Major Findings: Electronic medical records are essential to make pediatric medical homes a success, but systems for pediatricians fall short.
Source of Data: Expert commentary.
Disclosures: Dr. Johnson reported that he receives royalties from ICA Corp.
WASHINGTON — Pediatricians cannot truly provide an advanced medical home for their patients until they implement fully functional electronic medical record systems.
Although the current systems must still be improved to meet the needs of pediatricians, research is steadily accumulating that demonstrates the benefits of EMR systems for the specialty, Dr. Kevin B. Johnson said at the annual meeting of the American Academy of Pediatrics.
Papers published in the pediatric literature have shown, for instance, that integrated guidelines resulted in better guideline compliance, that physician-patient communication during visits was positively—not negatively—affected by computer-based documentation, and that electronic immunization tracking helps with case finding and improves coverage.
And for meeting the objectives of the medical home, EMR systems just make sense. “The most recent [national] conversation about the advanced medical home definitely thinks about the EMR as a key component of the infrastructure we need,” said Dr. Johnson, a pediatrician who is vice chair of the biomedical informatics department at Vanderbilt University Medical Center in Nashville.
The advanced medical home requires the use of EMRs that store and offer immediate access to all clinical data and test results, for instance, and that provide clinical decision-making support and links to other consultants and health care professionals.
EMRs also should provide the communication and scheduling systems that are needed for ongoing access to care and nonurgent advice, as well as open access scheduling (well-child care appointments in 1–2 days versus weeks, and more than 50% of appointments open each day).
“There is a lot of communication required in the medical home,” he said.
Communication is one area where currently available EMR systems fall short, however, and it's an area that pediatricians must speak up about, Dr. Johnson said. “Most systems don't [meet all our needs] because frankly [the vendors] don't understand what we want.”
When Dr. Johnson queried the AAP's “EMR review” Web site for perspective submitted over the past 2 years, he found other areas for improvement.
Sixteen percent of the 32 pediatricians who submitted information relevant to his query were not happy, for instance, with the immunization data handling/analysis capabilities on their systems. The same number—16%—said that growth parameters were not satisfactory, and 28% were not satisfied with their system's developmental milestone decision support.
“Your job,” he told the pediatricians, “is to help the systems get better.”
Dr. Johnson encouraged pediatricians to post reviews to the AAP's EMR Review Project Web site, which can be found at www.aapcocit.org/emr
National data indicate that about 15% of all practices have a basic EMR system (with patient demographics, problem lists, prescription orders, medication lists, clinical notes, and the ability to view lab results and images), whereas only 6% have a “fully functional” EMR system that allows them to send lab and radiology orders, for instance, and has evidence-based decision-making support.
“From what we know about pediatric primary care, the numbers are about the same,” Dr. Johnson said.
Pediatricians often tell him that they have a computer-based documentation tool but are hesitant to use it during visits because they “fear that it impacts patient-provider communication,” he noted.
In a study published last year, however, Dr. Johnson and his associates at Vanderbilt analyzed pediatric visits that were audiotaped or videotaped and found that any differences in communication dynamics between visits involving paper documentation and visits involving computer-based documentation “were in favor of computer-based documentation.”
The amount of conversation was slightly higher for visits involving computer-based documentation, for instance, as were the number of open-ended questions and “rapport-building statements” (Pediatrics 2008;122;590–8).
Numerous other studies have suggested that the use of computers in the exam room is not associated with worsening satisfaction, and his experience at Vanderbilt suggests that “parents love the technology,” said Dr. Johnson.
The advanced medical home requires the use of EMRs that store and offer access to all clinical data.
Source DR. JOHNSON