CorrectCare

The Litmus Test of Electronic Health Record Performance

by Joseph E. Paris, PhD, MD, CCHP-A

The push to “go electronic” gets stronger with each passing year. Although only a minority of prisons and jails has converted to an electronic health record system, the number of converts is growing. As an NCCHC surveyor of over two decades, I have been exposed to more than a dozen EHRs nationwide in facilities of different population sizes. As a surveyor I did not intend to gauge EHR efficiency, data completeness or general performance, but the need to survey computerized health records and logs did bring me into close contact with these systems.

Drawing from my experience with diverse, commercially available as well as home-grown correctional EHR systems, I was able to formulate a plan to quickly gather relevant clinical information. For surveys involving EHRs, I requested a staff person to be assigned to me for the whole survey, with the understanding that the assignment would fall on someone familiar with the EHR structure and thus capable of speedy review.

I reviewed weaknesses of certain individual EHRs in a previous issue of CorrectCare, pointing to workflow disruptions during conversion, inability to display multiple pages simultaneously, lack of tidy printed layouts, inability to flag and initial outside consultant reports, lack of a system to collect inmate signatures for consents or items received and general difficulty reading previous progress notes due to monotony of the layout.

This time, I will comment on common weaknesses of EHR systems when handling log-type or collective data belonging to all of the patients at a correctional institution.

It should be understood that I am convinced that EHRs are the way of the future and I do not advocate use of paper-based health records indefinitely. It is my hope that some of the lessons I learned reviewing correctional EHRs will be of value to correctional health care authorities considering the purchase of a new EHR system.

Data Tracking Logs
Correctional staff using paper records know that logs are needed to track some essential functions of their health care units. Logs in common use include intake screening, health assessments, sick call, consultations, chronic care, PPDs, annual and other physicals, labs, X-rays, grievances and the performance of age-dependent routine health care maintenance functions such as mammograms, Pap smears, stool hemoccults and the like.

Paper logs work well in institutions with fewer than 500 inmates and with low turnover, like most state prisons. Paper logs become unwieldy for large institutions, especially if turnover is brisk, as happens in most jails. In these, paper logs quickly become cluttered with “yellowed out” names of inmates no longer in the system. Interestingly, many a correctional system with paper records has evolved some home-grown computerized system for tracking some of the functions above listed. These are not integrated, however, and do not lead to the development of a unified EHR.

When surveying a correctional institution for accreditation, I usually ask the questions below regardless of whether EHRs or paper records are in use. These questions reveal essential aspects of the functioning of the health care system in effect.

As a side benefit, the same questions, which I term “litmus test,” can be used to gauge the functionality of a proposed EHR system before committing to its purchase.

Key Questions
The litmus test questions deal with sick call, consultation, chronic care, PPD, physicals, lab, X-ray, grievances and the performance of age-dependent routine health care maintenance functions, as noted above. I will request that the following be printed for my review:

• List of all new arrivals for the past three months, stating date and time of arrival, date and time of performance of intake screening, and date and time of the initial health assessment (intake physical). It is critical to be able to determine how much time has elapsed between intake and the essential health screening and assessment functions.

• For the past 30 days, the interval between logging an inmate’s sick-call request and the actual performance of the visit, along with figures disclosing how many sick-call requests did not result in a visit, and for what reason. For visits not taking place, print also the ultimate outcome, such as rescheduling, inmate release date and the like.

• For the past three months, the interval between consultation request and consultation performance, along with information regarding whether or not the consultation report was received and whether it was initialed by the institutional physician.

• List of all chronic care patients, sorted by chronic disease, plus a list of patients with two, three, four or more chronic conditions, listing all conditions. This enables me, or an internal reviewer, to rapidly ascertain the most complex cases and review these health records. The assumption is that if care is acceptable for these difficult cases, then care for simpler cases is most likely up to par. These lists are also useful as a snapshot of the prevalence of conditions.

• For all chronic care patients (or a suitable size sample), print the dates for chronic clinic visits in the past year, noting whether or not these were timely (usually every three months).

• List of all inmates showing the date of last PPD test, whether or not they were tested timely and results of the PPD reading in mm.

• List of all inmates showing the date of performance of their last annual physical (or the date it should have been performed but was missed). The purpose is to see quickly whether physicals are up to date.

• List of inmates for whom the doctor ordered a blood test in the past 30 days, showing whether the test was done, missed or postponed for any reason. This is to identify potential systemic problems with follow-up when a test is ordered.

• List of names of inmates with HbA1c of 10% or higher (other analytes may be used, such as hemoglobin under 10 grams, TSH of zero, high HIV viral loads, high bilirubin and the like). The idea is to quickly select electronic charts of inmates with significant laboratory abnormalities and to discern whether these had been properly addressed by the health staff.

• List of inmates who had a chest X-ray in the past three  months, with a comment as to whether or not the film had been performed and whether it was termed “abnormal” by the radiologist.

• List of inmates who filed a grievance about medical issues in the past three months, along with information on whether the grievance had been responded to within institutional timelines and whether it had been denied or granted to the inmate.

• List of names of inmates who became due for a mammogram, Pap smear, hemoccult testing and the like in the past three months, along with an explanation on whether or not the test was performed on time and whether the results were positive or negative.

Obviously, many of these requested lists would enable me to readily identify problems with follow-up, both in the timely performance of the activity and in subsequent care when indicated.

Hope for the Future
Of note, none of the correctional institutions I reviewed was able to produce all the information requested. A few systems were able to produce some data, and several were unable to respond affirmatively to any of the requests. It is my hope that this suggested list of desirable EHR characteristics will be factored in when considering an EHR purchase.

— About the author: Joseph E. Paris, PhD, MD, CCHP-A, is an independent consultant in correctional health care based in Marietta, GA. He also works as a physician at the DeKalb County Jail and the DeKalb County Public Health Department, both in Atlanta. He has long been involved with NCCHC as a physician surveyor, frequent conference presenter, CCHP trustee and other activities. He serves on the board of directors as liaison for the Society of Correctional Physicians.

[This article first appeared in the Fall 2009 issue of CorrectCare.]