We are in the age of patient information sharing - and electronic health records are making it possible
along with great effort from public and private groups focused on
establshing standards and healthcare facilities that are investing in
EHRs.
It is as though massive Tectonic plates of healthcare informatics have
shifted and an earthquake of seismic proportions and ramifications in
healthcare information technology (IT) has begun, according to Mark
Leavitt, MD, PhD, medical director of the Healthcare Information and
Management Systems Society (HIMSS).
A coalition comprised of the federal government, professional IT and
medical societies, private foundations, industry leaders and experts in
the field has resulted in adoption of standards that enable
interoperability, and other groundwork that will lead to the
development of national health information networks. Thirty years in
the making, the era of electronic health records (EHRs) - where secure
and private patient clinical information and medical images can be
shared safely and efficiently across the healthcare enterprise, the
community and even across the nation - is upon us. IT professionals are
ideally positioned to guide their institutions through the necessary
steps to enable smooth transitions into the changes that are coming.
"We are on the verge of the golden decade of healthcare IT, as it rolls
out and becomes part of everyone's professional life in healthcare,"
asserts Leavitt. He suggests that these IT activities have moved from
the position of questioning whether or not electronic health records
are possible to the understanding that the sharing of clinical data are
imperative and must be accomplished and the only question is what steps
are vital to meeting this mission.
UNCLE SAM & COMMUNITIES UNITE
Public-private initiatives on the national and local level have begun
to propel the development of interoperable networks to facilitate
secure sharing of patient information between healthcare providers on a
"need-to-know" basis. The federal government has established the Office
of the National Health Information Coordinator (ONCHIT), headed by
David Brailer, MD, to assist with coordinating efforts of the vendor
community and healthcare providers designed to drive these endeavors
forward. Professional medical societies have placed emphasis on
enhancing their members' use of electronic solutions to information
sharing. And many communities have begun establishing networks to
connect their disparate healthcare providers to central data
repositories.
The Markle Foundation in New York City convened the Connecting for
Health Steering Group comprised of more than 50 leaders and
decision-makers in healthcare to promote voluntary adoption of data
standards and communication protocols for the sharing of healthcare
information in 2002. In January, they renewed their commitment to
advancing the use of electronic connectivity in healthcare.
David Lansky, PhD, director of the health program at the Markle
Foundation explains that currently, we have an incredibly fragmented,
complex and sub-specialized medical care system, which
means that specific information about any individual patient is
difficult to collate for use.
"The Markle Foundation's work in this area is to support
interoperability from the very granular level of specific data
standards that need to be adopted uniformly, to the policy level of
encouraging governmental agencies and others to do their work in such a
way that it encourages standardization and interoperability," says
Lansky. IT professionals must become informed about the scope of these
activities, and learn specific steps necessary to insuring smooth
integration into regional information systems of the future.
CURRENT REALITIES
As healthcare IT has evolved over the past 30 years, from IT activities
solely directed at managing the financial aspects of a healthcare
institution to the introduction of departmental IT systems to the
current state of enterprise-wide IT solutions that integrate all of the
disparate departmental systems, the terminology has evolved as well.
The medical informatics community introduced the concept of electronic
medical records many years ago, according to Helmuth F. Orthner, PhD,
professor and director of the department of health services
administration and program director of the health informatics program
at the University of Alabama at Birmingham. The notion of electronic
health records (EHRs) is more recent.
"As we change the definition and terminology, it reflects the evolution
to a more comprehensive approach," explains Orthner. This all-inclusive
methodology requires structured interactive data, not merely scanned-in
paper documents and images.
J. Marc Overhage, MD, PhD, president and CEO of the Indiana Health
Information Exchange in Indianapolis, explains that although there are
major differences between the EMRs in a hospital and those in the
ambulatory setting, within an integrated EHR world, data must flow
smoothly between these two environments.
In a hospital, the patient record is more self-contained, with results
from imaging departments and laboratories and other well-defined
sources of information under some measure of control within the IT
domain. However, physicians in private practice who admit their
patients to the hospital are considered "infrequent users" because
their primary practice is in their office, and they may have admitting
privileges in more than one hospital. Becoming proficient in several
different EMR systems may present enormous challenges.
On the ambulatory side, the physician may receive data from a number of
different sources, which means that the interfacing issues or
connectivity issues become paramount. They may receive laboratory
results from 30 different sites. Imaging is a bit different, because
they are likely to receive imaging data from the hospitals or
stand-alone imaging centers, but that would be fewer in number than the
laboratories. The physician is more likely to use their EHR system day
in and day out, so they become quite skillful in working with a wider
variety of system features. However, there is no infrastructure of
support, no IT department to manage the system, so challenges arise
from that circumstance.
Another critical factor involves patient and physician identifiers. For
physicians, this means they have an identifier number for the
laboratory, and radiology and the echo lab, etc. Overhage says that as
a general internist in Indianapolis, he has 47 unique identifiers. "We
have this 'Tower of Babel' situation because we have all done what is
easy and expedient for us individually. The key is to get people to
look at the bigger picture, not just their tiny piece of the world."
The same scenario holds true for patients who do not have a centralized
patient identifier number that works for all of their encounters with
the health system.
GETTING AHEAD OF THE CURVE
Paul Tang, MD, chief medical information officer for the Palo Alto
Medical Foundation in California, says that with patient safety as a
pressing issue, most people have recognized that the status quo is
unacceptable, and the only way to improve the current situation
substantially is to put a health information infrastructure into place.
"I would try to get up to speed on this stuff," he says. "If you don't
have an EHR in place, there is an increasing chance that your
organization or health system will be getting one within the next five
to 10 years."
At Sutter Health, which is a huge health system with 27 hospitals in
Northern California, they anticipate full deployment of their
infrastructure within the next two years, investing about $154 million
by the end of 2006. "Radiologists and IT professionals need to know
this is something that is going to happen, and sooner rather than
later."
John F. Quinn, principal and CTO of Capgemini Global Healthcare
Practice in New York, agrees. He suggests that IT professionals must
become knowledgeable about standards implications, such as the latest
version of HL7 published in July as a baseline for starting to compare
levels of compliance.
"People need to understand what HL7 version 3 is, what SNOMED is, and
what it would take to create an environment that would interoperate in
that type of standards environment," says Quinn.
The importance of an institution or healthcare network incorporating
standards-based systems cannot be overstated. The future of the
evolution of a nation-wide health information infrastructure is the
development of Regional Health Information Organizations (RHIOs). If a
healthcare organization does not adopt standards-based systems, they
will not be able to participate when RHIOs are formed.
"If you're an IT professional and you're working in a provider
organization right now, someone needs to look at your competitors and
work with them, and your reference labs, freestanding imaging centers,
referring physicians, local payors, pharma companies that work in your
area, primarily the retail pharmacies, and start figuring out how you
are going to organize into RHIOs," Quinn advises. "Get in front of the
curve and be a leader in this. Don't wait for your competitor to figure
out something and then ask if you want to join."
At this point, there are two or three demonstration projects that are
up and running, with the most notable being the Indiana Network for
Physician Communications, which is part of the Regenstrief Institute in
Indianapolis.
Besides emphasizing the critical aspect of insuring that any new system
acquisitions are based on national data standards to enable
interoperability, Markle Foundation's Lansky urges IT professionals to
become involved in the development of local networks. "The direction
from the federal agency will be a regional network of interoperable
systems. These will ultimately be made up of these self-generated ad
hoc networks, but [healthcare professionals] must be aware of and
plugged into their local initiatives."
Ultimately, the Markle Foundation envisions a time when individual
patients will have control over their own health records. Lansky
asserts that when people are asked if they want their medical records
online, most will answer in the negative because they picture identity
theft, hacking and other privacy issues. But if you ask if they want to
be able to refill prescriptions online, or make appointments online, or
see their lab results online, most people would answer a resounding
"yes." Patients are the only individuals with the moral and legal
authority to gather information about themselves from a number of
different sources. This initiative will take some time because the
public has not yet begun to demand it.
Overhage from Indiana urges IT departments to clearly define goals,
beyond trying to go paperless, and determine precisely what they want
to do in the EHR realm. "They must be very clear about what they are
trying to accomplish by adopting an EHR. Are they trying to reduce
their staff? Are they trying to improve quality of care? They can have
more than one goal, but they must be clear and let that guide their
decision."
Eric Brown, vice president in Healthcare and Life Sciences Research
Team at Forrester Research, Inc. in Cambridge, Mass., raises the issue
of making decisions about how much of an existing IT infrastructure
should be retained. "There are digital hospitals built from the ground
up with no legacy systems, and one of the large vendors does the whole
thing end to end, conceived as a whole," says Brown. "But that is not
typical." Most hospitals have adopted departmental level systems, and
they cannot afford to discard all of those endeavors, but integrating
after the fact can be challenging.
HELP IN SELECTING THE RIGHT SYSTEM
Because experts understand how daunting the task of selecting an EHR
system can be - given the 100+ vendors offering systems - there are a
couple of initiatives that specifically direct those efforts.
As any IT professional would anticipate, HIMSS has served on the
forefront of these efforts. The Ambulatory EHR selector is an online
product offered by HIMSS, as described by Leavitt. "It is meant to help
the physician or practice manager winnow down their choices as they
look at vendors to supply their electronic health record systems."
Users enter data such as practice size, the key features that are
important to the practice, and using a matrix of about 350 parameters,
the selector offers a list of potential solutions. This subscription
service, which costs $149 for a yearlong subscription, also is
available for a 30-day trial period for anyone who attends the HIMSS
Physicians Adopting Computer Technology conferences.
Another project that HIMSS has entered with multiple other
organizations is the Certification Commission that is working to
certify EMR products for ambulatory care. This group determines
important standards, and whether or not vendor offerings are robust and
will interoperate. Vendors participate on a voluntary basis, but
end-users can use certification data in their decision-making process
about which system to purchase.
Besides those initiatives, Leavitt urges IT professionals to attend the
HIMSS conference in February in Dallas where they will feature two
large interoperability showcases, one called the ambulatory showcase,
and the other called the cross-enterprise showcase. Each will feature
about 5,000 square feet of display space, and involve hundreds of
vendors. These systems focus on interoperability between PACS,
radiology systems, laboratory systems and hospital VHRs.
David C. Kibbe, MD, director for the Center for Health Information
Technology in Washington, D.C., which is a division within the American
Academy of Family Physicians (a professional organization representing
more than 90,000 family practitioners), describes a software
application on their website called the Physician Product Reviewer.
Their members can access that service, and find more than 100 EHR
products that have been reviewed by their physicians.
There are system-wide solutions that have been constructed in several
communities that offer insights into important aspects of developing
these network solutions.
CONCLUSION
After 30 years of waiting in the wings, electronic health records have
moved to center stage for deployment. With all segments of the health
informatics community engaged, these initiatives are predicted to
accelerate into exciting new implementations. The importance of IT
professionals to these endeavors cannot be overstated, and experts
agree, they must become involved as a driving force.
Two facilities blaze the EHR path
Tom Smith, CIO of Evanston Northwestern Healthcare in Illinois - one
of the winners of the 2004 Nicholas E. Davies Award for excellence in
implementing electronic medical records technology - explains their
process for integrating their EMR network comprised of three hospitals
and 500 physician employees, who work in 68 different locations.
In late spring of 2001, their administration and professional
leadership staff set the implementation of a system-wide electronic
records initiative as their No. 1 corporate project for two years or
more. In the summer of that year, they selected Epic Systems Corp. as
their vendor, and their board of directors allocated $25 million for
the project.
In January 2002, they began systematic workflow analysis, which allowed
them to bring all of the end-users into the project. They produced
about 2,000 detailed workflow patterns after consulting with their 500
high-level staff members. Each of those individuals described their
processes at that time and how they could do it better with a computer.
For example, in their original system, when a physician wrote an order,
the nurse would often interpret and transcribe the order and send it to
a pharmacy through another system, where the order would be filled.
With electronic solutions in place, the physician now enters the order
electronically, selecting from a list of approved medications and
dosages, the system checks for potential drug reactions, or allergies,
and the order goes directly to the pharmacy without the need for any
interpretation.
Following their detailed workflow analysis, they used computer software
to build their end product to make it work the way they wanted. After
testing and training, they "went live" with their first office in
January 2003, and the first hospital two months later.
"In all of our locations, we no longer use a paper record for their
care," Smith says. "It's computerized from beginning to end in the
offices, in outpatient and inpatient settings. It cost about $35
million over the entire period for hardware and software, but we have
documented that we are now saving $12 million per year." At that rate,
in a few years Evanston Northwestern should re-coup all of their
capital expenditure.
John D. Halamka, MD, CIO of the Harvard Medical School and CIO of
CareGroup in Boston, describes how they have linked their nine million
patients and 3,000 physicians within their system.
"CareWeb interlinks all of the hospitals, all of the owned practices
and a few of our referring practices in a framework that allows on a
'need-to-know' basis in an audited, secure way a look at problem lists,
medications, allergies, laboratory and radiology studies," says
Halamka.
To be able to accomplish this system, they first needed to interrelate
all of the medical record numbers that a patient might have. The system
functions with several hospitals that each has its own internal
enterprise EMR systems and PACS. For example, one hospital uses an AGFA
PACS, another uses a Philips PACS and the third uses a GE PACS. Because
they all use DICOM as the underlying standard, interoperable images are
available through the web, so the physician can view any image
performed anywhere within the system. While all of the activity is
accomplished on the internet, Halamka describes strong firewalls, and
intrusion detection to insure that hackers do not gain access.
"Rolling out this technology is 15 percent a technology problem and 85
percent a process and organization problem. Convincing doctors to use
it, dealing with legal problems and compliance issues means you cannot
underestimate that there is much more to do than just get the servers
running and the software up," concludes Halamka.
He describes another exciting initiative that they are pursuing that is
designed to document cost savings enabled by adoption of EMRs. The
state of Massachusetts currently spends $30 billion per year on
healthcare. Experts have estimated that adoption of electronic patient records will eliminate about 15 percent of the
expense of medical care. This means that in Massachusetts, they could
save $4.5 billion per year. The Massachusetts eHealth Collaborative,
with funding from Blue Cross/Blue Shield, will
conduct a pilot project where they completely "wire" three communities
selected through a competitive process. They will analyze performance
over two or three years to determine whether having all physicians in a
network does really reduce waste and inefficient care as anticipated.
If it works, they plan to ask payors to contribute the billions of
dollars it would require to "wire" the entire state.
We are in the age of patient information sharing - and electronic health records are making it possible
along with great effort from public and private groups focused on
establshing standards and healthcare facilities that are investing in
EHRs.