In this digital age, more and more bulks of information which used to be paper-based, from library catalogues to telephone books, are digitized and stored in a central location for easy access. The idea of EMRs itself started about 40 years ago. However, there is surprisingly a strong resistance against the use of EMRs. Let us take a look at what the proponents and opponents of EMR have to say.

What are the advantages of EMRs?

The main proponents of EMR are health care providers, hospitals, clinics, and other sectors of the healthcare industry. Here are some of their arguments:

EMRs minimize errors
The use of EHR supposedly reduces errors in medical records. There is no doubt that handwritten records are subject to lots of human errors due to misspelling, illegibility, and differing terminologies. With the use of EMRs standardization of patient health records may eventually become acheivable.

compter in lcok and chainsEMRs keep records safe
Paper records can be easily lost. We have heard how fires, floods and other natural catastrophes destroy physical records of many years, data which are lost forever. Digital records can be stored virtually forever and can be kept long after the physical records are gone.

EMRs also help keep records of health information that patients tend to forget with time, i.e. inoculations, previous illnesses and medications. Online services such as the Cleveland Clinic’s MyChart, HealthVault and Google Health can help patients in record keeping. These will be discussed in detail below.

EMRs make health care cost-efficient
EMRs consolidate all data in one place. Previously, paper-based records are located in different places and getting access to all of them takes a lot of time and money. Think of the amount of time and money spent on phone calls, emails, and faxes to get access to records from other places. In some cases, medical tests that have already been done are repeated all over again, incurring unnecessary costs to the patients and the health care system.

Last month, the first city-wide electronic health information exchange in the US was implemented in Indianapolis. The Indiana Network for Patient Care was developed from the Regenstrief Medical Record System which is a database of 9.6 million patients. The system is expected to improve health and lower costs.

EMRs facilitate coordination between health professionals
The coordination between primary care providers and the hospital care of patients has always been problematic. In a systematic review, Kripalani et al. evaluated the communication transfer between primary care physicians and hospital-based physicians and found significant deficits in medical information exchange. They reported that discharge reports from hospitals frequently do not get to the general practitioners in time, resulting in decreased quality of care after hospitalization. Furthermore, the reports tended to be inaccurate and incomplete, often lacking relevant data about tests and new medications. The review recommended the use of EMRs to resolve these issues and facilitate the continuity of care before, during and after hospitalization.

The Cleveland Clinic has been always been on the leading edge in health information technology and was one of the very first to offer secure online services. The DrConnect service provide primary care clinicians “real-time electronic medical record information about the treatment their patients receive at Cleveland Clinic.”

EMRs translates into better treatment for patients
Efficiency and speed of diagnosis translates into better health care service for patients. Similar to the previously discussed point, correct and timely information can significantly increase the quality of health care service rendered to patients. Take the example of one asthma center’s experience with EMR:
“A major benefit associated with EMR implementation was the increase in the number of children who were hospitalized with an asthma exacerbation and received an asthma action plan upon discharge. Prior to the EMR system, [only] 4% received an asthma action plan upon discharge. After implementation of the EMR system, 58% received an asthma action plan upon discharge.”

EMRs can save lives
In many cases, EMRs can save peoples’ lives under unusual circumstances.
Researchers at the Regenstrief Institute in Indiana have been working on EMRs for years which can be used in disease surveillance during epidemics and bioterrorism.

VeriChip, developed by VeriChip Corporation is the first one of its kind ever approved by the US FDA. It is an implantable RFID microchip, not only for pets, but also for humans. The 16-digit code in the VeriChip, which can be read by a chip reader, can be used to access online databases, including EMRs.

VeriChip offers the following benefits:
• It enables rapid identification of at-risk patients and access to their medical history, thereby enabling rapid diagnosis and treatment especially in emergency situations. Classic examples are people with diabetes and/or heart problems who have high risk of collapsing and having attacks. However, VeriChip is also useful in vehicular accidents and other trauma incidents where the victims aren’t capable of answering questions.
• In cases of large-scale catastrophes, VeriChip facilitates tracking and identification of victims. According to a coroner in Mississippi, VeriChip helped identify victims during the Hurricane Katrina incident.
• VeriChip also facilitates “infant protection” and “wandering prevention” of children and those suffering from dementia and other neurodegenerative disorders.

Some types of EMRs give patients control over their health records
Several online health information management services have recently been introduced.

Earlier this year, Google Health was launched, an online personalized health record services. The service is based on the principle that since it’s the patient’s medical record, the patient should control it, decide what should be in it, and who gets access to it. "Personal health records is an area that's just beginning," said Roni Zeiger, the Google Health product manager. "The fact that only few people are using those tools means we--the computing and health care industries--haven't gotten it right yet."

Some of the nifty features of the service are:
• It allows storage and management of medical and health information in one central place.
• It is personalized – the patient decides what goes on the record.
• It can give doctors fast and easy access to the patient’s records but only if the patient allows it.
• It can import electronic records from hospitals and pharmacies that are Google Health-enabled or are registered Google Health partners.
• It is completely free.
• It is supposedly secure. 

Several prestigious medical institutions are working closely with Google Health. One of the major partners is Cleveland Clinic.

“Working with Google Health, Cleveland patients can now import their Cleveland Clinic medical records into their own, secure Google Health Account. This allows patients to maintain comprehensive medical records about themselves, including accurate medication histories, and other invaluable information. Cleveland Clinic's partnership with Google broadens the ability of all patients to utilize secure online technology to coordinate their own health care services, thereby furthering Cleveland Clinic's ultimate goal of empowering patients and transforming medicine through the use of innovative health information technology.”

The HealthVault is another online health information storage service offered by Microsoft with features similar to Google Health. Keith Toussaint, senior program manager with Microsoft HealthVault recently stated " leading hospitals like Beth Israel Deaconess Medical Center are actually integrating their systems with both us and Google -- because some people like one or the other. It's a Coke or Pepsi thing." Aside from medical records, Google Health also keeps fitness records and has joint projects with the American Heart Association to run online cardiovascular health monitoring platforms for patients such as Heart360 and the HeartHub. Cleveland Clinic also has recently announced “to pilot the patient-controlled data exchange between Microsoft HealthVault, a Web-based personal health platform; a suite of widely-used digital medical devices; and eCleveland Clinic MyChart, Cleveland Clinic's electronic personal health record …system.”

What are the disadvantages of EMRs?
Not surprisingly, privacy rights advocacy groups are the main opponent of EMR. Here is what they have to say:

EMRs threaten our privacy
In this day and age when people’s mantra is “I need my privacy”, not many people are comfortable about having their entire medical history recorded and digitized for almost just anybody to see – in other words, incursion into people’s privacy. The confidentiality of doctor - patient relationship is still sacrosanct. Besides, medical data can be used against a person in some cases – be it for a job application, insurance coverage or a college scholarship. Although it is against the law to discriminate against people with illnesses and disabilities, it is a fact of life that the fitter you are, the more competitive you are in the job market. The planned incorporation of genetic data in EMRs further adds to people’s fear of incursion into their private sphere.

EMRs can lead to loss of human touch in health care
In the process of digitalization, the interpersonal aspect in health care may be lost. In handwritten hospital charts, doctors and other health care practitioners may write what they think and they feel based on their personal observations in their very own words. EMR is simply about ticking off boxes and crossing out things in electronic forms. The doctors are forced to think in categories and can seldom express a personal opinion on an individual case. Because of the lack of flexibility of many electronic reporting systems, cases of misclassification of patients and their conditions have been reported.

EMRs are not that efficient
Yet, despite efforts in digitalization and standardization, EMRs are actually far from being standardized and not as efficient as it is purported to be. It often happens that one clinic’s EMR system is not compatible with that of a general practitioner or another clinic’s system, thus belying the claim of added efficiency.

In addition, not all users of EMRs are satisfied with the current state of the art. Although the objective is mainly efficiency and healthcare quality, one study showed that nurses in the Netherlands are not completely satisfied with their EMR implemented in 2006-2007. Furthermore, there was no marked improvement in time efficiency.

EMRs are not safe and secure
Very few people are confident about the data protection and security of electronic data such as those stored in EMRs. Many people are not convinced that their data are safe from those who would want to misuse it.

Google Health and HealthVault are quick in assuring patients of the safety of their online health accounts. Access to the patient’s account is only possible using log ins and password. In addition, HealthVault assures that “all health information transmitted between HealthVault servers and program providers' systems is encrypted” and that Microsoft does it best to use the “highest standards of security to safeguard consumer health information from theft, loss, or damage.”

However, there are cases wherein passwords and encryptions do not seem to be adequate as data protection tools. Stories of data hacking, stolen identities and blackmail abound. Even high security databases such as those run by banks and credit institutions are often compromised. This impression was aggravated by the many well-publicized incidences of data loss or breach. A few examples are listed below:

November 26, 2007, Canada. Hackers accessed medical information on HIV and hepatitis from a Canadian health agency computer.
September 22, 2008, UK. The National Health Service (NHS) reported the loss of 4 CDs in the mail containing information on 17,990 employees.
September 30, 2008, US. The company Blue Cross and Blue Shield of Louisiana confirmed breach of personal data, including Social Security numbers, phone numbers and addresses of about 1,700 brokers. The data was accidentally attached to a general email.

In addition, there is criticism over Google Health not being a “covered entity under the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (HIPAA)” under its terms and conditions and is therefore not subject to HIPAA privacy of individually identifiable health information. The HealthVault terms and conditions do not mention HIPAA privacy laws so it is not clear what its status is regarding this issue.

VeriChip is not for humans
It is to be expected that although many of us are amenable to the use of RFID chips in pets, the idea of implanting similar chips in human beings is bound to raise hackles in humans. No matter what the US FDA says. As expected, the introduction of VeriChip, as previously described, has been met with strong opposition.

A big opponent of the VeriChip and similar chips of its kind is the consumer advocacy group Spychip.com. In a position paper, Spychip and many advocacy and consumer awareness groups see RFID tagging (be it on your person or on the items you buy) as a major threat to privacy and civil liberties. They see the tagging as some kind of “Big Brother” operation.

Another group, the No VeriChip Inside Movement, likens VeriChip as “cataloguing” humans similar to the way the Nazis have tattooed numbers on the skin of concentration camp detainees.

Popular Hollywood films on privacy incursions (e.g. The Net, Public Enemy No. 1) increased further people’s paranoia about personal data.

Where do we go from here?
Without doubt, we have the technology to make EMRs standardized and efficient. Google Health, Microsoft HealthVault and similar online personalized health information accounts are enabling patients to take control of their medical records. The main issues that need to be overcome are data security, protection of privacy and gaining the confidence of the patients. It doesn’t seem evident that the use of RFID and similar tagging chips will become acceptable or popular anytime soon. However, we live in a digital world and we cannot hold back progress indefinitely. With improved technology and data protection tools, let us hope the EMR issue will be resolved soon.

References:
1. Business Insurance. Louisiana Blue Cross confirms data breach. 30 Sept 2008
2. Computer World. Global Dispatches: U.K. health service staff data lost in mail.
3. Global Secure Systems. Data loss a global endemic as Canadian Health Agency admits to Major Hack. 27 Nov 2007. Available at 
4. Hoffman MA.The genome-enabled electronic medical record. Biomed Inform. 2007 Feb;40(1):44-6. Epub 2006 Mar 15.
5. http://noverichipinside.com/
6. http://www.healthvault.com
7. http://www.hearthub.org/
8. http://www.verichipcorp.com/
9. https://www.google.com/health
10. https://www.heart360.org/
11. Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Potential misclassification of patients with psoriasis in electronic databases. J Am Acad Dermatol. 2008 Oct 1. [Epub ahead of print]
12. Indiana University. Nation's Only Citywide Electronic Health Information Exchange: Improving Health and Lowering Costs. 15 Oct 2008.            Accessed 6 Nov 2008.
13. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-41.
14. Tolomeo C, Shiffman R, Bazzy-Asaad A. Electronic medical records in a sub-specialty practice: one asthma center's experience. J Asthma. 2008 Nov;45(9):849-51.
15. Verwey R, Claassen RA, Rutgers MJ, de Witte LP. The implementation of an Electronic Nursing Record in a general hospital in the Netherlands: Lessons to learn. Stud Health Technol Inform. 2008;141:130-8.
16. http://www.clevelandclinic.org/