Single portal electronic medical record: friend or foe?

CONTEMPORARY Australian health care is complex, subspecialised and difficult to coordinate.  Patients live longer and incur a greater burden of illness and injury.

For example, a typical patient with poorly controlled diabetes mellitus suffering an acute myocardial infarction and gangrenous foot will require single acute episode endocrinology, cardiology and vascular surgical expertise in an acute care hospital.

Multispecialty care at a single hospital requires seamless integration, made possible by the timely awareness of what various clinicians are planning to do, enabled by an electronic medical record (EMR) (here, and here). EMRs are positive innovations that potentially reform medical care to improve life and health outcomes.

An EMR, with clinical management information able to be accessed by all clinicians at the treating hospital, optimises interdependent care. Synchronised care for the abovementioned calamitous threat could include a percutaneous coronary stent followed by surgical foot debridement and diabetes education prior to discharge from the ward.

E-health data access is even more critical in ambulatory and community care for chronic disease.  Our patient with diabetes will see a series of specialists and clinic nurses at different times over months, each with a limited view of treatments planned by colleagues. As health care becomes more specialised, communication with a GP charged with oversight assumes paramount importance. Poor communication leads to discontinuous and inefficient care, patient dissatisfaction and worsened health outcomes.

A neglected sector of health care that will improve with EMRs is prehospital care and transport to hospitals. Congested ambulance services that load share patients among member hospitals within a local area network could access integrated patient EMRs so that the right patient is brought to the right hospital in the right time.

Ambulance access to single portal EMRs could allow the balanced and clinically appropriate distribution of vehicles carrying unplanned patients requiring emergency care across local hospitals (here, and here). The ability to undertake real time interrogation of a patient’s need for specialist care is beneficial for clinicians coordinating ambulance destination. For example, in one study, a registered nurse in the hospital command centre was able to identify the preferred destination and make recommendations to emergency medical services providers for each transported patient utilising real-time measures of health system capacity, based on such factors as chief complaint, emergency department volume, and waiting room census. Ambulance access to EMRs could help patients be returned to a hospital they have been recently discharged from, hospitals that suit the patient’s clinical profiles and their anticipated specialist medical and surgical needs. However, established clinical pathways for trauma, burns, large heart attacks and strokes that present early should not be subverted even if the preferred or referral hospital is congested.

Emergency department congestion and ambulance ramping incur significant clinical risk that is only partly mitigated by ambulance case load sharing. The entire patient journey from ambulance attendance to emergency department drop off can benefit from prehospital staff being able to access hospital EMRs. This can better allow patients to be transported to the best hospital for their needs in an expeditious manner, particularly for time-critical illness or injury.

Widely accessible EMRs which are able to be securely viewed by a patient’s GP, outpatient and hospital clinicians could better integrate care for the whole of the patient’s journey during acute illness or injury. This is extended to benefits for chronic disease and preventative interventions over a lifetime. Comprehensive, updated and integrated clinical records available through a single portal enhance interdisciplinary communication and improve modern health care, at a time when the fractured inputs of innumerable subspecialists has become the norm for modern resource-intensive care.

Whole of population EMRs have the potential to allow disease registry metadata interrogation for reliable assessment of a disease’s prevalence and trends. Real-time tracking for symptoms may even help identify early infectious disease outbreaks. Population registry-based epidemiological and drug adverse effect studies are made possible with national lifelong health data registries, including for biobank genetic research.

Although well designed user friendly EMRs could enhance continuity of care from ambulance transport, through acute admission, hospital discharge and GP review, this “brave new world” instils fear about relying on powerful IT owners being trusted with private confidential information.

Administrative, physical and technical security safeguards and procedures may confer confidence in protecting against cyberware, fraud and confidentiality incursions. Nevertheless, there has been a vigorous debate and battle over privacy, autonomy and use of health information for MyHealthRecord in Australia.

Continued vigilance to address community concerns about data loss, access and control over private health information remains critical. A well designed EMR ensures billing, regulatory, research, clinical documentation and administration functions meet the specific requirements of health care workers. This encourages health care worker uptake of new EMR systems and community opt-in enrolment for personal EMRs to improve patient care over their whole lives.

An IT system that is not user friendly, with poor fit between design and daily clinical practice undermines faith and wider use.

Highly demanding documentation risks clinician burnout and dissatisfaction. This critical mismatch could be identified by a health IT safety measurement framework that monitors patient safety, staff satisfaction and innovations to address shortfalls.

The initial cost outlay for EMR engrafting remains a major obstacle. The Cerner EMR roll-out to 27 Queensland Health hospitals, for example, is predicted to require a massive outlay of $1.2 billion by 2025.

Despite the promise of single portal EMRs, patients remain wary of data and privacy breaches. The community will need to decide whether the benefits of widely accessible EMRs that optimise their 24/7 care from GP, ambulance, clinical and acute care outweigh the risk of privacy and security breaches.

Professr Joseph Ting is an emergency, prehospital and aeromedical physician as well as adjunct associate professor for clinical research methods and pre-hospital care at Queensland University of Technology’s School of Public Health and Social Work and Clinical Senior Lecturer in the Division of Anaesthesiology and Critical Care at the University of Queensland.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.