Book Review: Connected for Health: Using Electronic Health Records to Transform Care Delivery

Product Information:

• Hardcover: 272 pages
• Publisher: Jossey-Bass; 1 edition (May 17, 2010)
• Language: English
• ISBN-10: 0470639377
• ISBN-13: 978-0470639375
• Product Dimensions: 9.2 x 7 x 0.9 inches

Connected for Health: Using Electronic Health Records to Transform Care edited by Louise L. Liang is an account that chronicles the implementation of electronic health record (EHR) by Kaiser Permanente (KP). This EHR network serves more than 8.6 million Kaiser Permanente members.

One of the things that I like most about this book is the story that the editor shares on how KP HealthConnect actually got started in the very beginning by brainstorming for a compelling vision in line with the organizational aspiration and goal -- in this case, the primary goal is to transform care and service delivery (Chapter 1).

In this process, the key principle is: to start with the end in mind! I like the concept of their Blue Sky Vision (much like the blue ocean strategy). In order to create the unique Blue Sky Vision, KP invited "wild and crazy" thinkers to brainstorm and to think out of the box. These thinkers are the people that, as Liang said, "make us a bit uncomfortable". These are the people who are always pushing at the edges. As shared by Liang, at this stage, the focus to brainstorm is not about the actual practices, but the organization's aspiration and dreams.

Some of the challenges identified at this beginning stage include the continuing escalating healthcare cost pressure in the US and in many parts of the world, the changing demographic patterns due to globalization and immigration, workforce availability as well as the perceived infinite consumer demands for technology. In the process crystallizing their Blue Sky Vision, the committee came up with four major themes which I believe, really capture the trend of healthcare in the near future:

• Home as the Hub - the home and other non-traditional settings would grow significantly as locales of choice for care delivery. As with other consumer-driven domains like e-shopping, banking, etc, the patient and his/her family can now view their medical records and choose the hospital/clinic that they wish to follow up in, their doctors of choice, etc, etc from the comfort of their home with a click of the button.
  
• Integration and Leveraging - by integrating wellness activities, educational instructions and advices into the system, this would enable and empower patient and family involvement in care, much like a joint partnership between the physician and the patient/family. This is particularly essential in combating infectious diseases where community participation and compliance is very very essential to help contain the spread of the disease.
  
• Secure and Seamless Transition - while recognizing the potential of information technology*, the computer does not and can never replace the human touch. Rather, the computer acts as a supplementary avenue to doctor-patient relationship by enriching and enhancing care delivery system. By cohorting a longitudinal, integrated health information system made available to the patient and family, this would enable the patient and family to better understanding the panoramic picture of the health status, and to make better informed decisions.
  
• Customization - as mentioned earlier, patients would become true partners in their health. In a customer-centric care system, the patient would be able to customize their own healthcare preferences based on the various information available to them - for example, choosing between treatment option A and treatment option B; generic drugs vs original patented brands, etc?

As we can see, the unifying, all-encompassing, pervasive trend in all these four themes is about

placing the consumer (in this case, the patient/family) in the center as the true "healthcare provider"

Thereby, increasingly the physician will have to shift gear from playing the role of a paternalistic surrogate decision maker to playing the advisory role of helping patient/family to make informed decisions. EHR is seen as one of the platforms of doing so.

In other words, this is really about patient empowerment. In today's globalized, digital age, this is not surprising as customer empowerment has progressively encroached many other spheres of our lives - e-shopping, e-banking, e-learning, etc.

Furthermore, in the realm of emergency medicine, in many time-based actions and decisions, patient empowerment and community participation is absolutely essential. These include such criteral steps like as transporting a suspected heart attack by calling for ambulance as early as possible in order for thrombolytics to be given, initiating cardiopulmonary resuscitation, initiating inhaled steroids on top of the beta-2 agonist in acute asthmatic attack, administering s/c adrenaline in an established anaphylatic, transporting a suspected stroke patient (based on recognizing the F-A-S-T criteria [F - Facial asymmetry, A - Arm drift, S - Speech slurred, T - time of onset]) to a stroke center within the stipulated time frame 3 hours or so, administering glucose drink on the first reecognition the neuroglycopenic symptoms of hypoglycemia, etc, etc. All these red flag warnings and caveats can be integrated into the patient's EHR.

Back to the story of KP HealthConnect, after the identifying these themes, the next challenge for KP would be to flesh out these themes, and to do that, they have roped in experts from the operational side as the second team (independent of the first team that envision the themes). Essentially this is about translating the vision into action, putting the Blue Sky Vision into the actual system. The end result is the creation of KP's EHR, called the KP HealthConnect, created based Epic Systems, which includes personal health record, outpatient and in-patient data, billing info, meds info, lab results, etc. As mentioned, patients have access to their own medical record, lab results, appointments, etc. Patients can also send secure messages to their doctors to ask for advices, to change appointment dates, etc.

Another fascinating thing I learned from this book is the dynamics that were involved in collaborating and consolidating the system as detailed in chapter 2. A challenge that they faced in the initial stage was the need to juggle between local variations (exist because each region has unique needs; the "no one size fits all" philosophy) versus the long-term importance of streamlining and standardization.

To resolve that, the key concept KP employed is:

Diverging later would be easy, converging later would be almost impossible.

I think there is much truth in that statement, applicable not only in the realm of establishing EHR, but in almost any organization processes as well! But especially, when it comes to consolidating a system in its infancy stage, the need for a standardized paradigm model across the board is even greater -- more so when the patient's life can be at stake, due to diagnostic and therapeutic misses, near-misses, miscommunications, medication errors, etc, etc. An entire chapter is devoted on the issue of patient safety and how EHR in fact, can be beneficial in improving the safety net. Specific examples on how EHR is beneficial in improving patient safety are given diagrammatically on pages 164-65 of the book. Another interesting concept I learned from this chapter is the adaption and adoption of the Hierarchy of Control for Industrial safety into patient safety management. In essence, the focus to eliminate or reduce risk should be on the bottom billion of the pyramid where the measures are most effective. The principles behind that are:

1. Making It Hard To Do The Wrong Thing (eliminating chance for error, constraints and restraints) 2. Making It Easy To The Right Thing (order standard sets, minimizing variation in practice, reduce reliance on memory, improving access to information)

On improving access to information, one other interesting thing mentioned in the chapter on patient safety is that EHR can provide instant access to "patient-level data" that is true for a patient over time (not just on a given time or day) -- this include demographic data, past medical history, etc, etc. Immediately, I thought of the usefulness of these information in an acute emergency setting. For example, the SAMPLE history format (S = Symptoms, A = Allergy history, M = Medications history, P = Past Medical History, L = Last meal, E = Preceding Events prior to admission), 3 out of the 6 very essential information can be instantly obtained through the EHR and this can prove very crucial in determining the mortality or morbidity outcome of a patient in resuscitation (imagine giving penicillin-group to a patient with past history of anaphylactic shock secondary to this antibiotic)!

However, one of the issues I find lacking in the book which to me, is a major concern is on patient's confidentiality. Although on page 143, the author specifically highlight that the website is secure and that KP does not sell or disseminate patient's information as well as their promise to abide to the Code of Ethics, etc, etc; the brevity of information on a quarter page hardly do any justice to this vitally important aspect of patient care as enshrined as one of the golden biomedical principles (this issue is addressed in details in a separate article I highlighted below).

In summary, I find this book to be stimulating with so much nuggets to learn from. As a clinician, I am not involved directly in administrative issues such as patient medical record management, etc. As a Malaysian, I personally do not foresee any transformation of patient health record from a paper-based, hospital-customized filling system to an integrated electronic health record that can be accessed by any doctor at any given time, at any Malaysian hospital/clinic, be it private or public (encompassing the two major tier system: Ministry of Health and the Ministry of Higher Education), although, in the future, the Malaysian identity cards (a.k.a MyKad) may contain medical records, medications, etc, that the patient can carry around. When and how will this be implemented remain elusive although back in 2001, the MyKad is supposed to be a state-of-the-art SMART card with a 32Kb and a 64Kb EEPROM (Electrically Erasable Programmable Read-Only Memory) chip and Malaysia was one of the pioneer of using that chip. Click here to read the report from New Scientist.


Note:
* this is also elucidated well in Introduction section of chapter 2: "Technology is only an enabler; it is the people using the technology who change how work is accomplished or how care is delivered". The challenge really, is on how can we leverage the technology to our advantage?

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Disclosure of Material Connection: I received this book free from the publisher for the sole purpose of book review blogging. I was not required to write a positive review. The opinions I have expressed are my own. I am disclosing this in accordance with the Federal Trade Commission’s 16 CFR, Part 255 : “Guides Concerning the Use of Endorsements and Testimonials in Advertising.”
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Additional Information on Electronic Health Record.

Picture by Veer Images

Incidentally, around the time when I was reviewing this book, the Annals of Emergency Medicine published a 3-part series in their Aug to Oct 2010 issues (see references below).

Here are some additional information I gathered about EHR from the emergency medicine perspective:

Advantages of EHR:

1. EHR can be a very useful tool to reduce waste and errors, and is a cost-saving measure.
2. Patients do not always remember what conditions they have had, physicians they have consulted, and evaluations they have undergone, but by having EHR, this would enable instant access to such valuable information particularly in one-off visit to emergency department for a acute severe medical illness)
3. Using EHR, a physician can view uploaded video recordings of procedures (e..g surgical procedures, scope findings, etc) as well as uploaded images taken during past clinic encounters providing detailed visual archives (e.g. dermatologic conditions - to assess effectiveness of treatment by comparing pre- and post- pictures). This can be very very useful for reviewing progress of patients, and in particular, in emergency settings where such valuable information cannot be obtained at hand. With patient's consent, these valuable resources can also be used during teaching rounds. In fact, the consent processes themselves are enhanced by built-in prompts. pre-written wishes.

Disadvantages of EHR:

1. As mentioned, some patients maybe reluctant to offer complete medical histories to their physicians fearing that their sensitive pharmacologic, psychiatric, and infectious disease information might “go viral” in the non-medical sense, through the Internet.
2. EHR can be abused by fakers and addicts posing to the patients so as to receive care (sometimes including controlled painkillers) under someone else’s name. In the article, it is also mentioned of an experience where a single patient record was found to a listing of more than one blood type!

Ways on Improving the System:

1. Because of exponential progress of digital technology, the challenge is not only to build formidable system, but a sustainable one as well. One should ask: How might this system be asked to change in the next 10 years?’ 20 years? Such a system should allow for maximal flexibility.
2. For health IT to fulfill its potential as an aid to clinical practice, patients and physicians need a reliable information flow that they can trust: from initial input to all potential outputs, the data must be accurate and must end up in the right places. For an emergency physician, who may treat a patient only once, this is very important as he might be dependent solely on the quality of data entered into records by others.

Further thoughts on patient's confidentiality:

• While it is true that patient's confidentiality can be an issue, but we have actually been depending on digital technology for transmitting a lot of other potentially sensitive information: such as our national defense establishment, financial information, credit card information, utilities bills, etc. In the field of finance, for example, financial information has been transmitted electronically for years. This is as a case in which technology eventually earned popular trust. There are still some people who will not put in any credit card info no matter what, while there are those who really have no particular concern at all in doing so. In health care, we are probably going to see similar trend.
• In fact, paper records in certain respects can even be less secure than EHRs particularly if only there is a single record to the file without back up. In most hospitals, someone can just put on a white coat, and act authoritative enough to access the records in a nursing station, or into a record room to get a record. Or someone may also "pay a staff" to retrieve the record, and there can be no trace or track as to how that got released.
• Metadata tagging allows sorting of information into more granular categories and such segmentation of information can allow patients to designate which healthcare providers can view which sensitive information (e.g. genetic, psychiatric, or gynecologic history; information related to sexually transmitted diseases or substance abuse; or conditions the patient believes may affect employment)
• Anonymization can also strip off personal identifiers out of records for research or biosurveillance applications.

In conclusion. as Winston Churchill had said: “We shape our buildings, and afterwards our buildings shape us.” In future, this may be true of the EHR system that is being built into the healthcare system.

References:
Millard, W. B. Electronic health records: promises and realities: a 3-part series. Part I: The Digital Sea Change, Ready or Not. Ann Emerg Med, 56 (2), A17-20.

Millard, W. B. Electronic health records: promises and realities. Part II: Some early voyages in partially charted waters. Ann Emerg Med, 56 (3), A17-21.

Millard, W. B. Electronic health records: promises and realities. Part III: Information Privacy and Accuracy: Zero and GIGO Won’t Do. Ann Emerg Med, 56 (4), A19-25.