What are the prospects that electronic health records will improve care in chronic conditions such as diabetes or sleep apnea?
Physicians must first recognize these conditions, be proactive in diagnosing them, and can then use records to help them to monitor and track their patients and help the patients to be involved in their treatment.
We are hearing a lot about the importance of physicians' using electronic health records (EHR) and electronic medical records (EMR). Funds to enable such systems are likely to be a part of the Obama administration's program. Electronic records are record systems that can enable improvements in health care delivery, including for chronic disease management. But implementing these systems doesn't happen just because of funds to buy them. Doctors need to adopt new methods of patient care.
A disease registry is a special kind of record system. A disease registry lists all patients with a particular disease Imagine a sheet (as simple to do as a spread sheet) with several columns for such data as name of patient, blood pressure, and so on for several lab tests. Each line or row going reading across represents one patient. By scanning the sheet the clinician can spot data that is out of bounds. So, instead of waiting for the patient to come in for an office visit, all the patients are reviewed periodically and those with potential problems can be given immediate attention.
This is a paradigm shift for the clinicians who are used to looking only at the medical record for only one patient during an office visit. With the disease registry, they look at all the patients that have, for example, diabetes. They can readily monitor certain key indicators and intervene as needed to help the individual patient. Thus a registry can help a medical practice provide the best possible care. For patients with more than one condition, however, the electronic medical record system may provide even greater insight if combined with the disease registry system.
A disease registry has great potential for improving health care. And while a full-scale electronic health records system makes the work easier, a registry can be created and maintained using the office computer and a spreadsheet. This creates a small database for a medical practice covering only patients with a specific disease. David Ortiz, MD, describes how simple it can be to create a registry for diabetes. Using a Simple Patient Registry to Improve Your Chronic Disease Care.
Although 38% of physicians use electronic medical records in their office practices, only 4% of those surveyed by the National Center for Health Statistics had fully functional EMRs to support effective management of chronic conditions. These advanced EMRs include patient demographics, problem lists, clinical notes, medical history and follow-up, orders for prescriptions, orders for tests, prescription orders sent electronically, viewing laboratory and imaging results, warnings of drug interactions or contraindications, out-of-range test levels, and reminders for guideline-based interventions.
In a report published by the California HealthCare Foundation, Bodenheimer reviewed innovation in health care. He highlights just how difficult it is for medical institutions to adopt best practices and evidence based medicine. He gives examples of the various strategies that have worked in different contexts. The benefits of electronic health records were demonstrated as part of a comprehensive reform of medical practice in the Veterans Administration. Not only did the electronic health records help improve patient health, but the data for all patients in the system was available, helping managers to monitor each local institution to make sure they were adopting the new system. This tool helped to spread the innovation. In a very different context, a group of small primary care practices, adopted and implemented a diabetes registry The registry became an important tool to assist clinicians, and further, to assist patients to become active participants in their care. Thomas Bodenheimer, The Science of Spread.
The idea of a disease registry seems like such a logical, simple way to monitor a class of patients. But this can only apply where the disease has been diagnosed and where there are types of data that measure success or failure in treatment. This makes a lot of sense in diabetes, where there are several kinds of data that indicate how well the condition is being managed. Many people have been diagnosed with diabetes and the science is reasonably good.
Since sleep apnea has been so often overlooked, the disease registry may not be the place to start. Primary care doctors may not have enough patients with diagnosed apnea to recognize the need for ongoing monitoring. And one reason that so many people remain undiagnosed is the lack of training and awareness regarding sleep apnea among physicians. So the first step is better awareness, diagnosis, and treatment.
And, unless the sleep lab does the followup or the primary care physician is trained to do the followup, (or the home care company is especially diligent) there may be no one to do the followup.
However, adherence to treatment in sleep apnea uses fairly obvious measures: how many hours per night is the treatment used, is the apnea controlled? Some treatment devices are capable of recording this information, making it available to the patient, and of transmitting it to a clinician for analysis. We don't have numbers like the lab results for diabetes that can be used to track success in treating apnea on a routine basis, but the same symptoms and signs that help in diagnosis can be monitored during treatment. see Quiz from Sleep Apnea--the Phantom of the Night
David Kibbe reinforces the idea that electronic records and information technology are only a part of the solution to better health care, based on the experiences of the American Academy of Family Physicians. He urges that small medical practices need to take control of their electronic records systems in order to support a new model of delivering health care that will support participatory medicine, reduce costs, make care more convenient, and close the "collaboration gap" between doctors and their patients in much the same way that online banking and online airline reservation systems have done.
It appears that electronic records, including a simple and inexpensive disease registry, can offer benefits in chronic disease management, including for diabetes and sleep apnea. But the benefits depend on new patterns of managing disease including helping patients to be more involved as well as new patterns of monitoring and interaction by clinicians. Let's ask that Obama and Daschle set up some guideposts and standards that encourage effective change in health delivery, going far beyond new software systems that record information that support traditional behavior.