Medical Record Sharing for the Scribe

By Anne Bean, Scribe Training Administrator for AQuity Solutions

(Reprinted from the September 2019 issue of Vital Signs, AQuity’s monthly newsletter for the Scribing Division.)

There seem to be competing interests in the world of healthcare information management. How can healthcare information be shared freely while keeping it out of the wrong hands? On one hand, there are HIPAA laws requiring protection of private health information and easy access to that information by patients. On the other hand, there is the ever-increasing need to share medical information across platforms (interoperability) to assist providers in caring for patients with more continuity and less unnecessary testing. On the third hand (is there such a thing?), there is the always-growing threat of cybercriminal activity and we are constantly being warned about cybersecurity. Let’s talk about interoperability this month.

What is interoperability, why do we need it, and why is it so hard to accomplish? Simply stated, interoperability is the ease with which medical information can be shared. When you just had a CBC and CMP through your PCP 3 weeks ago, it would be nice if your hematologist could have access to it so they don’t order another one for you. If you had an MRI or CT scan done in the ER, it would be nice if your PCP could see the results of it when you follow up in their office. If you’re a provider treating a patient for a CVA, you’d like to see the head CT that was performed on your patient 3 years ago for comparison to the current imaging. It seems so simple, right? Well, it isn’t.

Why is information sharing so difficult? Several studies have revealed that barriers to interoperability include a lack of shared usability between different platforms, a lack of standards to create across-the-board consistency, the high costs of developing and optimizing health technology, a lack of trust between various interests regarding how proprietary information will be handled, and outdated administrative and documentation requirements.

Under the current US administration, the Department of Health and Human Services (HHS), and particularly the Centers for Medicare and Medicaid Services (CMS), have been extremely proactive regarding HIPAA, interoperability, and cybersecurity. (To be clear, the CMS involves more than just Medicare and Medicaid.) To that end, the current CMS administrator, Seema Varma, has given a personal testimonial to the need for being able to share information across platforms. She describes an episode during which her husband experienced a medical emergency while in an airport and underwent a multitude of tests, procedures, and a week-long hospital stay away from his home city. Upon discharge, he was offered a Discharge Summary and a CD-ROM to take back to his home doctors. Verma states, “After the federal government has spent more than #30 billion on EHRs…I left with paper and a CD-ROM. Most computers don’t even take CD-ROMs anymore. At a time when we are sending Teslas to Mars, patients are receiving health records on forms that are completely outdated.”

How does this affect medical scribes? For one thing, we can easily see how information comes in different formats when we consider all the different EHR platforms there are, each company with its own proprietary way of preserving records. We are sometimes called up on to work through 3rd party applications in order to make our scribing technology work with a facility’s EHR. M*Modal’s technology division (from which AQuity Solutions has been spun off) has done a great job of making its signature products operable within many different systems, but we can still occasionally encounter some of the glitches that come with sharing across platforms. Staying informed about the need for interoperability gives us insight into the various technologies we encounter as we do our work.

Stay tuned! Next month we’ll talk about the seemingly conflicting goals of easy record sharing compared to keeping medical records secure.