Electronic Medical Records and mHealth Anytime, Anywhere

In the era of paper medical records, accessibility was significantly limited by the physical location of the records and the inability of multiple clinicians to access them simultaneously. These problems have largely been solved with electronic medical record (EMR) systems— information systems containing computerized patient records which can be stored, retrieved, and modified—which have been shown to improve the quality and reduce the cost of medical care.

EMR adoption has been shown to streamline clinical decision support systems and event monitors, improving efficiency by shortening the time taken for the physician to institute appropriate treatment. There are many advantages to EMR, including flexibility; standardization of terminology, forms and data; collection of clinical data for research purposes; and ease of data transfer between systems and facilities. Clinicians can even write on mobile tablets with automated handwriting recognition.

At the same time, however, new complications have evolved specific to the electronic and mobile electronic environment. Perhaps the most significant of these is information overload. With higher rates of adoption of EMR systems, the hospital environment is exposing front-line providers to more clinical and administrative data than ever. Much more electronically generated data is now recorded in EMR systems and presented through static or mobile visual displays.

With the advent of smartphones and iPads, physicians also increasingly want to access their electronic medical records on mobile devices, and are choosing EMR systems with a mobile component. A recent study suggests that more physicians are using smartphones (56% of those surveyed) than comprehensive EMR systems (38%).1 

From a clinical perspective the EMR facilitates two essential functions (Figure 1): tools and methods for data entry, and clinical use of information. The mobile element allows clinicians to access EMR anytime, anywhere. However, the process of managing, storing, controlling, and transferring data is almost exclusively managed by non-clinician information technology specialists.

This separation of clinical and technical expertise can lead to unnecessary and wasteful constraints on provider ergonomics and counteract the benefits of the EMR. In addition, as EMRs and mobile enabled EMR systems evolved from accounting-oriented software products, their utility is still suboptimal for patient care.

Seven critical problems (which apply to mobile and non-mobile EMR access) that must be addressed to facilitate the transformation of the modern EMR to a patient-oriented product are:

Modern physiological sensors and associated processors have the power to generate and display vast amounts of high resolution data. Since it is important for building more sophisticated hardware-embedded algorithms, the question is how much data should be stored in EMR, particularly mobile-enabled EMR, which has limited data storage? Should a patient's heart rate for example, be recorded every 2 seconds?

Acute care settings such as the emergency department (ED), operating room (OR) and intensive care unit (ICU) have a much higher demand for real time data compared to other clinical settings. Acutely ill patients transferred from the hospital floor to the ICU produce 10 times more clinical data than those in regular inpatient settings, even when monitor data is excluded (Figure 2).

It is intuitively clear that information and mobile information needs for decision making differ between, for example, the outpatient care setting and the intensive care unit. However, the majority of current EMR platforms have been built as universal solutions.

Customization is an added expense for product developers, but ultimately, a flexible platform helps clinical providers do their work more effectively. This is a worthy investment in terms of patient care, and may even yield a downstream return on investment.

As patients transfer between hospital sites and practices, their medical data is often not available to providers in other sites. While interconnectivity between solo practices, clinics, and hospitals targets information exchange, little attention has been paid to how that information might best be utilized for better patient care.

Rules-based processing of such data may add value to healthcare delivery models. For example instead of querying the patient about home medications used, a mobile and interconnected electronic system could request all prescribed drugs from area pharmacies with dosages and the actual rate of refill.

The same applies to the growing market of home and mobile medical devices. A week of home blood pressure measurements automatically transferred prior to a hospital visit is more meaningful than a single measurement made during a stressful clinical visit.

Even a decision support system (DSS) which provides highly reliable guidance is imperfect if it does not provoke a good decision by a provider. Assuming that the decision support algorithm reliably reproduces the best decision output, to be successful, a DSS should always be built around three rules:

• a) The result should be made available to the appropriate decision maker (the right person).

• b) The result should be delivered to the point of care (the right place).

• c) The result should be delivered at the time a decision is being made (the right time).

The clinical value of a decision support system will decrease exponentially if insufficient attention is paid to implementation of decision support according to these rules. Alert fatigue is an additional problem which may be addressed by application of these rules.

Increased accessibility to clinical data through high speed wireless Internet and mobile devices fuels a growing concern about information overload. In addition, raw patient data overload, a myriad of other information, including advertising, junk mail, and messages, can block immediate access to vital patient data.

Frequent interruptions from ubiquitous data sources may also contribute to errors and omission in clinical decision making. One of the fundamental roles of the next generation of EMR systems should be to contain information overload through smart information management strategies.

Nowadays, clinicians spend significant portion of their time in front of computers that disconnect them from patients and their families. In the hospital and ICU environments, workstations are usually placed at some distance from patient rooms.

Mobile carts and laptops are a partial solution to this problem. However, lightweight, large-screen tablet computers that can be instantly switched “on,” and which have a long battery life could be most effective. Smartphones with a high speed 3rd or 4th generation (3G/4G) connection seem to be promising technology, but have organizational limitations in mostly clinical settings.

The critical issues with mobile EMR access are platform compatibility and accessibility to enable real-time patient information retrieval. Communication with colleagues, hospital staff, and patients is also vital.

Paper-based records are still by far the most commonly used method of recording patient information in U.S. hospitals, but electronically inclined clinicians are increasing. EMR systems facilitate improved patient care only if they complement and enhance clinical workflow, and if they can be effectively accessed via mobile devices. At present, we have the technical resources to create an EMR environment that adds value to healthcare.

What is required is a close and continuous collaboration between clinicians, information technology specialists and EMR vendors to deliver this future. What is certain is that as the current glut of dollars (federal government incentives) to adopt electronic medical records dries up over the coming years, the point of care performance of these systems will come under increased scrutiny. Disruptive business models often arise in such markets.