|
Howard J. Anderson, Executive Editor
Health Data Management Magazine, May 2007
Like the pioneers who headed West, blazing trails for millions of others to follow, a handful of hospitals and clinics in the final decades of the 20th century were electronic health records pioneers. They took the risk of automating clinical information at a time when many organizations were just taking the first steps toward automating financial records.
Many of these same trailblazers are leading the way toward a new generation of clinical automation decades after they began their original quests. And their efforts continue to yield many important lessons for others following in their paths.
The new goal of these trailblazers: James Holly, M.D., sums it up as electronic patient management.
"Electronic patient records are not the goal," says Holly, CEO at Southeast Texas Medical Associates, a 28-physician practice in Beaumont. Rather, the goal is to use clinical data to improve communication with patients while achieving better treatment results.
For example, Holly, who has been using an electronic records system from NextGen Healthcare Information Systems Inc., Horsham, Pa., for almost a decade in his clinic, now is using the technology to create daily progress notes at one hospital where he treats patients. These notes, organized in a disease management format, provide an "at a glance" look at all the key factors in the patient's treatment, enabling others on the medical team to more easily identify appropriate next steps.
"Very often in medicine the real benefit is paying attention to the simple things," Holly observes.
Rather than wait for the hospital to take the initiative, the 63-year-old internist designed the progress note with the help of his technological staff, creating a summary of hospital activity in what had been just an outpatient record. Because the hospital is not yet ready to incorporate the automated information, Holly and two other physicians are creating electronic progress notes and then printing them out, placing them in paper hospital records, providing a guide for others.
21st century innovation
Across the country, EHR pioneers are working on a broad range of 21st century clinical automation projects. Among the most common are:
- Embedding decision support capabilities, including appropriate alerts, into EHRs.
- Using clinical data to support research aimed at improving the quality of care and preparing for pay-for-performance.
- Looking for ways to increase connectivity so that hospitals and clinics can readily share life-saving clinical information.
- Supporting the growth of EHRs at clinics by coordinating these projects through hospitals.
- Phasing in personal health records that include data entered by patients.
- Adding new components to EHRs designed to make the data more complete. These include a broad range of test results, from diagnostic images to electrocardiogram strips. The military is even taking the step of adding dental records to its EHR (see related story, page 28).
- Providing easier access to EHRs at the point of care through wireless networks.
But all of these efforts are destined to fail unless physicians and nurses -those who actually use the data-are leading the way, executives at pioneering organizations stress. "My role is to evangelize about this," says James Morrow, M.D., vice president and CIO at North Fulton Family Medicine in suburban Atlanta. "My job on this earth is to help people to see that this is not the impossible task they hear it is." (See related story, page 30.)
Many EHR pioneers now are adding medication management or computerized physician order entry systems that include decision support mechanisms. Some are also building alerts into their EHRs to remind physicians, for example, that a patient is due for a test.
At Johns Hopkins Medicine in Baltimore, which started down the path toward EHRs back in the 1980s, CPOE is still being phased in as part of an effort to reduce medical errors. In addition, the organization, which is adding CPOE technology from Boca Raton, Fla.-based Eclipsys Corp. to complement its homegrown EHR, is creating alerts that tell a physician when new lab test results have been posted to the electronic chart, says Stephanie Reel, vice president for information services.
"CPOE is about helping doctors make better decisions at the point where they place the order," she says. This goes one step beyond automating clinical data to actually using the data to influence behavior, she explains.
The key to making CPOE and clinical alerts work, Reel adds, is ensuring that doctors design the systems. "We could never have done this in a million years without physician leadership," she stresses. "Our doctors are committed to patient safety, so they are willing to work an amazing amount of extra hours creating decision support rules to make sure they generate an appropriate number of alerts."
Similarly, the hospital widely acknowledged as the first to implement an electronic records system back in the 1970s is focusing its efforts on building alerts for medication management.
El Camino Hospital in Mountainview, Calif., formed a committee of physicians, nurses, pharmacists and I.T. staff to create alerts in its Eclipsys system, says Diana Russell, R.N., vice president of patient care services and interim CIO.
The group is identifying high-risk patients and then taking steps to create a minimum number of key alerts to influence treatment decisions. "If there are too many alerts, it becomes disruptive, and the tendency is to blow by them," she says.
Morrow, from North Fulton, also warns against creating too many "pop up windows" that ultimately get ignored. In most cases, his practice relies instead on a "patient manager" function that the doctor can use to seek out advice. The practice, which uses software from Allscripts Inc., Chicago, also can flag charts to send out a reminder to the appropriate clinician when a patient is due for a blood test.
"Even with an EHR, you still have to be a physician," Morrow says. "That's the bottom line here."
At one New York City delivery system, electronic records prevent doctors from even ordering a medication until they have entered information into the record about that patient's medication allergies. "It was important that we alert the physician to first ask about allergies," says Maricar Barrameda, CIO at Generations+/Northern Manhattan Health Network. Every physician on staff now uses the CPOE system, a component of software from Misys Healthcare Systems, Raleigh, N.C.
But when it comes to CPOE, timing is everything, cautions Ed Ewen, M.D., director of clinical informatics at Christiana Care Health System, Wilmington, Del. The two-hospital delivery system began using inpatient clinical information systems, primarily from Cerner Corp., Kansas City, Mo., back in 1995, and outpatient systems, from Waukesha, Wis.-based GE Healthcare, in 1997. But it's just now adding CPOE.
Back in 2000, I was getting significant resistance to CPOE from the medical staff," Ewen says. "Today, the attitudes have changed dramatically. Doctors are much more comfortable using computers. Back in 2000, physicians didn't accept as a matter of course that they'd be using computers in their daily lives. The pendulum has swung completely."
Christiana will start with electronic medication administration this summer, and then add full-blown CPOE next year once it builds 300 order sets.
Ewen says a big reason for today's acceptance of CPOE as well as EHRs is the recent emergence of hospitalists-physicians who specialize in treating only hospitalized patients. Because hospitalists at Christiana generate the vast majority of medication and test orders, the efforts to roll out electronic ordering can focus primarily on meeting their needs, he adds.
Support for research
In addition to paving the way for electronic order entry and clinical alerts, a robust EHR can support meaningful clinical research.
For example, Mid Carolina Cardiology, which has used records software from GEMMS, Indianapolis, since 1998, is involved in more than 35 clinical trials of new drugs. This would prove impossible without the data generated by the EHR, says Steve McAdams, M.D., CEO at the Charlotte, N.C.-based practice, which has 31 physicians.
The cardiology group has augmented its EHR with a specialized data warehouse from MDdatacor, Alpharetta, Ga. The warehouse for transcribed records facilitates queries for research. Using the technology, a doctor can ask the system to display all heart attack patients with specific test results and then check those patients' electronic records to make sure they've seen the appropriate specialist, McAdams explains.
Similarly, the data warehouse and EHR come into play when determining which patients best fit the specific requirements of a particular clinical trial.
These type of benchmarking and quality-improvement efforts are the precursor of full-blown pay-for-performance mechanisms that all the major payers will adopt in the years ahead, McAdams says. These new payment approaches will require that doctors document that they are delivering care that achieves good results-and this is impossible without a robust EHR, he argues.
One pioneering EHR adopter is using its software to help launch its own version of pay-for-performance.
Trinity Mother Frances Health System, Tyler, Texas, has had an outpatient EHR at its 210-physician clinic for about 10 years. Today, it's using the system, from GE, to track 10 clinical parameters, for such factors as whether doctors are ordering mammograms when appropriate or complying with immunization schedules. A portion of physicians' compensation is tied to whether they are following these parameters, says Thomas Hargrove, M.D., medical director of informatics. This method enables the clinic to ensure that clinical best practices are followed, improving the quality of care, he contends.
Building connections
For many pioneers, an initial effort to automate records in one setting- whether a hospital or clinic-is being expanded to include multiple settings.
"Connectivity is the next step; we have to go beyond 'electrified' paper," Morrow says. Every hospital should be able to electronically deliver to physicians on Monday morning all the details of their patients who were treated in the emergency department over the weekend, he says.
This step alone would eliminate hundreds of redundant tests ordered because the tests conducted in the ER typically are unavailable to the primary care doctors. "If we could eliminate these redundant tests, we could save enough to feed Somalia for a year," he says.
One of the trailblazers in the arena of connectivity is Ochsner Health System in New Orleans. In the wake of Hurricane Katrina, the organization has grown to six hospitals through the acquisition of several shuttered facilities. Now it faces the challenge of tying them together for the exchange of data.
Ochsner, which developed its own EHR back in the 1980s, now makes electronic records available enterprisewide at 4,500 workstations. Unlike local facilities that still relied on paper records, all of Ochsner's electronic patient records were readily available following the devastating hurricane, says Lynn Witherspoon, M.D., assistant vice president and CIO.
Now it's casting a broader net, gradually making its clinical information available via the Internet to primary care physicians around the state who refer patients to Ochsner, and ultimately linking up the community hospitals it recently acquired. "We are embarked on this community mission because things aren't happening very fast here; it's been very difficult after Katrina," Witherspoon says.
In addition to its own aggressive networking efforts, Ochsner is one of several participants in a broader post-Katrina effort to build a robust regional health information organization to facilitate the sharing of data.
In another connectivity effort, McAdams, the cardiologist from North Carolina, is beginning work on developing a portal to enable primary care physicians to send his practice the latest data on their patients' treatment as well as their insurance coverage. He hopes to enable the interoperability within a year.
At Christiana Care, software from MEDecision, Wayne, Pa., enables the hospital to access electronic health records that track care delivered at multiple sites in the community.
These clinical summaries are built primarily upon claims data collected by Blue Cross/Blue Shield of Delaware, which paid for the software. The record of diagnoses and procedures has proven particularly valuable in hospital emergency departments, where it helps to avoid redundant tests, says Ewen, the director of clinical informatics.
Ewen is hopeful that this is a small step toward a more comprehensive RHIO initiative involving all area hospitals and clinics.
Some hospitals and integrated delivery systems, including Christiana, that implemented EHRs a decade or more ago see group practice settings as their final frontier for automation.
The delivery system has rolled out outpatient electronic records to about 20 practices where its employed physicians work. It expects to spread EHRs to all its employed physicians within the next 12 to 18 months, ultimately adding electronic prescribing as well, Ewen says. This will prove vital to creation of a broader RHIO, he contends.
Across the country, hospitals are beginning to invest in EHRs for referring physicians as a result of the relaxation of the Stark regulations, which had largely restricted such I.T. investments.
Personal health records
For some health care organizations, the creation of a patient-controlled personal health record, which the patient helps create by inputting their own information, is an important long-term goal. "The PHR is not a subset of the EHR. They are intersecting circles,"
Ewen contends. While each may contain some of the same information, each also contains exclusive data as well.
Ewen argues that PHRs will give physicians a chance to collaborate much more closely with their patients, especially those who have chronic diseases. "For example, for a diabetic, rather than entering their blood sugar diary on paper and then remembering to bring it into their doctor's office, they can enter the information into the PHR daily, and the physician can review the results before the next visit," he explains.
Also, the physician can "publish" recent lab test results to the patient-accessible PHR so that it's available via the Internet to other caregivers if, for example, the patient gets ill while traveling, he adds.
Generations+/Northern Manhattan Health Network, which serves some of the poorest communities in the city, is in the early stages of researching how it might provide its patients with improved online access to information about their care.
As an important first step, the organization is surveying hospitalized patients and others in the community to determine if they have access to the Internet at home or at a local library or school, says Barrameda, the CIO. If Internet access is sufficiently widespread, the organization will consider creating a patient portal where personal health records could reside.
In addition to branching out into personal health records, some pioneering organizations are broadening the scope of information in their EHRs.
For example, El Camino Hospital is acquiring a new radiology information system and picture archiving and communication system to achieve its goal of including diagnostic images in its EHRs, says Russell, the interim CIO.
Similarly, Mid Carolina Cardiology is integrating a variety of cardiac diagnostic tests, including ultrasound, into its EHR. Reports generated through a PACS will automatically be populated in the EHR as well, he adds.
Meanwhile, Johns Hopkins just added images of electrocardiogram strips to its electronic records. "I never would have thought that would be a priority for our physicians," says Reel, the CIO. "But the non-cardiologists wanted to look at the strip so they could have a more informed conversation with their patients."
To make certain that complete clinical information is available at the point of care, many pioneers have installed wireless networks in their facilities. These enable doctors and nurses to use portable computers to access the data when and where they need it.
For example, wireless access to data is pervasive throughout the massive Johns Hopkins delivery system, an essential component in ensuring widespread use, Reel says.
Mid Carolina Cardiology went wireless back in 1999 at all five of its clinics. This was necessary, McAdams says, because a majority of the cardiologists wanted to use tablet computers in their exam rooms or their offices as needed. "We didn't want to have a desktop PC in every room," he says.
El Camino, considered the nation's first organization with an EHR, has a wireless network with 1,700 users. Caregivers access the electronic records system with tablet computers or computers mounted on mobile carts.
They also use hands-free voice communication devices from Vocera Communications, Cupertino, Calif. And technology from Sensitron Inc., San Mateo, Calif., enables the transmission of vital signs from monitors over the wireless network directly into the records system.
"This all makes the information more immediately available to other caregivers," says Russell, the interim CIO.
Adding Dental Records To The Mix
Sometimes, medical records aren't enough. The Department of Defense has concluded that a complete electronic health record should include dental records as well.
The military is beginning to roll out a dental records component of its broader AHLTA electronic health record.
"We don't want to send people into combat zones unless their dental care is up to speed," says Col. Bart Harmon, M.D., U.S. Army chief medical information officer, who works within the office of the assistant secretary of defense for health affairs. As a result, the military wants to include complete dental records in its EHRs to provide clear documentation that all dental care issues have been addressed.
The Department of Defense is using the same core components of its outpatient electronic health record system for the dental records, but it's building some new functionality to accommodate the special needs of dentistry, Harmon explains.
The military also is in the early stages of incorporating eyeglass orders into its AHLTA system. "We need to make sure those going into a combat zone have two pairs of glasses and protective eyewear before they deploy," the colonel says. "We need that information in the file electronically so that if their glasses get destroyed, we can ship them new ones quickly."
Moving forward, Harmon says, the Department of Defense will coordinate clinical automation for the full continuum of care at the military's medical facilities as well as those of the U.S. Department of Veterans Affairs, Harmon explains.
The AHLTA clinical data repository already includes electronic clinical records for more than 8.9 million beneficiaries. The systems integrator on the military's electronic health records projects is Northrop Grumman Corp., Los Angeles.
Back To Basics: Get Physicians Involved
EHR pioneers offer simple advice to those launching a major clinical automation effort: get the physicians involved early and often.
"Take the time to listen to what the physicians and nurses are saying," advises Stephanie Reel, vice president for information services at Johns Hopkins Medicine, Baltimore. "For so many years, I.T. people thought they knew what to do. That's why we didn't make as much progress as we could have."
Rather than focusing on winning physician buy-in, Reel urges CIOs to strive for physician ownership of any clinical automation project.
Lynn Witherspoon, M.D., assistant vice president and CIO at Oschner Health System in New Orleans, says it all comes down to addressing physicians' specific needs.
"The organization needs to have a dedicated clinical support team that will ensure that anything impeding a physician from doing their job is addressed, with experts who will come to their offices and help them work through any problems," he says. "It's more about understanding what physicians do than asking them to select a product."
At Trinity Mother Frances Health System in Tyler, Texas, executives determined that an incremental approach to automating clinical information would help build physician support over the long haul. Trinity started its journey with an ambulatory records system, and now is adding various components on the inpatient side before launching a full-fledged hospital EHR later this year.
"We found that physicians who are somewhat standoffish about technology, once they get their appetite whetted, start asking for more," says Thomas Hargrove, M.D., medical director of informatics.
James Holly, M.D., CEO of Southeast Texas Medical Associates, Beaumont, says physicians learn by example. "How do I persuade other physicians to use our new electronic progress notes? I'm doing it myself. I've proven to my peers that this can be done.
I demonstrate improvement in quality of care. So now they'll do it too."
Provider organizations need to take a team approach to any major I.T. initiative, involving physicians and nurses on the team that designs new workflows, establishes templates, and develops strategies, says Maricar Barrameda, CIO at Generations+/Mahattan Health Network in New York. "A nurse or a doctor can be trained to be technical; it's hard to train a technician to be a doctor," she says.
Sidebar
Helpful Hints From A Pioneering Physician
A physician who has been using an electronic health records system for nearly a decade offers s ome practical tips for group practices implementing clinical software.
Steve McAdams, M.D., CEO of Mid Carolina Cardiology, Charlotte, N.C., provides the following advice:
- Create a very well thought out plan for how to make the transition from the paper to the electronic world. The North Carolina practice formed a diverse committee to define all the necessary data in an EHR.
- Make sure to hire a true expert to design your network. Be sure to enter a contract with a specialist who has experience handling similar projects.
- Carefully follow the hardware specifications that the EHR vendor provides. McAdams warns that some software will not work well on certain hardware.
- Be aware that data storage needs will be "far greater than you can imagine," McAdams says. "We need terabytes a year; we didn't think about that at first," he explains. The cardiology practice has to keep certain sophisticated diagnostic test results on file for 10 years or more.
- Make sure you have a disaster recovery system in place before anyone begins using the EHR. At first, McAdams' practice relied only on storing backup tapes offsite. But as it automated vast amounts of data, it invested in backup storage at an offsite data warehouse. "Most medical groups don't plan that in their budget like a bank would," he adds.
|
