MedicalLife, Winter 2005
"At most hospitals, it happens every day," says Dr. Fausto Meza, 35, a Geriatrics Fellow at the Wright Center for Aging in New York City. "Mrs. Smith, 95, with multiple medical problems, comes to the ER, unable to tell anyone what's wrong with her and what her advance-directives are. Continuity of care is interrupted. She is treated aggressively and sent to the ICU, which she didn't want. But at our clinic the Electronic Health Record (EHR) system tells us that Mrs. Smith is in the ER. I can print out her problem list, medications, health care proxy advance directive and notes from her last visit. ER docs are happy to see us."
That scenario is a snapshot of how things may soon be everywhere. Experts are now predicting that just as (information) technology transformed most other professions during the 1990s, it will significantly change the practice of day-to-day medicine in the coming decade. In the very near future, EHRs will eliminate paper charts, paper files, paper records, paper prescriptions, paper directives and anything else now recorded and transmitted on paper. The long-term goal is even grander: not just stand-alone EHRs in every hospital, clinic and physician's office, but software configured so that data can be shared by everyone in the health care system, including patients.
"Some grocery stores have better technology than our hospitals and clinics," Tommy Thompson, Secretary of Health and Human Services
What is an Electronic Health Record?
Broadly speaking, an Electronic Health Record helps physicians maintain, update and exchange patient data in a way that is easily accessed by all providers who care for a patient. (See Sidebar) An Institute-of-Medicine (IOM) report commissioned by HHS Secretary Tommy Thompson in 2003 envisioned an interactive system that allows patients and clinicians to:
Such an EHR system is not a reflection of what currently exists. In the real world, physicians, clinics and hospitals have been installing a hodge-podge of systems designed by a variety or vendors. Many began as office management systems to which health care functions were then added.
For example, in the mid-eighties, Jim Hollenberg, a physician with an interest in software development, offered to computerize the billing system of the medical clinic where he saw patients. "Doctors had no interest in the system. It was only to service the business side." Since then, he has expanded his system's functions. "We've moved the system from single doc offices to larger clinics to multiple clinics and multiple hospitals, giving doctors more and more things they could do with it."
Yet today, even within the hospital in which he sees patients, there is no single EHR system. "Standardization, even within a single entity is very difficult," says Hollen berg, 49, an Associate Professor of Medicine at Weill Cornell Medical College.
"Once people have put years worth of data into a system it's hard to get them to move to another one." In fact, hospitals and physicians have been slow to integrate information technology into their practices. According to a HHS report, in 2002 only 13% of hospitals and 14-28% of physicians used electronic systems in their practices. The highest levels of EHR usage was found in staff- and group-model health maintenance organization practices, medical school faculty practices and large group practices.
Dr. David J. Brailer Is the first National Coordinator for Health InformatIon Technology
The high cost of buying and maintaining EHR systems, coupled with continued doubts about its financial benefits to physicians, has remained a major barrier to adoption. Other obstacles include: a lack of technical standards, confusion about which products to buy and what "certified" functions to include, fear of information overload, risks and liabilities connected with interconnectivity and lack of capital to purchase systems.
Change is Coming: The Decade of the EHR
Despite many unresolved issues, EHRs are coming. Like ATMs and bar codes, which were a vision in one decade and a reality in the next—EHRs are coming. Momentum is building from all quarters, including physicians themselves.
Eight years ago Dr. Peter Basch, 52, a general internist on Capital Hill, was "drowning in paper." He decided to put in an electronic system. Today, Basch is at the forefront of change. His paperless practice is part of MedStar Health, a seven-hospital system in the Baltimore-Washington D.C. area. His office was recently chosen as the first site in the area to participate in a pay-for-performance pilot program sponsored by a large private insurer, CareFirst. Basch never instituted a quality improvement program and didn't expect to improve care quality.
"We were just trying to get our arms around missing pieces of data and paper that was clogging the system. But after several years we found that our practice of medicine was better, our care was better, our quality was better, and in addition to just enjoying the practice more, the largest beneficiaries were our patients." In fact, his practice went on to receive a (quality) award for its EHR use in improving adult immunization rates.
To see why momentum is building for change, just listen to Dr. Victor Player. In addition to his private practice, Player, 51, is President of the Maryland-D.C. Collaborative for Health Care Information Technology. He became interested in EHRs about five years ago when the volume of paper involved in transferring records back and forth from hospitals and referring physicians began to seem overwhelming. "Paper charts are getting way out of hand. Medicine has gotten extremely complicated. We feel that by having EHRs, it will help us not only organize our charts but it will help us organize our thoughts."
The reality is that given medicine's ever increasing complexity, our fragmented health system and our aging demographic, paper-based information systems are not up to the job of providing quality care. The lOM has pointed to ineffective health care coordination as a key cause of poor care and recommended electronic health records as a way to improve quality. Poor coordination is also inefficient and expensive for the major purchasers of care: federal health programs, insurers, managed care organizations, self-insured corporations and self-insured unions. The medical journal Health Affairs estimates that $78 billion a year could be saved by switching to electronic patient records in a network with open communications standards.
For all these reasons, implementing an electronic health care system is now a goal shared by interested parties across the political spectrum. Health care professionals and policymakers, institutional providers and patients, think tanks and foundations on the right and left all agree. Representative Patrick Kennedy of Rhode Island, son of Senator Edward M. Kennedy, announced last year, "I have never agreed with Newt Gingrich on anything in my life [except] we do both agree that health information technology should be a national priority."
In April 2004, President Bush called for widespread adoption of EHRs within 10 years. The following month Secretary Tommy G. Thompson noted "the most remarkable feature of 21st century medicine is that we hold it together with 19th century paperwork." betore appointing Dr. David J. Brailer as the first National Coordinator for Health Information Technology.
Dr. Brailer's ten year plan to implement the President's EHR vision includes public-private investments, incentives for EHR adoption and regional collaborations, coordinating open communications standards, building an interoperable national health information network, promoting tele-health systems and personal health records. Dr. Brailer envisions a health care industry that is consumer-centric, in which medical information follows the consumer, and information tools guide medical decisions. In this new world of medicine "clinicians can spend more time on patient care and employers gain productivity from health care spending."
In the private sector, The Markle Foundation, which is a leading healthcare and information technology group, recommended a network accessible to everyone via open, non-proprietary technical standards, much like e-mail. This approach has been endorsed by eight of the country's major technology companies, including IBM, Microsoft, Oracle, Intel, Cisco and Hewlett-Packard. It also recommended that the Federal Government provide a mix of incentives and seed money to spur the purchase of hardware and software by physicians and hospitals.
Harvard Business School Professor Regina Herzlinger, a leading authority on the healthcare industry, sees another approach. "I don't see this getting off the ground on the doctor-hospital end because it's too decentralized and they don't have the incentives." She adds, "No other industry requires the federal government to help them set up their electronic records." Herzlinger believes that "electronic health records will be kept by consumers and not physicians because, of all the stakeholders in the health care system, they benefit the most." She foresees health care computer programs (similar to tax-preparation programs) being developed and successfully marketed to consumers.
While few disagree that EHRs will play a major role in improving our fragmented health care system, many wonder if a national network isn't a long shot. "The issues of broad connectivity are exceedingly complex," says Dr. Basch, "and the potential problems are minimized by people who say the issues are purely wiring and standards." Clearly, a number of policy issues must be resolved before a national network of interoperable EHRs becomes a reality. Nevertheless, even if a national health network is not built, city and regional consortiums, hospitals and physician practices, are increasingly building information systems that link multiple providers. Lessons learned from these EHR models will inform policies, standards and solutions of the future.
A Model System
Those who dream about an electronic system across the continuum of care—ambulatory, in-patient, skilled nursing, ER, home health, also accessible by patients via the web—need dream no longer. Kaiser Permanente, a totally integrated health care delivery system and the nation's largest HMO, is making a $3.2 billion investment in KP Health Connect (KPHC). When complete, KPHC will link Kaiser's in-house pharmacies, labs and imaging centers with 12,000 physicians, 30 hospitals, 431 medical offices, and 8.2 million members.
The swiftness with which KP Health Connect is being implemented is astonishing. Co-leading its implementation is Dr. Andrew M. Wiesenthal, Associate Executive Director of the Permanente Federation. "We signed a contract in March 2003 with Epic Systems, gathered people from our medical and operations groups to work collaboratively, and emerged with a completely unified data model across our operation in six months." Each region decided the order and speed of deployment and how to train its people. Colorado got its system up and running in less than a month, and now can move information back and forth between regions and offices. If a Virginia member breaks her leg in Aspen, her Colorado orthopedist can access her Virginia health records.
Kaiser is enthusiastic about its web portal for patients, one million of whom are already logged on. They have links to a health encyclopedia, can make appointments and get prescription refills. Eventually, they will be able to access their lab results, physician instructions and health records (as well as update their records), and receive their own "decision support," which will advise them to come in for a mammogram, vaccinations, etc. In three years, Kaiser expects to have no health care paper transactions whatsoever.
Fifty percent of Kaiser's budget is devoted to training and the "anticipated loss of productivity" during training. "It isn't learning the features and functions that is hard," says Wiesenthal. "The hardest thing is it changes how you work day to day. For example, when I had a paper chart, I knew I had a patient to see because the nurse would stick the chart in a rack on the door. The first day with an EHR I looked down the hall, and there was nothing in those racks. I didn't know where to go. And that was just the beginning. Learning how to do an electronic record, for example, and still have a pleasant interaction with the patient is a new skill." Wiesenthal disputes the myth that "old guys have the most trouble adapting." He says, "It's the one's in the middle, about 40, at the top of their game, who don't want to be made less efficient. Doctors love technology. They just don't want to disrupt their competency and pay for it."
Dr. Wiesenthal, who testified before the House Ways and Means Subcommittee on Health in June 2004, is passionate about the promise of information technology to improve quality and safety. "This is the way medicine is going to be practiced. It is no longer justifiable to say you can remember what you need to remember when you see a patient. When I go to visit my doctor, does he know whether I've had a colonoscopy or a tetanus booster in the last 10 years or whether I've had a lipid screening? Probably not. Is there a way to help him? Yes. So it's good for the patient and good for the physician."
Moving Forward Regionally
A different model is operating in Indianapolis, which has the nation's only citywide EHR system. The Regenstrief Medical Records System (RMRS), launched 30 years ago, evolved from a single hospital-based clinical information system to a system that now links eleven hospitals. RMRS has been widely recognized for its role in improving patient safety and quality care, increasing efficiency, and preventing medical errors. The Institute also pioneered the development of HL7, now the standard for electronic data interchange in health care.
Regenstrief's ultimate goal, says Dr. Clement McDonald, Institute Director, and an Indiana University Distinguished Professor of Medicine, "is to have the whole city fully automated, fully wired for medical information so that it would serve all needs, including public health." Yet despite the growth of RMRS, "we still have paper," says McDonald. And while he is optimistic about having large and medium sized organizations integrated in the next couple of years, he is less so about individual physicians. He ascribes physicians' slow uptake of EHRs both to their price and limitations.
McDonald sees two major barriers to broad EHR acceptance. The first, predictably, is cost. "Fax machines puttered along until they got down to $200 a box. Then it was like a forest fire. If we could get an EHR down to $200 a physician, it would help." The second is standardization. "You've got to achieve unified data flows, structures and codes. That's why the Markle Foundation and others are working to build a standardized infrastructure, where everyone uses the HL7 standard to send messages." Lack of standardization is also a factor limiting the usefulness of current software. For example, e-prescribing does not deliver records of all the prescriptions taken by the patient.
Another issue is privacy. Authenticating 5,000 to 10,000 Indianapolis providers and 1 .2 million citizens remains a problem. "How do we really know it's you and not your kid or neighbor that is requesting the medical information? We've already had a spousal suit over patient data. We're learning the lessons as we go." McDonald believes eventually everything will happen "but these software issues are still big barriers."
What To Do
EHR software systems come in a variety of styles. shapes, sizes and prices: some are geared to small and solo practices, some to medium and large practices. When shopping for EHR software, be aware of the fact that a Certification Commission for Health Information Technology, formed in 2004, will soon be certifying the functionality, security, reliability and interoperability of electronic health records for the ambulatory or outpatient setting. Specific standards will be required. Before purchasing a system, ask whether it contains the technical requirements to be certified.
Pick the package, or have your vendor configure one, that works best for you and your staff. Share with your software vendor how your office works and what you hope to accomplish with your computerized system. Do you want a program that automatically extracts medications and allergies and creates an instant problem list? Do you want internal messaging capability? Do you want an e-prescribing management system? Test a system's screen and navigation system. Is it user friendly?
The key to success is training and incremental change. Since EHR systems consist of different modules, for maintaining the electric chart, for transcription, for prescribing, for lab results, for scanning documents etc., you can get up to speed one module at a time. Schedule fewer patients on those days when you are training. If there is a tech-savvy physician or staff person in your office, consider designating them in-house trainers who can support and supervise others.
What is it like to use an EHR system? Your patient arrives at the front desk. The receptionist logs the patient into the computer. The patient's name on the calendar turns a different color after the receptionist has logged the patient in. The physician, no matter where he is, can log in, see his calendar and access prior visits, lab and xray reports and pending issues. The physician copies and pastes a problem list to give him a template for the new visit. During the office visit, while listening to the patient, the physician inputs new information into the medical record. He then enters his prescription, which is printed out at the front desk, ready for the patient to pick up before leaving. The entire visit is now in the physician's EHR. The scheduling, billing and office-management system are also electronic.
How To Get Started
Select a physician leader to evaluate, purchase and implement the system. Identify the issues you want the EHR to address and allocate sufficient time and money for success.
Find experts to guide you. Ask colleagues who have already made the switch or talk to a computer specialist at your hospital. Other options include hiring a EHR consultant, for example www.emrconsultant.com, or conferring with your medical specialty society, for example www.aafp.org
Attend the 2006 TEPR Conference & Exhibition, which brings together 180 vendors and experts. www.tepr.com.
Check out different vendors. There is no one best system, although there are best products for different functions. Some major vendors include: www.nextgen.com, www. epicsystems.com, www.pmsi.com, www.synamed.com, www.dl-first.com, www.allscripts.com, www.eclinicalworks.com, www.midmarkdiagnostics.com, www.medfusion.net, www.medicware.com, www.surescripts.com, www.kryptiq.com
Do some online research. Some places to start: http:// www.hhs.gov/healthit/, www.e-healthinitiative.org, www. markle.org, www.chcf.org, www.himss.com, www.centerforhit.org, www.amia.com, www.capg.org, www.familydocs.org.
Contact organizations that offer incentives to switch:
Sharing EHR Costs
EHRs offer the promise of improved care and lower costs. That is one reason why, for example, the U.K. has accepted the cost of electronically linking its hospitals, clinics and physician's offices. In contrast, in the U.S. the burden of implementing EHRs rests on physicians, while the financial benefit flows to the purchasers of care. Experts predict that when public and private insurers agree to share the costs, physicians will more readily agree to transform their systems.
Health information technology systems are expensive to buy and maintain, require staff and clinician training and initially add time and complexity to a practice. Moreover, according to Dr. Basch, "when you use the EHR tool as it should be used, you end up spending more time with patients, seeing patients less often since a lot can be accomplished through virtual management, and do more pro-active care coordination, disease management and preventive-care management. Currently, these are not reimbursable. Reimbursement for optimizing health care quality in a fiscally-responsible manner will motivate physicians to purchase, and therefore EHR vendors to create, the tools that enable good stewardship of precious health resources."
More payors, from BC/BS to CMS, are nudging doctors along with a financial incentive. They have initiated pay-for-performance plans which rewards doctors for better care and which favors electronic systems. (please see sidebar) If you change how you practice medicine to improve the outcomes of your patients, you will receive a premium in addition to your regular reimbursement. The increase should pay for the technology that will transform your practice from episodic, reactive care to interconnected, pro-active and continuous care. Some physician practices, with bonuses tied to how well they are managing their diabetic patients, expect a six-figure boost in their revenue this year. "If CMS pays more for those who use EHRs to improve care," says Wiesenthal, "everybody else will follow suit. I think they are on the path to getting there. If the federal government isn't part of the picture, then it will take a whole lot longer to get there. But get there we will."
The Future Is Now
With so much at stake and so many converging interests, it is clear that the digital revolution is coming to health care. Just like all other aspects of their lives, patients increasingly want easy, computerized access to their records, and virtual access to their physicians. Resident physicians will preferentially choose electronic practices when they join they finish their training. Major financial players, including the federal government, are advocating widespread adoption of EHR systems. The President's Ten Year Health Information Technology Plan is being implemented in collaboration with the private sector. Uniform standards for the electronic exchange of clinical health information are being hammered out. Federal grants and pilot programs are being awarded to create incentives for investing in EHR technology. The convergence of so many interests clearly foreshadows the computerized future of medicine.
In short, patients, physicians, payors and politicians all agree: there is an EHR is your future. The only question is when.
— Eleanor Foa Dienstag
Eleanor Foa Dienstag is a freelance writer whose work has appeared in The New York Times, Travel & Leisure, McCall's and Harper's among others. She is the author of two books, Whither Thou Goest, a memoir, and In Good Company, a corporate history. She writes frequently about health and medicine.
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