Important note: Information in this article was accurate in 2004. The state of the art may have changed since the publication date. It's Friday afternoon. The director of your Department of Corrections has been summoned to testify before the legislature on Monday morning concerning the correctional health care budget. You have been given one hour to provide her with the following information:
-complete outcome data for all patients evaluated and treated for hepatitis C in the past 18 months
-HIV-infected patients stratified by nadir and most recent T cell count, viral load, and current HAART regimes
-percentage of your diabetic patients who received urine protein screening, podiatric evaluation, and hemoglobin A1C monitoring within the past year
-total expenditures by drug for the twenty most costly medications on your formulary.
You:
a) freeze the gate, and put all available staff to work pouring over your paper medical records
b) decide to accept that early retirement you have been contemplating
c) query your EMR and obtain all the requested data (and more) within the time allotted.
The effective medical management of any chronic illness depends upon the ability to record and recall data. In addition, reimbursement and risk management often hinge upon the maintenance of an accurate, complete medical record. As treatments become more complex, it has become increasingly difficult to accomplish these tasks solely through the use of a paper record. In response to these growing demands, a wide variety of electronic medical record (EMR) systems have been created. EMRs are being used for charting, to remind clinicians when patients with chronic illnesses such as HIV, diabetes, or hypertension need routine testing, to schedule healthcare appointments, to prompt clinicians to order lab work and vaccinations, and to record data in a way that it can be accessed and manipulated by health care providers. EMRs can simplify the movement of data for patients who are seen by multiple clinicians at many different facilities. It has been estimated that between 10 and 20 percent of physicians in this country are currently using EMRs.
Although some clinicians have been slow to embrace these new technologies, the federal government may accelerate the use of EMRs by requiring them as a condition of participation in programs such as Medicare. In 2001, the Institute of Medicine (IOM) published a report outlining obstacles to the provision of quality healthcare. The IOM specifically recommended the use of information technology to address organizational deficiencies in the treatment of chronic conditions. The American Academy of Family Practice has announced a goal of having electronic medical records in place by 2006. The academy is evaluating a number of web-based systems, and believes that an EMR will reduce medical errors, improve safety, increase screening and preventive care, reduce complications including drug errors, and facilitate the introduction of evidence-based guidelines.
Although most of the commercially available EMR systems have been designed to comply with the Health Insurance Portability and Accountability Act, (HIPPA), security of web-based systems continues to be of paramount concern. For this reason, some health organizations have chosen to maintain all information on a local server. Some clinicians have not embraced EMRs because of the start-up cost involved or concerns about the need for ongoing logistical support. Furthermore, converting paper records to electronic format can be a daunting task. With recent technological improvements, it is now possible to scan electronically existing medical records, simplifying the conversion process to an EMR. Once an EMR is in place, clinicians can input medical information using a personal computer or a notepad-sized wireless personal digital assistant (PDA).
What follows are comments on some of the EMRs currently being used in correctional settings around the country. Rather than being an exhaustive review, this spotlight is intended to stimulate discussion and information sharing concerning information technologies among our correctional colleagues. We encourage feedback from readers about systems in use in jail or prison settings around the country.
Dr. David Paar of the University of Texas Medical Branch utilizes an EMR that he describes as an "in house" custom designed program called Emerald. With Emerald, the ordering physician views a menu and enters a request for labs to be drawn. Once obtained, the results of these tests are then entered into the system and emailed to the ordering physician. Dr. Paar notes the convenience of an integrated electronic system whereby the physician simply clicks on a patient's chart and puts lab results into context. Dr. Paar suggested the need for a similar system for radiographs and other imaging studies. "We shouldn't limit our thinking to just laboratory values. This concept could be applied to other studies to manage all diagnostic tests and biopsies, such as chest x-rays, so all of these test results could come back in timely fashion."
Dr. Lou Tripoli of the Correctional Medical Institute uses Serapais®, an EMR that has been modified for the correctional setting. Serapais® allows the user to search a patient by name, inmate #, account #, DOB, and SSN. This system can capture detailed patient information including demographics, problem lists, health assessments, and test results. It provides alerts for identifying potentially chronically ill patients during the health screening process and sends out reminders for appointments, test preparations and test results. Moreover, Serapais® generates SOAP or "Subjective, Objective, Assessment and Plan" notes during patient encounters with the healthcare provider. Accordingly, this system not only offers the "four building blocks" required for an effective EMR, but also effectuates the final step whereby the progress notes are generated electronically.
Dr. Joseph Paris of the Georgia D.O.C. uses a system developed by Quest Diagnostics® called TORO. His correctional facility opted for a vendor with an extensive server that has the capacity to store medical information for tens of thousands of inmates. For a given correctional facility to reproduce these data is not only time-consuming, but expensive. TORO allows providers to access their own database that is housed on Quest's server by paying a very reasonable surcharge. According to Dr. Paris, the biggest advantage of this EMR is instant laboratory data retrieval. Although TORO does not presently have plotting capabilities that can graph specific results, Dr. Paris feels that this feature, which will be available in the near-future, will further improve upon what is already an excellent system.
Lab Tracker™ from Ground Zero Software (info@labtracker.com) is a full-purpose electronic medical record (EMR) with disease-specific programming for HIV and other infectious diseases, including hepatitis. The database platform was originally developed as a way to manage and graph laboratory results and medications specific to HIV, and has since become an all-inclusive EMR. The platform currently houses records for 10 percent of HIV patients in the U.S. through institutions such as Emory University and the University of Miami, and two-thirds of all hemophilia patient records in the U.S. through coordinated efforts of Baxter Bioscience and the CDC.
What follows are case examples of three representative installations: statewide (Louisiana), regional (Owen Clinic at the University of California at San Diego), and an individual facility (Cape Vincent Correctional Facility in New York).
The Health Care Services Division (HCSD) of Louisiana State University Health Sciences Center comprises eight state hospitals. A wide-area network (WAN) of shared servers connects the healthcare center in New Orleans to geographically dispersed hospitals.
New Orleans implemented a customized version of Lab Tracker for HIV-infected patients in May 2003. Currently, four hospitals use Lab Tracker to accommodate approximately 5,000 unique patient files. The Lab Tracker initiative is led by Newton E. Hyslop, Jr. MD, Clinical Lead of LSU HCSD's HIV Disease Management Initiative, and Nathan Daigrepont, Lab Tracker Project Coordinator.
Prior to Lab Tracker, providers had to retrieve information from several different systems and sources for a complete patient profile. Daigrepont says the criteria for the new EMR were ambitious in scope, and included a single database that integrated all SOAP notes, radiology, laboratories, clinics, and pharmacies.
Lab Tracker data integration and data mining capabilities were a key product differentiator, according to Daigrepont. At the patient level, Lab Tracker provides graph and trend analysis using linear plots and logarithmic scales to show how, for example, a given patient's CD4 counts or viral loads have responded by medication, dosage and other variables over time. The visual image can be used as an education tool to encourage patient adherence. At present, 300 laboratory tests have been validated for the system. Medication data is uploaded from a pharmacy database. Modifications are underway to automate medication entry, as well as simplify SOAP notes entry with optional voice recognition. When fully integrated, graph and trend analysis are expected to significantly reduce the amount of time needed to retrieve records, analyze patient health, and prepare for patient visits. Lab Tracker has recently added screens that will allow clinicians to more effectively track hepatitis data. These screens provide "at a glance" information to clinicians, which will be useful in avoiding unnecessary repetition of tests and procedures.
At a statewide level, the ability to bring together disparate patient files in a single uniform database will enable LSU HCSD to improve utilization management from a central location. It will be possible to conduct costs analyses budgetary forecasts and access patient data archives to assess needs for improvements for patients who are failing treatment or falling out of care.
Under the auspices of Special Projects of National Significance grant from the U.S. Department of Health and Human Services, LSU HCSD is conducting an analysis of the impact of introducing Lab Tracker as a medical record system to the LSU HCSD HIV Clinics.
The Owen Clinic at the University of California San Diego Health Center has been using Lab Tracker since 1997. Approximately 9,000 unique patient files dating back more than 10 years are housed in the EMR, of which 2,000 are active files.
Since 2000, the Liver Clinic has been using a version of Lab Tracker tailored to hepatitis and liver cancers for approximately 5,000 patient files. More recently, the Mother, Child & Adolescent HIV Clinic implemented a pediatric version of Lab Tracker in 2002 to help manage its 500 patient files. Presently, each clinic runs its own versions on separate servers with the option to share data as needed.
At the Owen Clinic, physicians have reduced preparation time using Lab Tracker to access patient histories and SOAP notes, and enhanced patient visitations with the visual snapshots of patient progress using graph and trend analysis. The clinic uses Lab Tracker's analytical capacity to compile internal reports on a variety of factors, including longitudinal studies based on CD4 counts or viral loads, and cross-sectional studies, such as the most recent Hepatitis C status.
The Cape Vincent Correctional Facility in New York is an example of how Lab Tracker can benefit healthcare at smaller, individual sites. Attending physician Dr. Charles Moehs is a family physician who has worked in corrections for 10 years and is a member of the American Association of HIV Medicine. Of the total Cape Vincent population of 900 to 1,100 inmates, Moehs sees approximately 75 HIV and hepatitis C patients on a regular basis.
Prior to Lab Tracker, Moehs handled records by hand. Patient charts would be circulated among many places and difficult to locate. At times he went into patient visits without knowing whether the patient was adherent. In order to bring order to the process, he began entering patient data in Microsoft Excel. He sought an EMR that enabled him to sort and conduct population trends; the program had to be intuitive, simple to install and easy to use.
Moehs has used Lab Tracker since 1999. The EMR converted all existing Excel data, allowing him to begin entering additional data immediately and customizing the program to fit his needs. He estimates a new patient profile takes 15 minutes to create, and that his preparation and analysis time has been reduced to about five minutes per patient encounter.
According to Moehs, the biggest benefit of Lab Tracker has been its graph and trend analysis. It provides him an instant snapshot of CD4 counts, viral loads and other key indicators in relation to current and new medications. Moehs believes that the graphs have enhanced the patient-provider relationship. When a patient can see a graph of his progress, the level of trust in both the clinician and the treatment improves. As research by HEPP Report's Dr. Rick Altice has demonstrated, these are two of the main factors predicting patient adherence. Lastly, Lab Tracker has improved the patient discharge process. Moehs can provide a complete packet of pertinent patient information and medication records so that released inmates experience a more seamless transition in continuing treatment at an outpatient clinic.
Regardless of institutional size, correctional health care providers can benefit from an all-purpose EMR. At smaller facilities, an EMR can enhance the quality of provider service, improve levels of patient trust and adherence, and streamline the discharge process. At a regional level, an EMR can provide integrated records management that links hospitals, clinics, laboratories and pharmacies in one uniform database. In its clinical capacity, an EMR can save time in preparation and analysis, allowing doctors to offer equal level of care more effectively.
High-level outcome studies can enable administrators to manage chronic diseases by indicators. The statewide example of the Health Care Services Division at Louisiana State University indicates that a fully networked EMR can significantly improve utilization management from a central location. Once direct data entry by providers of critical information such as medications and immunizations is implemented, an EMR's potential ability to perform any number of outcomes studies will ease the burden of conducting cost analyses and budgetary forecasts.
Additional considerations for corrections facilities in particular are that improved records management can reduce the expenses associated with unnecessarily repeating studies on patients who have moved from one facility to another. Better archival and records management can also improve litigation management and correspondence with a state's Medical Board. Most importantly, an EMR enables healthcare providers to improve care, ease the transition of records to new providers, and reduce the human toll of outdated bureaucratic information flow.
Disclosures:
* Nothing to disclose
** Nothing to disclose
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©1997,1998,1999,2000,2001,2002, 2004. IDCR, a forum for correctional problem solving, targets correctional administrators and HIV/AIDS and hepatitis care providers including physicians, nurses, outreach workers, and case managers. The editorial board and contributors to IDCR include national and regional correctional professionals, selected on the basis of their experience with HIV and hepatitis care in the correctional setting and their familiarity with current HIV and hepatitis treatment. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to Julia_Noguchi@brown.edu. Website: IDCR - Infectious Diseases in Corrections Report (Formerly HEPP Report).
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