Part one of a two-part series:
A rule book used by the federally supported Certification Commission for Healthcare Information Technology to test electronic health-record systems and the policy manual of the American Medical Association to guide doctors are in apparent conflict over whether it's a good thing to put a patient's diagnosis on a prescription.
The dueling CCHIT testing criteria and AMA policy position represent "another classic case of tension between patient privacy and patient safety that we are increasingly seeing with the growing utilization of computers in healthcare," according to physician informaticist Lyle Berkowitz, medical director of clinical information systems for Northwestern Memorial Physicians Group in the Chicago area.
The current criteria against which CCHIT tests EHRs that are used by physicians in ambulatory care have two requirements when it comes to diagnoses and prescriptions.
The initial CCHIT requirement for its so-called 2006 round of testing stated that EHRs "shall provide the ability to associate a diagnosis with a prescription." In database lingo, the criteria calls for the joining of database fields in an electronic record that could, for example, help a physicians group track in-house the noncompliance of their colleagues to clinical protocols.
But a second requirement, added for the 2007 round of CCHIT testing and certification, states that EHRs must be able to "display the associated problem or diagnosis (indication) on the printed prescription." In other words, in order to pass muster with CCHIT, an EHR must be able to transmit both a patient's diagnosis and his or her prescription elements outside the EHR, either to a printer or, presumably, via electronic data transfer to an outside pharmacy or pharmacy benefit manager.
Under explanatory material for the second criteria, the guideline said that, "At least one diagnosis shall be able to be displayed, but the ability to display more than one is desirable," and adds that the "associated problem or diagnosis can be nonstructured data or structured data."
Both criteria were carried forward in the 2008 CCHIT ambulatory EHR testing criteria in use today.
According to a list posted on the CCHIT Web site, 50 EHR systems for use by physicians in ambulatory care have been tested using the 2007 criteria and are capable of linking and printing both the diagnosis codes and drug data on a prescription.
CCHIT is a Chicago-based not-for-profit organization formed in 2004 by various industry groups that won a $7.5 million HHS contract in 2005 to test EHR systems, the idea being that physicians would be more likely to buy them if they could be assured of the systems' basic functionality.
The AMA, however, has a policy on the books that appears to clash with the CCHIT criteria.
Passed by the ruling House of Delegates and made official by the AMA in 1993, the policy has been reaffirmed by that governing body four times sincemost recently in 2002.
The statement said that "in order to protect patient confidentiality and to minimize administrative burdens on physicians," the AMA should work to "eliminate requirements by pharmacies, prescription services and insurance plans to include such information as ICD-9-CM codes, (Drug Enforcement Administration) numbers and diagnoses on prescriptions."
That policy still stands, according to Joseph Heyman, who is a gynecologist based in Amesbury, Mass., and the current chairman of the AMA's board of trustees. Heyman has been an EHR user since 2002.
"I would say that the AMA policy is that we don't want to combine diagnosis with the actual prescription because we are concerned about a patient's privacy," Heyman said. "We know that there is data-mining going on. We also know there is some rating system based on prescription history. We know that this will put patients at risk."
Heyman said that the AMA would encourage physicians to use the prescription/diagnosis transmission feature only when required by law.
Some clinical value
Being able to pull up a view of prescriptions and diagnoses together on an EHR has clinical value, according to William Bria, a pulmonologist who is chief medical information officer at the Shriners Hospitals for Children system in Tampa, Fla., and president of the Association of Medical Directors of Information Systems, a professional association of medical informaticists.
Bria said he sees the combining of diagnosis and prescription data as part of a quest to put computerized databases to work in the exam room.
"It goes all the way back to Larry Weed that a problem-ordered electronic medical record can facilitate better medical care," he said. Weed, a Vermont physician, is a pioneer in developing electronic clinical decision-support systems. "At the point of care you say, 'Why are you ordering it?' "
Berkowitz, an AMDIS member, said, "I think it makes sense to have this particular functionality enabled as an option, but I would suggest that physicians and patients be able to make the final decision as to whether it is utilized in any specific situation."
This story initially appeared in this week's edition of Modern Healthcare magazine.
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