The Virtual Patient Record

Note: This article is the personal opinion of the author and does not necessarily represent the views of ProCare Health Limited.

• Abstract
• Introduction
• The "Holy Grail" of EHR
• Building on existing information models
• Moving towards the Virtual Patient Record
  • Works within the applications already used by clinicians
  • Targets a specific set of patients
  • Requires patient enrolment
  • Targets specific clinical information
  • Achieves well understood clinical outcomes
  • Targets specific clinicians
  • Governed and led by primary care
• Extending the VPR to other contexts
• Conclusion
• Case Study: Marie’s Story
• References

Abstract
This paper presents a proposal that the Electronic Health Record (EHR), as typically portrayed by academics, is unlikely to be practically achieved and provides the rationale for this thinking. It represents the views of the Author only.

Introduction
The suggestion that a comprehensive Electronic Health Record (EHR) is unlikely to be practically achieved may be regarded as heresy in some circles, but there is sound rationale for such thinking. This paper introduces an alternative proposal that the goals of a comprehensive EHR are more likely to be achieved through a series of more narrowly scoped projects that:

• work within the applications already used by clinicians
• target specific patients
• require patient enrolment
• target specific clinical information
• achieve well understood clinical outcomes
• target specific clinicians
• are governed and led by primary care.

Additionally, it is proposed that the goals of a comprehensive EHR are more likely to be achieved through improved electronic communication between providers than through a centrally held and managed database.

This concept is generically referred to in this paper as the "Virtual Patient Record" (VPR).

The "Holy Grail" of EHR
When one first researches the concept of deploying an EHR, it is typically described in terms that could be referred to as the "holy grail" of EHRs. This model of EHR holds all medical information about a patient, is contributed to by every clinician involved in the patient’s care, and is deployed for every patient. For a clinician to access the record, they must go onto the internet, enter a patient’s ID and, voilà - everything about that patient is instantly available.

Proposals for EHRs typically suggest that there would be improved health outcomes for patients by virtue of clinicians having a comprehensive view of patient data^{[ 1 ]}, without necessarily being specific about how this would be achieved. EHR development projects quickly encounter difficulty (not surprisingly) when examining the issue of how to ensure that all relevant information is systematically, comprehensively and consistently recorded.^{[ 2 ]}

I propose, instead, a different approach - a starting point that would actually be achievable and, perhaps, could one day be the basis of an EHR that meets a purer definition of what an EHR should be. From this point progress could be made and it would be possible to learn from mistakes through a working system that was delivering well understood benefits to both patients and clinicians.

The proposed starting point is the "Virtual Patient Record" (VPR). This would not be a central repository where all a patient’s medical information is stored. It would instead be a virtual world where all clinicians involved in a specific patient’s care could receive and contribute information relevant to the other clinicians in the context of a specific care plan. It is a model oriented more to transferring information between clinicians than building a portal or a database that captures and stores all patient data.

This concept of a VPR is described in more detail below. However, it is valuable to precede this with an acknowledgement of the successful precursors to the EHR that may make the VPR achievable in New Zealand.

Building on existing information models
In the secondary care context, the EHR is often proposed as a way of bringing together patient information from many different silos and presenting the clinician with a single, consolidated view of a patient. For example, the clinician needs to see pathology, radiology, ward notes and medications in a single view. Some very good software has been designed to solve this problem and is now available for secondary care use. New Zealand can be proud to have some leading edge implementations of this technology. ^{[ 3,4 ]}

In the primary care context, we in New Zealand are fortunate to have a choice of sophisticated practice management systems that are world class. Many general practices in New Zealand are now fully computerised and are paperless to such an extent that incoming paper-based correspondence is scanned and electronically filed in a patient’s notes (which is often very frustrating when it is known that the paper document has been produced in an electronic form but sent via conventional mail).

Further, GPs are very often perceived by patients as the logical person to hold all relevant medical information. Typically, a general practice team is involved to some degree in all significant medical events that take place during the life of the patient although, increasingly, this may change over time due to the growing role of other primary care providers such as nurse practitioners, independent midwives and practitioners of alternative medicine. Even when the health care service provided to a patient is not being delivered by a general practice team, it is often delivered as the result of a referral by a GP and it is standard practice for the service to which the patient is referred to send information back to the referring GP with details of the outcomes of the service provided.

Accordingly, I would argue that the EHR, within the domain of a single GP, largely exists already and is alive and well in New Zealand. Some significant progress has been made over the last few years including, for example, hospital discharge summaries being sent electronically to GPs ^{[ 5 ]}. That is not to say that there are not still some significant holes to be plugged, and the health sector has much to gain if we can increase the quantity and quality of electronic communication from private specialists, community-based services (especially district nursing) and after-hours facilities.

The existence of the EHR within general practice also suggests that much of what we are looking to achieve using an EHR can sometimes be achieved more effectively using more traditional approaches. For example, when treating a patient who needs to see a cardiologist, the current process of making a referral and then receiving a letter from the cardiologist indicating the outcomes of the assessment are very effective. It is difficult to see how an EHR would add sufficient additional value to this scenario. In particular, the GP would have undertaken a formal process of summarising and reviewing a patient’s clinical information in a form relevant to the specific referral. For example, a cardiologist would not be interested in the recent treatment of an ingrown toenail (and if the GP considered that some aspect of this were relevant, then the GP could elect to include this information) and, similarly, the information sent by the cardiologist back to the GP would be that subset of information required by the GP for ongoing care and management of the patient’s heart condition.

Moving towards the Virtual Patient Record
A description of what a Virtual Patient Record (VPR) should be can be assisted by first suggesting what it is not. A VPR does not:

• include all medical information about a patient
• include all clinicians involved in a patient’s care
• apply to all patients.

A VPR is more likely to be achieved if it demonstrates the following essential characteristics. For an example of how these characteristics could be practically applied, refer to "Marie’s Story" shown below.

Works within the applications already used by clinicians
Many EHR proposals require the clinician to go "outside" the application software they normally use to access the EHR. To do this, the clinician must first be aware that an EHR exists for the patient under consideration and, secondly, must routinely find in that EHR information that is relevant and not previously known in order to make the effort expended leaving the clinician’s usual context worthwhile. Our experience in implementing the "Prompt" decision support tool for the screening and management of cardiovascular disease has been well accepted by our members and we are of the view that one of the significant reasons for this is its level of integration within their existing systems.

ProCare, has been involved with the implementation of an EHR with Counties Manukau District Health Board for the secondary prevention of cardiovascular disease. (ProCare is a Primary Care Organisation in New Zealand; PCOs are health service structures that provide primary health care to an enrolled population; District Health Boards (DHBs) in New Zealand combine the health care purchaser and provider functions.) Information from this system, known as the "Integrated Care Server") is available to secondary care clinicians, but have encountered a significant problem whereby the "hit rate" of finding a patient that has additional information available is so low that the clinician quickly gives up finding the process frustrating and time-consuming.^{[ 6 ]}

With a VPR, information about patients is integrated into a clinician’s normal workflow and application so that, in some cases, a clinician may not even be aware that the information has been provided by other practitioners working in a different facility using a different application. Similarly, information contributed by the clinician is entered in the clinician’s normal application. The clinician may need to be reminded that the information recorded is also being made available to others who would not normally have direct access to the clinician’s own system.

This requirement applies regardless of who the clinician is - GP, specialist, or social worker.

Targets a specific set of patients
To make the existence of a VPR more predictable, a VPR should be used only for that group of patients where explicit and significant benefits can be expected from the sharing of information between clinicians. This ensures that:

• clinicians and patients receive value commensurate with the effort required to change their normal way of working
• a high level of passion from those involved in the development of such a project
• the information required can be more easily agreed.

By contrast, if we do not target specific patients and instead involve all patients that access health care, the goal becomes too difficult to define and communicate with the consequent loss of buy-in from those who must provide and use the information.

Although it is not difficult to make a case for sharing more information between clinicians regardless of patient, I am of the view that priority should be given to patients who have chronic conditions that involve complex, shared care between several clinicians. For these patients, clinicians involved in their care are already ensuring that information about care is communicated, even if this takes the most basic form of correspondence or, better still, through the processes of electronic referral and discharge.

To achieve this, only a "small step" (relative to full scale EHR implementation) would be needed to change existing referral and discharge message formats from free-text to structured data. For example, discharge summaries currently being received from secondary care providers include medications prescribed, but not in a structured format that can be read and interpreted by other systems.

Requires patient enrolment
In order for a system based on VPRs to be successful, patients would have to formally enrol in a programme specifically designed to improve their care. Many such programmes already exist within Primary Care Organisations (including ProCare), including projects for the management of diabetes, secondary prevention of cardiovascular disease, smoking cessation and the management of ischaemic heart failure.^{[ 7 ]}

When patients enrol in such a programme, they are able to consent to relevant information about them being shared and to agree with their GP the clinicians that should receive and contribute information to their VPR. In many cases, a patient’s GP may act as an agent for the patient in identifying appropriate clinicians and ensuring that these clinicians participate in the process. This is, of course, a process that happens right now albeit in the context of a paper-based referral.

Targets specific clinical information
The information contributed to a VPR must be relevant and accurate. This is unlikely to be the case unless all parties clearly understand what information is relevant and should be included and clear stewardship is assigned to the maintenance of this information.

Creating a VPR specific to the management of a patient’s diabetes (or acute lower back pain or ischaemic heart failure, etc) makes the job of specifying the information to be collected and transferred much easier and allows all parties to understand the need for data to be structured and verified.

This view is also supported by the WAVE project ^{[ 8 ]} that also proposes that a tightly-defined project is more likely to gain acceptance and be used.

Achieves well understood clinical outcomes
Buy-in from all clinicians that contribute to and use a VPR is an obvious requirement, for an electronic patient record that is not used becomes yet another information systems casualty. Successful implementation is more likely, therefore, if the benefit for the patient that could be attributed to the use of the VPR were precise and quickly realised. The "holy grail" EHR is, by definition, imprecise and almost requires an element of luck to allow a clinician to come across situations where the EHR would provide immediate benefit that would not have otherwise been realised through other avenues. By contrast, a VPR designed specifically to improve the management of severe diabetics would be more likely to allow precise identification of the clinical benefits and, thus, it would be significantly easier to obtain clinicians’ support for implementation.

When managing acute lower back pain, significant benefit could be realised simply from knowing which clinicians were involved in a patient’s care and presenting a consistent view of what outcomes were expected from each clinician.

Targets specific clinicians
Accepting that in most cases a VPR would, by definition, be designed to be contributed to and used by multiple clinicians, this would nonetheless create a significant barrier to implementing the VPR quickly and easily given the widely differing views on how such a concept should be implemented, the information to be contributed, and the technical architecture to be used. Given that an interface for multiple systems using inconsistent coding structures and data would have to be included, the way patient information was to be collected and stored would have to be methodically designed in each case. Then, having agreed on a standard for transferring the data (as opposed to storing the data), one would have to develop sophisticated data collection and manipulation applications to interface with the various computer systems that would be contributing information to and using information within the VPR.

When ProCare implemented a decision support tool for the management of cardiovascular risk^{[ 3 ]}, it was very time consuming (but worthwhile) to obtain consensus from the various clinicians involved about what information was relevant to the management of cardiovascular risk, and this suggests that this is also likely to be an issue when designing an EHR.

Accordingly, I am of the view that for the first generation of VPRs, we should choose to constrain their use to a select group of clinicians that agree to participate. This does restrict the patient’s choice of clinician for those programmes that utilise a VPR. Accordingly, the benefits of restricting their choice of clinician will need to be clearly explained to the patient.

And as mentioned above, if combined with patient enrolment in a specific managed care programme, it would become acceptable to direct patients to those clinicians that have agreed to contribute to and use the VPR associated with the programme in which the patient is enrolling.

Governed and led by primary care
Implementation of most VPRs would require significant data contributions and use by primary care clinicians. Further, much of the information required for a VPR would originate from or be sent to a patient’s GP. As proposed above, the GP might also be acting as an agent for the patient to determine which clinicians should contribute to and make use of the VPR.

In New Zealand, a number of well-intentioned projects are attempted that do not have the support of the primary care clinicians. I am of the view that for a successful VPR implementation (and, for that matter, any other project where primary care clinicians are significantly involved) the project must be owned by primary care itself, rather than the weaker option of consultation or other forms of engagement.

Extending the VPR to other contexts
It is not difficult to extend the VPR concept to include other providers involved in a patient’s routine care. For example, after-hours facilities could be included if the specific programme in which the patient has enrolled would require services to be provided outside of normal practice hours for the convenience of the patient, or where special equipment or facilities are required that are not normally available within a general practice.

A VPR could be extended to ensure that the patient was able to view the information that makes up the VPR and, interestingly, perhaps this could be the precursor and catalyst to creating an EHR based on the VPR. It may also be relatively easy, since the scope of the VPR could be constrained to the information relevant to patient self-management and would need to involve only those clinicians and patients who would add value to this opportunity.

Conclusion
An EHR that would hold all medical information about a patient available to all clinicians is, in my view, unachievable in the foreseeable future. It is, quite simply, too hard. Further, the advantages of a comprehensive EHR compared to more traditional information transfer are difficult to define. By definition, it requires all clinicians to participate and all medical information to be systematically contributed and recorded. Should this ever be achieved, then I speculate that it would be as a result of the coming together of many smaller projects that create a VPR which would then evolve and transmogrify into an EHR.

Marie’s Story
The following is a fictional example of how a VPR might work in practice, using the principles outlined in this paper.

Marie is a 37-year-old female who has recently been discharged from hospital after treatment for a heart attack. Dr Westgate, her ProCare doctor, suggests she should consider enrolling in ProCare’s Heart Care project, which has been specifically designed to optimise care for people at risk of further cardiovascular events. Dr Westgate explains that, as a condition of enrolling, she would agree to have relevant information about her condition shared by the health care providers involved in managing her heart condition.

Dr Westgate recommends that, as a starting point, she would be referred to the cardiologist involved in the programme, a Dr Richards, and with Marie’s agreement, immediately arranges the preparation of a structured version of her clinical notes containing relevant details of her past history and current medications. This is then sent electronically to Dr Richards’s practice and to ProCare’s heart-care nurse, who calls Marie later in the day to see if she has any questions about the programme.

When Marie visits Dr Richards the following week, Dr Richards reviews her medication and makes a few minor adjustments. These adjustments are automatically transferred to Dr Westgate and updated within his practice management system along with the reasons why Dr Richards changed the medication.

Dr Richards also notes that Marie is overweight and would benefit from seeing a nutritionist. Marie has tried unsuccessfully to lose weight before and feels that right now she couldn’t cope with another attempt because she is a solo mother, already barely managing at home with three young children, and doesn’t know how she’d cope with attempting to lose weight right now. On hearing this, Dr Richards and Marie agree that she should receive a visit from the local Community Health Coordinator to ensure that she receives all the help she needs so that she can focus on getting her health under control.

The Community Health Coordinator visits Marie in her home and makes a series of recommendations about the help she needs and begins to coordinate this for her. The Community Health Worker sends a note to Dr Westgate to inform her of her findings and the plan she has put in place, which is automatically filed in Dr Westgate’s practice management system.

References

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2. Hall J, Tomlin A, Martin I, Tilyard M. A general practice minimum dataset for New Zealand. NZMJ 11 October 2002; 115(1163).
3. Ministry of Health. Sharing Excellence in Health and Disability Information Management. Aug 2003.
4. Clarke D. Integrated Care with minimum project risk. Medicamundi Aug 2002; 46(2).
5. Cae Study: A Technology Partnership Delivering Results Orion Health Publications.
6. Rowe I, Brimacombe P. Integrated care information technology. NZMJ 21 February 2003; 116(1169).
7. Refer list and description of ProCare services.
8. 8. Ministry of Health. From Strategy to Reality: the WAVE Project. October 2001.