In the hospitals, their ERs and subspecialty practices where the EMR is already very useful, if not indispensible, patients are admitted or refered in for the care of patients with already well categorized conditions. That is, the body system or organ in trouble has already or is easily identified and the right subspecialist takes off from there with his/her very specific, in-depth training, and instrumentation to hone in on a more finite set of problems and interventions. There is no point in asking far-reaching questions for which the answers may lead you down many paths. The set of questions and the set or answers can be listed as in a drop-down menu or one or two word phrases that fit into a box. This is data. It can usually sort electronically into algorhythm(s). It can be utilized to help answer research questions.

Not so the primary care practice. The far-ranging possibilities in our “interesting” cases is often what drew us into primary care in the first place. Let me illustrate with an example from my practice. I am a Pediatrician with additional training in Adolescent Medicine. I leave it to you to decide if I am, therefore, a subspecialist. For me, this is as primary care as it gets. A female teen was refered to me after three hospitalizations and many tests led to the diagnosis of Chronic Fatigue Syndrome, a diagnosis of exclusion if ever there was one. I requested the records from her previous doctors, in particular her primary care physician throughout her short life. Not a summary of any kind. I wanted every page. Did you know that if you sit down and read the complete, unedited narrative of a person’s medical record in one sitting there is a flow to people’s lives? When she was six years old that flow changed. A summary would NEVER have revealed it. A set of categorical responses to categorical questions would NEVER have picked it up. I wasn’t clever. I felt the change. She began to be seen in clinic for easily diagnosed problems that had vague, or non-specific, or no objective findings. I read back to find the point after which the flow changed. There I found the only reference in her chart that mentioned the inclusion of a genital inspection along with the rest. I called the physician who had taken care of her for sixteen years and I asked why he notated a genital exam for the first, (and last), time. There was silence on the other end. Finally he said in a different tone of voice that he suspected the possibility that she had been touched inappropriately because of the subtle appearance of vulvar irritation. But such an accusation carries a huge consequence of major family upheaval, destroyed lives, even lost lives. Besides, he told me, the person in their small community he would have to report this suspicion to happened to be her mother. Fortunately, a psychiatrist fairly new to the town was willing to take on the case and turned her life right side up in fairly short order.

To date, I don’t believe an EMR program has been conceived that can really absorb this kind of narrative. When doctors write a patient encounter into their computer, they, (I), always summarise to some extent and rarely record the exact words of the patient that can be very telling. Am I wrong? Has anyone figured out how to both record the narrative and its subtlities into an EMR and preserve the functionality of the EMR? Until they do, the EMR as presently conceived is an inappropriate tool for the primary care practitioner. Not all technological advances equal progress.

We agree that there will need to be a determination of how to arbitrate or highlight data discrepancies across data sources. We anticipate that guidance and standards in this area will emerge under the governance structures created under the American Recovery and Reinvestment Act.

In response to Ms. Thorsen’s questions about professional certification for individuals: The Commission has no plans for undertaking this. You have already correctly indentified a few organizations that can provide guidance. You might also review the work of the American Medical Informatics Association (AMIA).

Sue Reber, Marketing Director
CCHIT

I’m considering returning to school for a bachelors or masters at a CAHIIM Accredited HIM Program, so I can sit for an AHIMA exam / certification. However, if there will be a new organization providing IT certification(s), other than the 2 listed in my comment above, I may postpone my decision.

American Health Information Management Association – http://www.ahima.org/certification/index.asp

Healthcare Information and Management Systems Society –
http://www.himss.org/ASP/certification_cphims.asp

However, since I have no experience in this area, please correct/add to this info.

In response to Dr. Webb’s comments about inclusion of pharmacy services and incorporation of pharmacy data as required elements and standards within any process for certification of HIT systems: CCHIT encourages those who have expertise in this domain to apply for participation during its upcoming development work group recruitment period. This might include participation in any number of groups, including the ambulatory, inpatient, or long term care groups. We will begin recruitment for new development work on March 23 through April 20 at http://www.cchit.org. Interested parties may also participate through CCHIT’s regular public comment periods on criteria and test scripts held throughout the year.

In resp0nse to Mr. Berry’s questions about certification for IT professionals: The Commission’s scope of work is limited to developing certification criteria and processes for health IT products and services. It does not extend to individuals at present.

Sue Reber
Marketing Director, CCHIT

ACCP would welcome the opportunity to work with other interested parties to address this key element of an HIT certification framework.

C. Edwin Webb, Pharm.D., M.P.H.
Associate Executive Director
Director, Government and Professional Affairs
American College of Clinical Pharmacy
1101 Pennsylvania Ave., NW
Suite 600
Washington, DC 20004-2514
(202) 756-2227