The promise of EMRs to improve the efficiency and quality of care makes their universal adoption a matter of when, rather than if.
From EMS to EMR
For the most fortunate STEMI and heart failure (HF) patients, the EMR is being deployed to catalyze their care beginning with the arrival of emergency medical services (EMS). At select heart centers, upon STEMI patient arrival, EMRs are opened and the hospitals’ cath lab teams are activated by EMS’s electronic transmission of ECGs, which are added to EMRs as PDF files.
“Electronic transmission of data is very effective in enabling us to achieve 90-minute door-to-balloon times on a regular basis,” says Craig S. Smith, MD, director of the coronary care clinic at the University of Massachusetts (UMass) Heart and Vascular Center of Excellence in Worcester, Mass. “We’ve driven down hospital heart attack mortality rates and improved compliance with our overall quality metrics.”
Ambulance call reports, including everything from blood pressure and initial exam results, drugs administered in the field, patient history and critical time intervals may be uploaded electronically into the EMR at certain institutions. But with 50 or more ambulance companies serving a single hospital, standardization has lagged.
“Once patients hit the emergency department (ED), just about everything gets entered into the EMR,” explains Smith. The process, however, is not immediate. ED doctors quickly confirm the paramedics’ diagnosis of STEMI and jot down notes in the patient’s chart. As with the cardiologists’ progress notes that are dictated post-procedurally, these data also are entered into the EMR only after it has been scanned by medical records—sometimes weeks later.
When it matters most, the EMR turns out important advantages. With lab and test results, pressure readouts, medications and allergies immediately accessible to cardiologists alongside the patient’s history, “patient care is improved,” according to Timothy Henry, MD, director of research at the Minneapolis Heart Institute in Minneapolis.
In some cath labs, entire reports are completed electronically, including information on blockages, lesions, blood pressure and heart rate, as well as test results and procedure details and outcomes. Medications, stents and other equipment may be scanned straight into the EMR via barcodes or noted by physicians and nurses for direct post-procedure entry.
At Ottawa Heart Institute, the EMR and cath reports have been customized and integrated so cardiologists cannot sign off without entering “many details and completing many mandatory fields,” says Michel Le May, MD, director of the coronary care unit and regional STEMI program at Ottawa. Whereas reports would previously consist of short and commonly illegible notes, and could sit for months unsigned with important details omitted, due to their use of the EMR, “you just don’t see that anymore.”
The EMR is beginning to transform how STEMI and HF patients are monitored by making information more accessible and better communicated, even with small changes. Attending physicians bring computers on wheels to patients’ bedsides, where they can more quickly access patient information. Meanwhile, UMass has begun round-the-clock monitoring of cardiac intensive care patients. The critical care specialists and physicians have remote access to patients’ EMRs, including real-time updates of ECG, labs and medications.
As payors become increasingly unwilling to reimburse for HF readmissions within 30 days, home monitoring of HF patients is becoming more sophisticated. HF patients referred to SunCrest Home Health in Madison, Tenn., are equipped with devices to measure their blood pressure, oxygen saturation and heartbeat for arrhythmia, as well as smart scales, according to Karen M. Garfield, RN, director of clinical development for SunCrest. “These devices transmit patient information wirelessly or via phone lines to SunCrest, where 180 telehealth patients are monitored by a staff of critical care nurses.” Garfield says the program has reduced HF readmissions by 50 percent.
The EMR costs, but does it pay?
A host of obstacles stand in the way of tailoring the EMR to reach its potential or even to exploit the above uses on a broader scale. “Cost is an issue that needs to be answered in a very serious and rigorous way,” says Clyde W. Yancy, MD, immediate past president of the American Heart Association and medical director