ASA.
When you walk into any physician’s office or hospital, computers are everywhere. By 2013, nearly 70 percent of hospitals had moved away from paper charts and toward electronic health records, or EHRs, and more are making the change every day.
From the patient’s point of view, it’s reasonable to think that the EHR will know everything about you. But you might be surprised to know how many pieces of paper your hospital chart may still contain. And we should all be aware — even alarmed — about all the gaps in critical information that may exist in any patient’s computerized record.
Let me give you an example from my own practice. As a physician who specializes in anesthesiology, one of my biggest concerns is to make sure that every patient receives plenty of oxygen during anesthesia. Often, I need to put in a breathing tube to ventilate my patient. If the patient has a difficult airway for any reason — such as arthritis in the neck, or abnormal anatomy — it may be technically difficult to insert the breathing tube. That is information I absolutely need to know.
Recently, I was taking care of a patient who had anesthesia a month earlier. Although we have an electronic anesthesia record, that system is not compatible with the hospital’s EHR. After a case we print the electronic anesthesia record and place it in the paper portion of the patient’s chart, for later scanning into the EHR. In this case, the paper anesthesia record for this patient’s earlier procedure appeared not to have been scanned into the hospital’s system. I had no way of finding out if the patient experienced any problems during the case, and the patient didn’t remember.
Indeed, the patient proved to have a difficult airway, and I needed specialized equipment to place the breathing tube. It would have been very helpful to know this information in advance. Later on, I was able to speak to the previous physician anesthesiologist. The information about the patient’s difficult airway had been well documented by him, but it was unavailable to me when I needed it — lost in translation between the paper and electronic record-keeping systems.
The problem of hybrid paper and electronic records is not limited to anesthesia records. Often when patients come to the hospital to have surgery, their blood test and x-ray results are faxed from their primary doctor’s office. The result is a random amount of paper information that is different for each patient, and it must be reviewed by the doctors and nurses in addition to what’s already in the hospital’s EHR. It should come as no surprise that papers may be lost or misfiled. Frequently, pages are missed or damaged and critical information is lost.
According to the Office of the National Coordinator for Health Information Technology, hospital adoption of EHRs increased more than five-fold between 2008 and 2013. As a consequence, hybrid systems of paper and electronic records proliferated.
The Boston Globe reported in July on a study of malpractice claims, finding 147 instances in which EHRs “contributed to adverse events that affected patients — half of them designated as serious.” The review found that “faulty use of ‘hybrid’ paper and electronic records” was a frequent cause of harm.
Clearly, my patient’s problems with EHRs and paper records aren’t unique.
Another challenge is what’s known as interoperability. The sad fact is that different EHR systems often can’t communicate. The two largest systems used by hospitals, produced by Cerner Corporation and Epic Systems, don’t share data with one another, to say nothing of the multitude of EHR systems used in physician offices. A recent article in the New York Times addressed this very issue. One physician said: “We’ve spent half a million dollars on an electronic health record system about three years ago, and I’m faxing all day long. I can’t send anything electronically over it.”
At the ANESTHESIOLOGY™ 2014 annual meeting of the American Society of Anesthesiologists, two California physician anesthesiologists, Christine Doyle, M.D. and James Moore, M.D. faced off in a debate over the question, “Do Electronic Health Records Improve Patient Safety?” Dr. Doyle took the position that EHRs won’t eliminate the problem of poor documentation and communication practices. She cited the recent likely lapse in communication in the care of an Ebola patient in a Dallas hospital as an example.
All physicians, not just physician anesthesiologists, need to be vigilant in examining the data available about individual patients from all sources. We need to correct errors in systems and data entry as we discover them, and work with our institutions to improve communication between facilities and providers. And we need to advocate for a national unified method for the interoperability of the many and various EHRs.
Patients can assist in their anesthesia care by not assuming that all their health information exists in either the electronic or paper record.
On the day of surgery, it is wise for a patient or caregiver to bring along a complete list of medications, as well as a list of previous operations or procedures. It’s also very helpful to discuss with your physician anesthesiologist all other medical conditions such as hypertension, diabetes, heart disease, or chronic obstructive pulmonary disease (COPD), and any past problems with anesthesia. Information about a difficult airway, or problems placing a breathing tube, can be especially important.
Unfortunately, physicians and patients cannot trust EHRs to be fully accurate or complete. Until they are, it is up to all of us to work together toward better communication, more complete information and the safest possible health care.