Electronic Medical Records in Colorectal Surgery

Abstract

Electronic medical records (EMRs) are being widely implemented today, either as stand-alone applications in smaller practices or as systems-based integrated network solutions in larger health care organizations. Advantages include rapid accessibility, worldwide availability, ease of storage, and secure transfer of protected health information (PHI). Computerized physician order entry (CPOE) and decision-support capabilities such as the triggering of an alarm when multiple medications with known interactions are ordered, as well as the seemingly endless possibilities for electronic integration and extraction of PHI for clinical and research purposes, have created opportunities and pitfalls alike. Risks include breaches of confidentiality with a need to implement tighter measures for electronic security. These measures contrast efforts required for the realization of common data formats that have national and even international compatibility. EMRs provide a common platform that could potentially allow for the integration and administration of clinical care, research, and quality metrics, thus promoting optimal outcomes for patients. Technical and medicolegal difficulties need to be overcome in the years to come so that the safe use of PHI can be ensured while still maintaining the benefits and convenience of modern EMR systems.

Keywords

electronic medical record - protected health information - data - colorectal - colon - surgery - HIPAA - billing

• References

• 1 The Robert Wood Johnson Foundation. Health information technology in the united states: where we stand, 2008. Available at: http://www.rwjf.org/files/research/062508.hit.exsummary.pdf . Accessed March 21, 2012
• 2 Hsiao CJ, Hing E, Socey T , et al. Centers for Disease Control and Prevention: NCHS Health E-Stat. Electronic medical record / electronic health record systems of office-based physicians: United States, 2009 and preliminary 2010 state estimates. Available at: http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm . Accessed March 20, 2012
• 3 Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med 2009; 360 (15) 1477-1479
• 4 Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act). , Pub. L. No. 111–5, Div. A, tit. XIII, Div. B, tit. IV, Feb. 17, 2009, 123 Stat. 226, 467 (codified in scattered sections of 42 U.S.C.A.); 2012
• 5 Meystre SM, Savova GK, Kipper-Schuler KC, Hurdle JF. Extracting information from textual documents in the electronic health record: a review of recent research. Yearb Med Inform 2008; 128-144
• 6 Murff HJ, FitzHenry F, Matheny ME , et al. Automated identification of postoperative complications within an electronic medical record using natural language processing. JAMA 2011; 306 (8) 848-855
• 7 Denny JC, Peterson JF, Choma NN , et al. Extracting timing and status descriptors for colonoscopy testing from electronic medical records. J Am Med Inform Assoc 2010; 17 (4) 383-388
• 8 Xu H, Fu Z, Shah A , et al. Extracting and integrating data from entire electronic health records for detecting colorectal cancer cases. AMIA Annu Symp Proc 2011; 2011: 1564-1572
• 9 Kush RD, Helton E, Rockhold FW, Hardison CD. Electronic health records, medical research, and the Tower of Babel. N Engl J Med 2008; 358 (16) 1738-1740
• 10 Gurland B, Alves-Ferreira PC, Sobol T, Kiran RP. Using technology to improve data capture and integration of patient-reported outcomes into clinical care: pilot results in a busy colorectal unit. Dis Colon Rectum 2010; 53 (8) 1168-1175
• 11 Sarrico C, Hauenstein J. Can EHRs and HIEs get along with HIPAA security requirements?. Healthc Financ Manage 2011; 65 (2) 86-90
• 12 Chaudhry B, Wang J, Wu S , et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144 (10) 742-752
• 13 Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163 (12) 1409-1416
• 14 Bates DW, Teich JM, Lee J , et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6 (4) 313-321
• 15 Jha AK. The promise of electronic records: around the corner or down the road?. JAMA 2011; 306 (8) 880-881
• 16 Mangalmurti SS, Murtagh L, Mello MM. Medical malpractice liability in the age of electronic health records. N Engl J Med 2010; 363 (21) 2060-2067
• 17 Ralston JD, Coleman K, Reid RJ, Handley MR, Larson EB. Patient experience should be part of meaningful-use criteria. Health Aff (Millwood) 2010; 29 (4) 607-613
• 18 Adler-Milstein J, Bates DW, Jha AKUS. U.S. Regional health information organizations: progress and challenges. Health Aff (Millwood) 2009; 28 (2) 483-492
• 19 Blumenthal D. Launching HITECH. N Engl J Med 2010; 362 (5) 382-385
• 20 Mourad M, Cucina R, Ramanathan R, Vidyarthi AR. Addressing the business of discharge: building a case for an electronic discharge summary. J Hosp Med 2011; 6 (1) 37-42
• 21 Heidelbaugh JJ, Riley M, Habetler JM. 10 billing & coding tips to boost your reimbursement. J Fam Pract 2008; 57 (11) 724-730
• 22 Pear R. New York Times, January 17,2009. Available at: http://www.nytimes.com/2009/01/18/us/politics/18health.html?_r=3&ref=health . Accessed March 19, 2012
• 23 DesRoches CM, Campbell EG, Vogeli C , et al. Electronic health records' limited successes suggest more targeted uses. Health Aff (Millwood) 2010; 29 (4) 639-646
• 24 Virapongse A, Bates DW, Shi P , et al. Electronic health records and malpractice claims in office practice. Arch Intern Med 2008; 168 (21) 2362-2367
• 25 Jones SC, McMenamin J, Kibbe DC. The interoperable electronic health record: preserving its promise by recognizing and limiting physician liability. Food Drug Law J 2008; 63 (1) 75-87