October 2006

This is the second of three articles on electronic health records (EHRs) at the Palo Alto Medical Foundation (PAMF).

Imagine a physician has many patients with diabetes. Before electronic health records (EHRs), physicians would not have the time to comb through hundreds of paper medical charts to find diabetic patients who were overdue for a test, or identify patients at risk of developing diabetes to help them take preventive measures to ward off the disease. However, this is just one example of the way physicians at PAMF are currently using EHRs to provide cutting-edge care to patients.

"The focus for the first few years was simply on making the conversion from paper to electronic medical records, and implementing the basic functionalities, such as ordering tests and medical supplies, and receiving patients' lab results," said Laurel Trujillo, M.D., medical director of clinical innovation and chair of the Quality Improvement Tool Specification Subcommittee (QuITSS), which is examining ways to improve and expand the decision support tools made available to physicians within the EHR. "In the past several years, we have moved to optimizing the EHR to improve patient care and care processes."

One of the tools that is helping optimize the EHR is the Health Maintenance Tab, which uses a patient's personal medical history and nationally recommended guidelines for screening exams to determine if and when a patient needs a test, such as a Pap smear, mammogram or colonoscopy, or a routine test for a chronic medical condition. When a patient is due for such a test, the physician will be alerted. (If enrolled in PAMF's complimentary e-health service, PAMFOnline, the patient will also receive a reminder.)

"With paper medical charts, physicians could really only respond to their patient's health problems reactively -- treating the symptom when it became bad enough to warrant an office visit," said Albert Chan, M.D., a family medicine physician at the Redwood Shores Health Center and member of QuITSS. "I chose to practice medicine at PAMF specifically because of its EHR system. With EHRs, doctors can focus on prevention because they have the tools they need to instantly search through hundreds of patient files, and identify patients who need tests and other interventions."

In fact, one of the decision support tools PAMF is working to expand is its Best Practice Alerts, which provide evidence-based recommendations to physicians when caring for patients with certain diseases.

For example, a patient's EHR may indicate that he or she has congestive heart failure. Clinical evidence has shown that many individuals with this condition do well on beta blocker and ACE inhibitor drugs. Therefore, if a patient has this condition and is not currently taking these medications, the physician will receive an alert suggesting this type of treatment. PAMF is also working to expand the list of medications identified in the EHR, as some medications may not have expiration dates or their trade names are not recognized by the EHR. These details could prevent the system from detecting a potentially dangerous drug interaction -- one of the most useful aspects of EHRs.

"Instead of just being an electronic medical record, the EHR becomes an interactive tool to help physicians provide care," said Susan Smith, M.D., a family medicine physician and chair of the Quality Improvement Steering Committee, of which QuITSS is a part.

The EHR system does more than just help physicians; it also makes available PAMFOnline. Patients can use the Web-based health service to view test results and key portions of their PAMF electronic health record, request appointments and prescription renewals, receive health information and communicate electronically with their physicians in a secure setting.

"We're looking at ways to offer more services to more people, and expanding the online tool sets encourages patients to ask questions and take a more proactive role in their own health care," said Steven Lane, M.D., MPH, a family medicine physician and medical director of Health Information Management. For instance, PAMFOnline also has two new programs that allow adults to log into the PAMFOnline accounts of children or adult loved ones for whom they are overseeing health care.

"The quality of care (under EHRs) has improved dramatically because patients' information is more accessible," said Dr. Smith.

Quality has also improved through the addition of new technologies supported by the EHR system, such as PAMF's secure electronic image and data archiving system, called PACS (Picture Archiving and Communications System). PACS stores and handles patient imaging studies, such as X-rays, from all of PAMF's Radiology departments.

The PACS system is faster and produces better-quality images than old film systems. Images are immediately available for X-ray technologists, radiologists and ordering physicians to see. Storing the images electronically also makes them available whenever and wherever they are needed, thereby improving physicians' ability to provide care in a timely fashion.

When PAMF first introduced EHRs, there was a sense that there would be a distinct beginning and end to the process of implementing the system, according to Dr. Lane. However, he said, "We're continually evolving the current EHR applications to improve patient care and the ways physicians deliver that care. EHRs have made us look at health care in a new way."

Dr. Trujillo agreed. "We'll never be done," she said. "It's a learning process, and there are always ways to improve."