Why patients and providers need a more complete patient medical record
December 19, 2016
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The move to electronic medical records carries great promise for improving patient care, but there are many challenges, including poor interoperability between systems, unstructured data, disconnected medical image information and more. However, the capability to improve data flow and develop a more complete patient medical record exists. SmartBrief spoke with OnBase by Hyland's Michelle Maly about how and why health systems must ensure all relevant patient data reaches the clinicians who provide health care.

What’s included in the typical electronic medical record today, and what information is missing?

A large portion of the medical record is often stored within the EMR and can be shared across IT systems and between organizations through the use of interoperability standards.  This includes content such as progress notes, vital signs, allergies, problem lists and medication lists.  Clinical imaging data is often stored separately from the EMR, within an organization’s vendor-neutral archive or picture archiving and communication systems.  Strategies for exchanging imaging content tends to be different than for other medical data, and imaging information is not always easily accessible. Finally, content exists in other relatively inaccessible locations, including items stored on home-grown systems, content stored on a shared drive and information that exists on paper.

Michelle Maly
Michelle Maly

How do these EMR data gaps affect patients?

The effects that EMR data gaps have on patients can be enormous. When clinicians lack access to a complete medical record, the risk of poor clinical decision-making increases. In addition, repeat tests are often required because data from past tests is unavailable.  This affects both the cost and level of care provided to patients.

Can you describe the particular challenge and value of unstructured data?

Unstructured data may be useful and effective for the treatment of a patient.  However, content with little or no defined structure can be difficult to properly classify, and it is difficult to extract relevant information from this type of data.  Unstructured data can come in many forms, including notes scribbled on a piece of paper or within images captured on different devices, to name a few.

What is needed for health systems to break down silos and develop more complete EMRs?

First, the content that is siloed on shared drives and small platforms can be moved to OnBase as an ECM solution so that this content can be available for both interoperability purposes and for access via the EMR through the OnBase Patient Window.

In addition, with today’s interoperability standards, capabilities exist to share both discrete and unstructured content, including images. As organizations continue to build an infrastructure for interoperability, these standards should continue to ease the technical sharing challenges.

How are workflows and other activities on the provider side affected when data are merged in a more complete EMR?

Providers should have the ability to make smarter and more complete decisions with more data surrounding the patient.  In addition, fewer repeat orders should be needed if images or results are shared across organizations, benefiting patients and providers. 

Michelle Maly is associate vice president of healthcare development at Hyland Software, maker of OnBase enterprise content management software. Michelle is responsible for collaborating with all internal and external customers to understand the market and needs within the healthcare industry and draw out a vision for the OnBase Healthcare Product Suite.  She is involved in the design and architecture with her team of dedicated healthcare development focused on executing on the vision for the software.