Electronic Medical Records in Dermatology: the Good, the Bad, and the Ugly
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GUEST EDITORIAL Electronic Medical Records in Dermatology: The Good, the Bad, and the Ugly Ebrahim Mirakhor, MD he American Recovery and Reinvestment Act of that are compatible with the Health Insurance Portability 2009 introduced the Health Information Technology and Accountability Act are the forerunning concerns, T for Economic and Clinical Health (HITECH) Act and the interconnectivity of EMR systems becomes more and allocated $19.2 billion to promote the implementa- important as MU enters its later stages (eg, increased tion of an electronic medical record (EMR) by hospitals electronic transmission of patient data during phases of as well as physicians in private practices.1 The EMR care, reliance oncopy e-prescribing, population-level analysis stores longitudinal health information and constructs a of patient data to improve health outcomes). Additionally, comprehensive picture of a patient’s medical history.2,3 the cost to implement and maintain an EMR deters many Following its debut, the US Department of Health & physicians in smaller practices from shouldering the Human Services set forth meaningful use (MU) criteria,1 charges, as they do not necessarily see increased produc- which aimed to increase quality of care, safety, and effi- tivitynot with this technology.2 Last but not least, unintended ciency. Meaningful use criteria also sought to decrease consequences of EMR implementation can involve the health disparities; improve coordination of care; engage dangers of upcoding and overdocumentation.1 patients in their care; refine population and public health Dermatology is a visually dominant field serving a measures; and finally ensure accessibility, privacy, Doand high volume of patients that require both medical and security of patient data.1,2 surgical care. These factors do not preclude the imple- The EMR offers potential gains at multiple levels mentation of EMRs in our specialty but rather necessitate of the patient–physician–public health hierarchy: a the utilization of a system specifically designed to cater to decrease in medical errors and duplicate services, timely the needs of specialists in dermatology. This editorial will access to test results and records, timely notification of address some fundamental considerations in implement- patients in need for preventive services, and preserva- ing an EMR in dermatology; discuss what platforms and tion of medical records in the event of an environmental patient interfaces are most practical; reiterate the impor- disaster.1-3 Furthermore, physiciansCUTIS can take advantage tance of interoperability; and highlight the implications of informational reciprocity with other providers, gain of this powerful tool in education, research, training, and remote access to medical records, be reminded of need monitoring quality of care. for service, e-prescribe, monitor for drug interactions, and utilize clinical information for research purposes.1,3 Lastly, public health organizations can use EMRs to improve outcomes by employing surveillance measures NEW PODCAST and creating patient registries that serve to protect the Dr. Ebrahim Mirakhor discusses electronic medical society at large.1 records in dermatology with Cutis Editor-in-Chief Although it seems that the broad-scale implementa- Vincent A. DeLeo, MD, in a new episode of the tion of EMRs will undoubtedly enhance the quality of “Peer to Peer” podcast. patient care in the years to come, many obstacles must be overcome to reach this potential. Certification of EMR >> http://bit.ly/2n9VsHO systems and implementation of confidentiality measures From Cedars-Sinai Medical Center, Los Angeles, California. The author reports no conflict of interest. Correspondence: Ebrahim Mirakhor, MD, 8700 Beverly Blvd, Los Angeles, CA 90048 ([email protected]). WWW.MDEDGE.COM/CUTIS VOL. 102 NO. 2 I AUGUST 2018 79 Copyright Cutis 2018. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. GUEST EDITORIAL Implementation and Specific only physicians involved in the care of the patient should Considerations in Dermatology be allocated access.4,6 One of the biggest areas of concern in adopting an EMR is the associated financial burden.2-5 Although govern- EMR Platforms ment incentives of MU cover a part of the initial cost of When computers were first introduced into examination purchasing an EMR, expert maintenance costs, changes rooms, many physicians were reluctant, as computers in workflow dynamics, and a steep learning curve can were thought to disconnect physicians from patients, translate into lost productivity and revenue, discourag- arousing a sense of remoteness and further depersonal- ing many dermatologists from implementing an EMR.3,5 izing the encounter as physicians spent more time typ- Furthermore, physicians who are nearing the end of ing and less time making meaningful eye contact with their careers may not realize the longer-term benefits patients.5 The practice of dermatology requires patient- of implementing an EMR and therefore may decline to centered communication that serves to enhance the do so despite the disincentives of lower Medicare reim- quality of care while at the same time allowing physicians bursements.2 In fact, when juxtaposing the upfront cost to fulfill professional competencies and reduce medical of implementing an EMR against the expected increase errors, which may ultimately translate into patient satis- in revenue after its implementation, there are general faction.7 In fact, when the patient-physician relationship concerns that there will be a net loss on the part of the is interrupted, patients are more likely to pursue legal provider, which is a barrier to adoption of EMRs.3 action in the wake of a bad treatment outcome.5 Beyond the cost-benefit analysis, dermatologists Employing a tablet-friendly EMR can help circum- often report multiple lesions in different anatomic sites vent (or at least minimize) this problem by providing the or identify multiple biopsy sites that have been conve- physician with a light, user-friendly device that elimi- niently recorded on body templates included in their nates the need for laptops or desktop computers.4 Going paper-based examination forms. Converting that infor- one step further,copy the utilization of tablets eliminates mation into words to be entered into an EMR can be the need for accessory digital cameras, as most tablets excruciatingly time consuming and not easily compre- come with built-in high-resolution cameras for captur- hensible upon follow-up visits with the patient, which ing clinical photographs and immediately linking them again results in decreased efficiency and productivity.4 to the patient’s medical record. Lastly, tablet technology Therefore, selecting a dermatology-compatible EMR that allowsnot physicians to access consent forms while in the aims to make this transition easier is of utmost impor- examination room with the patient to more readily obtain tance. One developer introduced an EMR with a touch a signature for procedural or research consent.4,8 interface containing a human body in all its facets that can be rotated, zoomed, and marked multiple timesDo Interoperability, MU, and Quality of Care for accurate and convenient recording of lesions and The real goal in nationwide implementation of EMR intended procedure sites. This system automatically pro- technology is to accomplish MU criteria. Different EMRs duces codes for examinations and procedures; facilitates should not only allow data to be imported and exported e-prescription and ordering of laboratory results; prints but ideally should be compatible and interoperable with pathology requests and consent forms; and includes one another.2 The myriad of different EMR platforms information for patient education regarding their care. available impedes maximal functionality as MU moves For example, the physical examination section of an H&P into its final stage. For example, if an academic dermatol- (history and physical examination)CUTIS can be generated with ogy program in the setting of a larger hospital is required a few taps on the screen, translating into increased effi- to use the generic hospital EMR, the dermatologist’s spe- ciency and productivity. cific needs may not be effectively met; on the other hand, The visual nature of dermatology demands the use of if a dermatology-specific EMR is implemented, access to images, and as such, photographs have become integral the hospital’s larger database of patient information may in the diagnosis and follow-up of dermatology patients. be sacrificed. Optimal EMR systems should be designed Digital and dermatoscopic images not only help to elimi- to allow specificity for a given specialty while being able nate unnecessary biopsies but also can promote early to receive and integrate laboratory values, dermatopa- detection and management of malignancies.6 Thus, the thology and radiology results, and notes from consulta- capability to link photographs to a patient’s medical tions by other physicians. Such integration may reduce record using an EMR is an invaluable gain. However, duplicate services, increase patient satisfaction, and fulfill employing this feature in clinical practice has ethical MU criteria. In fact, the fear of many physicians, especially implications that must be addressed, given that taking those in a field such as dermatology, are the unwanted photographs can evoke an avoidable fear in patients costs that come with implementation of