There has been some talk about online patient health records and how the patient can now be better informed and take better ownership of their health now that their health information is so easily available. However, does the ability to access the information make us better and more informed patients or does it have the potential to confuse us even more?


Last month my husband went to the doctor for a yearly physical. He had no health complaints, he felt healthy and fine. The doctor and he both thought it would be a good idea to do a few tests to establish a base line for the future. Many of those tests were done while he was there and the doctor provided him with feedback on how he fared. However, the blood test had to be sent to the lab and he had to wait for the results. The doctor mentioned that the nurse would call him with the results, but if he wanted to he could also sign up to access his health record online and see the results as well.


My husband is a web developer and viewing things online, whether it is his bank account, Netflix account, or his health records is right up his alley. He registered and activated his account and promptly forgot all about it until the nurse called and left a message on the phone to call back regarding his blood test. He got the message after work and after the doctor's office hours so he naturally went online to view his blood test. What he saw was a bunch of abbreviations and number values, all of which meant absolutely nothing to him.


His mother, mother in law, and his aunt are all nurses. His wife is a medical librarian. What does he do? Does he call the medical professionals in the family who might be able to help him? Nope. He goes online. Does he ask the information professional who lives with him about some good sites? Nope. He did what many people do, he Googled it. In his attempt to read the results he looked for what would be the normal values for his test. In the process he noticed that some of his numbers were slightly on the low side or the high side of "normal," and one or two numbers were "barely" on the wrong side of normal. He wanted to know what that meant and what could have caused him to fall outside of the normal range. Thus began his brief bout of cyberchondria.


He found every reason for each set of values from diet, weight gain/loss, hormones, to all sorts of illnesses. It was only after he spent a couple of hours on the computer did he mention to me that his blood test results were available online and that he was diagnosing himself. Feet propped up, beer in hand, he finally confided that he might as well call the nurse tomorrow to hear what she had to say because he couldn't make head or tails out the test results. He said if he looked any more at what the Web was telling him he would be convinced that his lab results said he was most likely going through menopause and suffered from dwarfism.


Sure enough the next day when he called the nurse she said his test results were normal and she answered all of his questions regarding what he thought were some slightly high/low numbers. For all purposes he was healthy and normal.


Not only was he normal physically, but I think he was more normal than you realize. According to the Pew Research Center, he did what 8 million other consumers did, he consulted Dr. Google. Unlike many other American consumers, he had three health care professionals in the family, yet he still chose to go online and do health research for a few hours rather than picking up a phone and calling nurse mom for a few minutes.


This made me sit back and think a little bit. Did having access to his online patient health record make my husband a better informed patient or did it just muddy the waters? In fellow medical librarian blogger, EagleDawg's post on the acronym craziness, she feels the big question is whether patients even really care about PHRs. She directs us to The Health Care Blog's post, Google Health and the PHR: Do Consumers Care?, which states "What’s missing from all of these conversations is the elephant in the room: Do consumers really care about having online personal health records?" Prior to his doctor's visit my husband didn't care about having access to his online medical record. I think if you asked him, it didn't even make it to the bottom of his list of priorities. However, when there was something on there that confused him, it certainly shot to the top. Not having patient educational resources available to explain the results just created more anxiety and work than if he didn't have online access and had to wait to call the nurse.


Which brings us back to EagleDawg's comment about medical librarians and the EMR/EHR/PHR, "I think medical librarians need to have an increased role in EMRs, EHRs & PHRs because I'm not convinced other entities are looking at things from the perspective of patients as more than sources of data and revenue. We are experienced not only in information organization, but in information-seeking behavior and consumer health literacy and I'm not hearing much about how these are being incorporated in PHRs or patient-accessible EMRs and EHRs." The EMR and PHR area is still very new. I think we are going to see some competitors dropping off or being absorbed in the following years. But, because it is a new area, it makes it even more important for designers as well as medical librarians and consumer health librarians to work together to provide a record that minimizes confusion and maximizes patient involvement and understanding. Access to quality patient education materials within the record is part of that equation. Doctors already complain about patients self diagnosing through Dr. Google, an online PHR without any patient ed. resources is just going to make it worse not better for the patient as well as the doctor.

Labels: EMR, PHR

Here is what I think might be an interesting article for everyone who is interested in the EMR and how the library fits in.

Integrating Knowledge-Based Resources into the Electronic Health Record: History, Current Status, and Role of Librarians. Albert, Karen. Medical Reference Services Quarterly 26(3) 2007 1-19. (subscription required for full text)

Abstract:
Satisfying clinical information needs remains a major challenge in medicine, underscored by recent studies showing high medical error rates and suboptimal physician adherence to evidence-based practice guidelines. Advanced clinical decision support systems can improve practitioner performance and patient outcomes. Similarly, integrating online information resources into electronic health records (EHRs) shows great potential for positively impacting health care quality. This paper explores the evolution and current status of knowledge-based resource linkages within EHRs, including the benefits and drawbacks, as well as the important role librarians can play in this process.

Oooh I have got to get my hands on this article. I really think the next step for librarians is to expand their services by providing point of care resources that can be integrated in the EMR. Unfortunately, I think many librarians are spinning their wheels trying to figure out how to get involved.

Labels: EMR, Technology

I have gotten a few inquires from other librarians about library resources embedded or linked through the EMR. I confess this topic has been bouncing in my head for the past year or two and just now am I starting really look at to see what is being done and what is out there.

I don't have any answers but I found some interesting articles that I need to read through to become more aware of the issue and I thought I would share the links I have found. The most relevant I found so far is the article by Karen Albert. The other articles listed below look at the use of info buttons and the need for information resources (Medline, full text articles, etc.) at the point of care.

If you know of any good articles, resources, people, etc., about this topic, please feel free to share them through the comments.

Albert, Karen, "Integrating Knowledge-Based Resources into the Electronic Health Record: History, Current Status, and Role of Librarians." Medical Reference Services Quarterly. Vol. 26(3), Fall, 2007 (in press). (subscription required)

Abstract:

Satisfying clinical information needs remains a major challenge in medicine,
underscored by recent studies showing high medical error rates and suboptimal
physician adherence to evidence-based practice guidelines. Advanced clinical
decision support systems can improve practitioner performance and patient
outcomes. Similarly, integrating online information resources into electronic
health records (EHRs) shows great potential for positively impacting health care
quality. This paper explores the evolution and current status of knowledge-based
resource linkages within EHRs, including the benefits and drawbacks, as well as
the important role librarians can play in this process.

Humphreys, Betsy L. "Electronic health record meets digital library: a new environment for achieving an old goal." J Am Med Inform Assoc. Sep/Oct 2000, Vol. 7 Issue 5, p444-452. (free full text)

Abstract:

Linking the electronic health record to the digital library is a Web-era reformulation of the long-standing informatics goal of seamless integration of automated clinical data and relevant knowledge-based information to support informed decisions. The spread of the Internet, the development of the Web, and converging format standards for electronic health data and digital publications make effective linking increasingly feasible. Yet many challenging informatics
research problems must be solved before flexible and seamless linking becomes a reality, and before systems become capable of delivering a specific piece of information needed at the time and place that a decision must be made. Connecting electronic health record to the digital library also requires positive resolution of important policy issues, including privacy, high-speed communications, electronic intellectual property rights, and standards for health data and for digital libraries. Research problems and policy issues should be important priorities for the field of medical informatics.

Cimino JJ, Li J, Graham M, Currie LM, Allen M, Bakken S, Patel VL. "Use of online resources while using a clinical information system." AMIA Annu Symp Proc. 2003;:175-9. (free full text)

Abstract:

Clinical information system (CIS) use is likely to evoke information needs, yet
information resources use during CIS use has not been studied. METHODS: We used CIS log files and a survey to characterize clinicians' use of resources and infobuttons (context-sensitive links from a CIS to specific resources) while using a CIS. RESULTS: We examined 38,763 uses of resources and infobuttons by 2,607 users to identify specific sources and contexts (CIS functions) in which they used them. Laboratory results review was the most frequent context and Micromedex was the most popular resource. Differences in resource use were related to context and user type. The survey confirmed that resources and infobuttons were perceived as useful for patient-specific questions while using a CIS. CONCLUSIONS: Understanding context- and user-type-specific information needs can guide the development of infobuttons for use in a CIS.

McGowan JJ, Overhage JM, Barnes M, McDonald CJ. "Indianapolis I3: the third generation Integrated Advanced Information Management Systems." J Med Libr Assoc. 2004 Apr;92(2):179-87. (free full text)

Abstract:

In 2001, the Regenstrief Institute for Health Care and the Indiana University School of Medicine (IUSM) began an IAIMS planning effort to create a vision and a tactical plan for the first Integrated Advanced Information Management Systems (IAIMS) implementation to cross a large area and include unaffiliated institutions. A number of elements made this planning effort unique. Among these elements were the existence of a network infrastructure that supported the
Indianapolis Network for Patient Care, the existence of a mature medical informatics program at the Regenstrief Institute, and the existence of a wide-area knowledge network fostered by the IUSM libraries. However, the leadership for a strong information technology role in the IUSM that could promote collaboration in support of education and research across the diverse Indianapolis hospital systems had been lacking. By bringing together various groups, each with a commitment to improve health care quality and public health across the Indianapolis metropolitan area, regardless of individual institutional affiliation, the strategic directions for I3-Indianapolis IAIMS initiative have been defined and the foundations for a third generation IAIMS construct have been laid in Indianapolis, Indiana.

Maviglia SM, Yoon CS, Bates DW, Kuperman G. "KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs." J Am Med Inform Assoc. 2006 Jan-Feb;13(1):67-73. Epub 2005 Oct 12. (free full text)

Abstract:

OBJECTIVE: Infobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. The objective of this study was to determine whether infobuttons effectively answer providers' questions about medications or affect patient care decisions. DESIGN: The
authors implemented and evaluated a medication infobutton application called KnowledgeLink. Health care providers at 18 outpatient clinics were randomized to one of two versions of KnowledgeLink, one that linked to information from Micromedex (Thomson Micromedex, Greenwood Village, Co) and the other to material from SkolarMD (Wolters Kluwer Health, Palo Alto, CA). MEASUREMENTS: Data were collected about the frequency of use and demographics of users, patients, and drugs that were queried. Users were periodically surveyed with short questionnaires and then with a more extensive survey at the end of one year. RESULTS: During the first year, KnowledgeLink was used 7,972 times by 359 users to look up information about 1,723 medications for 4,961 patients. Clinicians used KnowledgeLink twice a month on average, and during an average of 1.2% of patient encounters. KnowledgeLink was used by a wide variety of medical staff, not just physicians and nurse practitioners. The frequency of usage and the questions asked varied with user role (primary care physician, specialist physician, nurse practitioner). Although the median KnowledgeLink session was brief (21 seconds), KnowledgeLink answered users' queries 84% of the time, and altered patient care decisions
15% of the time. Users rated KnowledgeLink favorably on multiple scales, recommended extending KnowledgeLink to other content domains, and suggested enhancing the interface to allow refinement of the query and selection of the target resource. CONCLUSION: An infobutton can satisfy information needs about medications. Although used infrequently and for brief sessions, KnowledgeLink was positively received, answered most users' questions, and had a significant impact on medical decision making. The next steps would be to broaden the domains that KnowledgeLink covers to more specifically tailor results to the user type, to provide options when queries are not immediately answered, and to implement KnowledgeLink within other electronic clinical applications.

Labels: EMR