Web-Based Electronic Medical Records Offer Portability, Disaster Protection

In areas of Louisiana and Mississippi affected by Hurricane Katrinarelated flooding, nearly 6,000 physicians directly involved in patient care were displaced, and numerous others suffered disruptions to their practice. As offices flooded and charts became waterlogged or computer discs were damaged, loss of medical records directly threatened patient care. Even worse, patient records containing identifying data and other sensitive information may have floated downstream into the wrong hands, leaving patients susceptible to loss of privacy and even identity theft.

"There is concern about privacy issues, identity theft, and the ability of physicians to continue caring for their patients, particularly those who have complicated treatment plans that have been formulated over many years for chronic conditions," Jeffrey Glaser, MD, an anesthesiologist from Spinal Pain Associates of the Valley in Encino, California, told Medscape. "There's nowhere to go to be able to effectively retrieve their records. Another concern is that medical records contain information such as Social Security numbers, copies of drivers' licenses, and if those records get in the hands of the wrong people, that would pose a real problem."

One way to minimize practice disruption from catastrophes and to ensure patient privacy and continuity of care is with an electronic medical record (EMR) and an office management system that is Web-based. Examples of these products include Medical Office Online, a HIPAA-compliant application that integrates EMR and medical scheduling and billing software ($275 per provider per month); SmartEMR, a specialty-specific EMR application that organizes records and documents, facilitates billing and reimbursement, and integrates with prescription writing and imaging; and EZMedicalOffice, a private, custom-designed, HIPAA-compliant EMR application and database with automatically installed upgrades and data back-up, a search engine for office records, and strong encryption of all physician and patient information.

One Web-based EMR system, MD Synergy, is offering free training, activation, and use of their system for six months to any physician affected by Hurricane Katrina. Ordinarily, the initial start-up fee is about $5,000, with ongoing charges of about $200 per month, which includes automatic updates. This active server pages (ASP)-based system includes scheduling, demographic, and EMR information in a HIPAA- and privacy-protected format. The data are available on both the local server at the physician's office, as well as through the MD Synergy server, and it can be downloaded by the physician in a variety of file formats.

"The data can be backed up at many different locations at many different times, so even if one location is hit by a disaster, the data are consistently available," said Dr. Glaser, who has used MD Synergy in his practice for the past three years. "What sold me on MD Synergy, even before I thought about any possible disaster, was the ability to move my office to another location without having to move and reorganize thousands of medical charts. This way, everything's at your fingertips.... Imagine you're in vacation in Tahiti and you're contacted with a question about one of your patients  as long as you have Internet access, anywhere in the world, you can have access to all of your patients' records."

Thanks to the Windows-based, color-coded, drop-down system and online manual, Dr. Glaser was able to implement MD Synergy after 10 days of self-instruction and about two hours of training for his office staff. He has specific formats designed specifically for his practice, such as letters to referring physicians. Based on diagnosis and procedure, the system performs ICD-9 and TPT designation, and it can even do a CMS audit to ensure that documentation meets the requirements of level 2, 3, or 4 visits.

"It definitely made my practice more efficient and more cost-effective," Dr. Glaser said. "I sleep better at night  I'm a real detail-oriented guy, and I like using a HIPAA-compliant system that gives me comfort in knowing that my data is secure and protected. Even if there's a fire or flood, or if I move my office, that data is available at my fingertips."

During the American Academy of Family Physicians (AAFP) Scientific Assembly on Oct. 5, AAFP leaders and members affected by Hurricane Katrina endorsed the recently implemented Project Continuity of Care. The aim of this project is to develop a continuity of care record (CCR), an electronic file containing summarized health information for each patient. To minimize practice disruption and facilitate ongoing care, this file could be easily accessed, transported by patients on an inexpensive USB drive, printed as an Adobe Acrobat or Microsoft Word document, viewed by care providers using common Web browser software, and uploaded at hospitals or providers' offices.

Since early summer, the AAFP has collaborated with about 40 EMR vendors to incorporate the CCR standard into their products.

A similar approach is the System Providing Access to Records Online (SPPARO) software, consisting of a Web-based, patient-accessible EMR containing laboratory results and radiology results, an educational guide, and a messaging system enabling electronic communication between patients and staff. The system often includes safeguards to make sure that ordering physicians have a chance to contact patients before particularly sensitive information, such as pathology reports, is released. Patient access to clinical notes has been much less common, but it has been studied at sites including the University of Colorado Hospital (UCH) in Aurora.

In a randomized controlled trial of 107 patients with heart failure enrolled in a specialty practice at UCH, published in the May 2004 issue of the Journal of Medical Internet Research, the intervention group was not significantly superior in self-efficacy, but was superior in general adherence, and there was a trend toward better satisfaction with physician-patient communication. No adverse effects were reported from use of the system.

"Many patients find these systems to be of great value," lead author Steve E. Ross, MD, an assistant professor of general internal medicine at the University of Colorado Health Sciences Center, told Medscape. "Patients find it reassuring to be able to confirm their test results online, soon after they are completed, rather than waiting for a notification about the test results by mail (a notification that too often may be delayed or even neglected). They also report being able to assist in sharing clinical information from specialists with primary care physicians who may be part of a different medical system."

Although physicians anticipated that implementing SPPARO might increase their workload and hinder clinical interactions, post-trial interviews revealed that physicians and staff reported no change in their workload and no adverse effects (the results were reported in the September/October 2004 issue of the Journal of the American Medical Informatics Association). All physicians involved ultimately endorsed the concept of allowing patients online access to their clinical notes and test results.

"In general, physicians have been concerned that giving patients access to unfiltered medical information may confuse or worry them," Dr. Ross said. "Our own experience, however, is that patients who choose to review their records do so with very realistic expectations  they realize that they will not understand everything in the medical record, but they still get value from reading it, and appreciate the 'transparency' of clinical reasoning that patient-accessible medical records provide. Overall, our experience is that rather than feeling worried, these patients usually feel reassured and more confident about their care."

The UCH trial demonstrated that providing the medical record, including clinical notes, to patients with heart failure tended to improve compliance, but the authors concluded that additional research is needed to determine if patient access to these notes improves broader measures of health.

"How access to clinical notes might work in primary care is also an open question, since these clinical notes often contain assessments of sensitive social issues, such as marital discord, and psychological issues, such as substance abuse or depression, that could cause patients embarrassment or anxiety," Dr. Ross said. "In surveys, some patients have been concerned that online, patient-accessible medical records will pose security and privacy problems, but to date I am not aware of any reports of significant security breaches related to these systems."

During 2002, about 100 million Americans used information obtained online, including health information, as a basis for making decisions, according to Simon de Lusignan, a senior lecturer in primary care informatics at St. George'sUniversity of London in the U.K. Although physicians, as a group, tend to use the Web more than do many other subgroups of the general adult population, they are not yet sufficiently convinced that the Internet can help them provide higher quality care.

Before Web-based health applications fulfill their vast potential for improving healthcare, patient satisfaction, and utilization of healthcare dollars, further advances are needed, Dr. de Lusignan writes in a review published in the May 2003 issue of the Journal of Medical Internet Research. He recommends new e-technology formats including key clinical variables and incorporating a coding or classification system

"The pros of Web-based records are that they are simple and cheap, and are readily accessible wherever in the world you are," Dr. de Lusignan told Medscape. "My view is that having my medical record within an integrated health service computer system may be the best place for it. However, we should be encouraging internationally standardized unique identifiers to be developed that can be used regionally, if not worldwide."

To improve efficiency and patient safety, healthcare systems across the globe are either making computer systems interoperable, such as the Commission on Systemic Interoperability in the U.S.; or integrated, such as the National Health Service's Connecting for Health program in the U.K. However, few of these projects are applicable internationally. For example, the European Union has no unique identifier to date. Although there is free movement of labor within the EU, individuals will have to start a new medical record in nearly every country where they take up a new residence.

"The principal difficulty, in my view, is whether Web-based medical records can be made interoperable with the computerized or other medical record systems of any healthcare provider that a patient might visit," Dr. de Lusignan said. "At the lowest level, there might not be Internet access at the point of care. Where there is Internet access, how will the record be structured?"

Which coding or classification system is used in the Web-based EMR is particularly important. Currently, there is no international standard for how medical data are coded. For example, some parts of the U.K. use Read Codes whereas other parts use International Classification of Disease  Clinical Modification (ICD-CM) codes, and much of Europe uses the International Classification of Primary Care (ICPC) codes.

Other concerns raised by Dr. de Lusignan are accuracy of the Web-based record; who might have edited it; and potential privacy issues, which he suggests are probably overestimated but also vary among individual users.

"An international itinerant might feel that the benefits outweigh the risks, whereas a person in the public eye may take a different view," Dr. de Lusignan said. "Obviously the data security of a site containing medical records would be paramount. Many people from extortionists to health or general insurers would be very interested in these records! At what age parental responsibility passes to children may also be an issue, especially around issues like terminations of pregnancy and contraception."

Disclosure: Dr. Glaser holds shares in MD Synergy and was at one time on its medical advisory board. Dr. Ross and Dr. de Lusignan disclose no relevant financial relationships.

Reviewed by Gary D. Vogin, MD
By: Laurie Barclay, MD