By Howard Mevis

A productive, busy orthopaedic practice relies heavily on digital technology in the provision of patient care. In implementing an electronic medical record (EMR) system, orthopaedic surgeons need to be mindful not only of data security and data storage/infrastructure issues, but also of the system’s impact on patient communications, its ability to interact with other systems, and its limitations.

Patient communications
As orthopaedic practices become more familiar with digital technology and using the Internet, the use of online patient portals to improve productivity, practice efficiency, safety, and communications will increase. A patient portal can become one of the practice’s most valuable productivity and communication tools.

According to Louis F. McIntyre, MD, chief of orthopaedics at Westchester Orthopaedic Associates in White Plains, N.Y., a well-organized patient portal can reduce or eliminate unnecessary patient visits, improve patient adherence to treatment through regular communications, and create 24/7 availability. Patients will be able to submit questions and receive responses through a secure portal, explained Dr. McIntyre during at the EMR and Other Technologies course.

When integrated with your EMR system, a patient portal can enable patients to schedule appointments, request pharmaceutical refills, access records, pay bills, and review lab results. It creates shortcuts enabling the practice to meet some of the EMR meaningful use requirements established by the Centers for Medicare & Medicaid Services (CMS).

Security is a major concern for patient portal usage. Regulations under the Health Insurance Portability and Accountability Act (HIPAA) specify what patient information must be held in confidence. Therefore, a portal should include access controls to validate log-in, usually with a name, password, and another form of authentication.

In the future, patient portals will facilitate e-visits, especially for patients who live long distances from the practice. Imagine getting paid for managing a patient with back pain through an e-visit!

Health information exchangesState and regional health information exchanges (HIEs) will also present technology challenges for orthopaedic surgeons in 2011. The goal of each HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, and equitable patient-centered care.

HIEs will facilitate data exchange between different data systems, creating pathways for the exchange of patient information data between physicians and between physicians and hospitals. Timely and accurate data exchange promotes patient safety and reduces the need to repeat tests, thus reducing healthcare costs.

Currently, most orthopaedic surgeons receive patient information from another physician in the community via a paper chart, photocopy, or fax. Data in an EMR system could be transferred electronically, if the sending system and the receiving systems are compatible—a big IF.

To exchange data, an HIE intermediary will be necessary. The Health Information Technology for Economic and Clinical Health (HITECH) Act included about $550,000,000 in funding to establish 56 HIEs across the nation. HIEs may be publicly or privately funded and may operate statewide, or within a region, metropolitan statistical area, or even a hospital system—and they may overlap each other.

A recent internal study by one HIE set the cost of paper data exchange at about $17,000 per physician annually. But eliminating paper won’t eliminate the expense of exchanging data, because there will be charges to participate in statewide or regional HIEs.

Under the auspices of the CMS Office of the National Coordinator, the government is seeking to meet the following goals:

• Create and implement up-to-date privacy and security requirements for HIEs
• Coordinate with Medicaid and state public health programs to establish an integrated approach to data exchange
• Monitor and track meaningful use HIE capabilities in each state
• Establish a strategy to meet gaps in HIE capabilities
• Ensure consistency with national standards

To meet these goals, HIEs will require a universal exchange language that facilitates the transfer of health information while protecting patient privacy. A recent report from the President’s Council of Advisors on Science and Technology concluded that a universal language could give patients more control over their medical information that is disseminated and used in an automated fashion.

HIEs will need to develop rapidly for physicians to meet meaningful use criteria in stage 2 (2013) and stage 3 (2015) EMR implementation. Now is the time to begin making connections with HIEs.

EMR limitations
No matter how good an EMR system is, it will have limitations that present technology issues for orthopaedic surgeons in 2011.

EMR systems do not work the way orthopaedic surgeons work. AAOS members who are currently using an EMR system know this to be true. Practices that are not yet using an EMR system will learn this reality soon after adopting one.

William Mallon, MD, a member of the AAOS EMR Project Team, is well aware of this issue. According to Dr. Mallon, EMR systems frequently have the following limitations:

• Terrible user interfaces—Most EMR systems are designed to capture data and do not have built-in applications that can help automate and improve a doctor’s workflows and time management.
• Inadequate data security—Although EMR systems do employ some data security techniques, most have no protections to ensure patient privacy or to enable patients to decide what health information is shared with whom and when.
• Nonexistent integration standards and capabilities—Most EMR systems are incapable of communicating with other systems.

EMR systems will need to evolve rapidly from this early generation—built upon the idea of a database—to applications that support the way doctors work as they interact with patients, colleagues, and staff. Some EMR vendors are realizing this and are creating systems that use extensible markup language (XML) and visual displays that facilitate physician work patterns. The day is coming when orthopaedic surgeons might say, “Now this works for me!”

In summary, orthopaedic practices will need to address five technology issues in 2011—data storage, data security, patient communications, interoperability, and technology limitations. The AAOS wants to know how members are meeting these challanges. Share your story in an e-mail to emrstories@aaos.org

Howard Mevis is director of the electronic media, evaluation programs, course operations, and practice management group. He can be reached at mevis@aaos.org