Fall - National Commission on Correctional Health Care

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The Litmus Test of Electronic HealthRecord Performanceby Joseph E. Paris, PhD, MD, CCHP-AThe push to “go electronic” gets stronger with eachpassing year. Although only a minority of prisonsand jails has converted to an electronic healthrecord system, the number of converts is growing. Asan NCCHC surveyor of over two decades, I have beenexposed to more than a dozen EHRs nationwide in facilitiesof different population sizes. As a surveyor I did notintend to gauge EHR efficiency, data completeness orgeneral performance, but the need to survey computerizedhealth records and logs did bring me into close contactwith these systems.Drawing from my experiencewith diverse, commercially availableas well as home-grown correctionalEHR systems, I was ableto formulate a plan to quicklygather relevant clinical information.For surveys involving EHRs,I requested a staff person to beassigned to me for the wholesurvey, with the understandingthat the assignment would fall onsomeone familiar with the EHRstructure and thus capable ofspeedy review.I reviewed weaknesses of certainindividual EHRs in a previousissue of CorrectCare, pointing toworkflow disruptions during conversion,inability to display multiplepages simultaneously, lack oftidy printed layouts, inability toflag and initial outside consultant reports, lack of a systemto collect inmate signatures for consents or items receivedand general difficulty reading previous progress notes dueto monotony of the layout.This time, I will comment on common weaknesses ofEHR systems when handling log-type or collective databelonging to all of the patients at a correctional institution.It should be understood that I am convinced that EHRsare the way of the future and I do not advocate use ofpaper-based health records indefinitely. It is my hope thatsome of the lessons I learned reviewing correctional EHRswill be of value to correctional health care authorities consideringthe purchase of a new EHR system.Data Tracking LogsCorrectional staff using paper records know that logs areneeded to track some essential functions of their healthcare units. Logs in common use include intake screening,health assessments, sick call, consultations, chronic care,PPDs, annual and other physicals, labs, X-rays, grievancesand the performance of age-dependent routine health caremaintenance functions such as mammograms, Pap smears,stool hemoccults and the like.Paper logs work well in institutions with fewer than 500inmates and with low turnover, like most state prisons.Paper logs become unwieldy for large institutions, especiallyif 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 evolvedsome home-grown computerized system for trackingsome of the functions above listed. These are not integrated,however, and do not lead to the development of aunified EHR.When surveying a correctional institutionfor accreditation, I usually ask thequestions below regardless of whetherEHRs or paper records are in use. Thesequestions reveal essential aspects of thefunctioning of the health care system ineffect.As a side benefit, the same questions,which I term “litmus test,” can be used togauge the functionality of a proposed EHRsystem before committing to its purchase.Key QuestionsThe litmus test questions deal with sickcall, consultation, chronic care, PPD, physicals,lab, X-ray, grievances and the performanceof age-dependent routine healthcare maintenance functions, as notedabove. I will request that the following beprinted for my review:• List of all new arrivals for the past threemonths, stating date and time of arrival, date and time ofperformance of intake screening, and date and time of theinitial health assessment (intake physical). It is critical to beable to determine how much time has elapsed betweenintake and the essential health screening and assessmentfunctions.• For the past 30 days, the interval between logging aninmate’s sick-call request and the actual performance ofthe visit, along with figures disclosing how many sick-callrequests did not result in a visit, and for what reason. Forvisits 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 consultationrequest and consultation performance, alongwith information regarding whether or not the consultationreport was received and whether it was initialed bythe institutional physician.• List of all chronic care patients, sorted by chronic disease,plus a list of patients with two, three, four or morechronic conditions, listing all conditions. This enables me,or an internal reviewer, to rapidly ascertain the most com-14<strong>Fall</strong> 2009 • CorrectCarewww.ncchc.org
(continued)plex cases and review these health records. The assumptionis that if care is acceptable for these difficult cases,then care for simpler cases is most likely up to par. Theselists 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, notingwhether or not these were timely (usually every threemonths).• List of all inmates showing the date of last PPD test,whether or not they were tested timely and results of thePPD reading in mm.• List of all inmates showing the date of performance oftheir last annual physical (or the date it should have beenperformed but was missed). The purpose is to see quicklywhether physicals are up to date.• List of inmates for whom the doctor ordered a bloodtest in the past 30 days, showing whether the test wasdone, missed or postponed for any reason. This is to identifypotential systemic problems with follow-up when atest is ordered.• List of names of inmates with HbA1c of 10% or higher(other analytes may be used, such as hemoglobin under 10grams, TSH of zero, high HIV viral loads, high bilirubin andthe like). The idea is to quickly select electronic charts ofinmates with significant laboratory abnormalities and todiscern whether these had been properly addressed by thehealth staff.• List of inmates who had a chest X-ray in the past threemonths, with a comment as to whether or not the filmhad been performed and whether it was termed “abnormal”by the radiologist.• List of inmates who filed a grievance about medicalissues in the past three months, along with informationon whether the grievance had been responded to withininstitutional timelines and whether it had been denied orgranted to the inmate.• List of names of inmates who became due for a mammogram,Pap smear, hemoccult testing and the like in thepast three months, along with an explanation on whetheror not the test was performed on time and whether theresults were positive or negative.Obviously, many of these requested lists would enableme to readily identify problems with follow-up, both in thetimely performance of the activity and in subsequent carewhen indicated.Hope for the FutureOf note, none of the correctional institutions I reviewedwas able to produce all the information requested. A fewsystems were able to produce some data, and several wereunable to respond affirmatively to any of the requests. Itis my hope that this suggested list of desirable EHR characteristicswill be factored in when considering an EHRpurchase.Joseph E. Paris, PhD, MD, CCHP-A, is an independent consultantin correctional health care based in Marietta, GA. Healso works as a physician at the DeKalb County Jail and theDeKalb County Public Health Department, both in Atlanta.In addition to his work as a physician surveyor, he has longbeen highly involved with NCCHC as a frequent conferencepresenter, CCHP trustee and other activities. He recentlyjoined the board of directors as liaison for the Society ofCorrectional Physicians. E-mail joeparis@pol.net.The predecessor article to this one is titled “Going toCourt With an EHR” and appeared in the Summer 2009(Volume 23, Issue 3) issue of CorrectCare.whs_2nd_NCCHC_ad.qxd 8/14/08 5:38 PM Page 1At Wexford Health, we take our responsibilities seriously. That’s whywe have been a trusted partner to more than 250 correctional facilitiesacross the country, helping them to control costs without sacrificingquality of care, cutting corners, or inappropriately denying services.The pride we take in meeting your needs is plain to see.412-937-8590SALES@WEXFORDHEALTH.COMMEDICALMENTAL HEALTHDENTALPHARMACYSTAFFINGEMRUTILIZATION MANAGEMENTCLAIMS PROCESSINGTELEMEDICINEwww.ncchc.org<strong>Fall</strong> 2009 • CorrectCare15
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