State of the EMR

State of the EMRWhen can three minutes add up to $13.5 million? When an EMR is teamed with PACS at the University of Texas M.D. Anderson Cancer Center. It’s no riddle. An internal study by the University of Texas M.D. Anderson Cancer Center found that by integrating a picture archiving and communications system into an electronic medical record (EMR), the Houston institution saved $13.5 million per year simply by eliminating the three minutes on average it took clinicians to visit the radiology department to access images.

For the variety of institutions contemplating a move to electronic records and imaging, the value could be even greater, mostly because the cost of making the switch has come down so drastically in recent years.

The M.D. Anderson study noted that the components of a typical radiologist’s electronic workstation dropped from a list price of $160,000 in 1998 to a very affordable $20,000 seven years later.

Over the same time period, the setup evolved from four analog monitors to three flat-panel displays, reflecting a vast improvement in PACS interpretation software, according to Kevin McEnery, MD, associate division head for informatics in the Division of Diagnostic Imaging. Essentially, the workstation evolved from a big-ticket capital investment to a commodity purchase in just seven years.

Today, digital imaging is making a difference at virtually every major teaching hospital in America to some degree, and it is starting to make its way into the community hospital — but putting in technology is never a simple process.

Cedars-Sinai Medical Center in Los Angeles went live with PACS in radiology in April 2001, but it took five more years for the hospital to automate the rest of its imaging. (It’s still not 100 percent digital, as scoliosis studies and some mammography remain on film.)

Cedars may not have saved much money making the conversion, as IT professionals making top dollar replaced legions of low-paid film handlers, but digital imaging has grown in popularity as medical technology has advanced.

“Traditional surgeries are demanding more imaging,” Franklin Moser, MD, the hospital’s director of clinical and interventional neuroradiology, said at an international conference this year. At the same time, Cedars has converted traditional operating rooms into “interventional suites” for high-tech, minimally invasive procedures like virtual colonoscopies, and such techniques rely heavily on advanced imaging.

In September, just a year after watching the surrounding community get all but washed away by Hurricane Katrina, Memorial Hospital in Gulfport, Miss., started a nine-month migration to a filmless and digital imaging system in cardiology. The hospital already had been fully filmless in radiology and, thanks to an EMR, essentially paperless as well.

The automation helped Memorial survive the killer storm without losing so much as one patient chart. Ask other Gulf Coast healthcare providers if they can make that claim.

It also made sure that physicians scattered by the hurricane could access records from anywhere, via a secure internet connection. More importantly, complete medical records were available for the untold tens of thousands of patients who fled coastal Mississippi.

“What we learned from Katrina was the value of the digital record,” says Gary G. Marchand, president and CEO of Memorial Hospital.

It didn’t take a hurricane to create massive fragmentation of patient information at the George Washington University School of Medicine and Health Sciences in Washington, D.C., just 41 different specialties and subspecialities, each with its own paper charts.

That changed when George Washington University Medical Faculty Associates went to an EMR, pulling scattered snippets of information into a single, complete record of each patient’s encounters with the entire 280-physician faculty practice. “We’ve got all of the data instead of some of the data,” says CEO Stephen L. Badger.

And since the Department of Medicine became paperless in July 2005, the practice has saved more than $1 million in staffing costs and freed up 5,100 square feet of space for its nuclear cardiovascular, cardiac treadmill and nursing triage programs. All that square footage previously was reserved for chart files.

“This has been a home run for us,” Badger reports.

The automation includes an internet portal for patients to communicate with their physicians, view test results, request prescription refills and set appointments. Except in the event of abnormal values, laboratory reports go out electronically, shortening patient notification time to less than 24 hours from what used to be a week or two.

Revenue has jumped, as clinicians are able to see more patients rather than having to spend their time chasing down pharmacists, technicians or file clerks, and the referral process has been streamlined.

“It’s changed us from being a reactionary physician practice to being a proactive one,” Badger says. “It’s allowed us to go from defense to offense.” That includes the reduction of defensive medicine because the EMR’s audit trail leaves no doubt if a physician performed the proper test or informed a patient of various treatment options.

How the numbers stack up

The Healthcare Information and Management Systems Society (HIMSS) estimated in February 2006 that about one-quarter of U.S. hospitals and integrated delivery networks have gone to EMRs.

Later in the year, a Commonwealth Fund study said that about 28 percent of primary-care physicians had some form of electronic record — far behind their counterparts in other industrialized nations.

The truly interoperable electronic health record (EHR) — one accessible to clinicians across health systems, not just within a single institution — remains an even more far-off goal in all but a few pockets of the country.

A nationwide push for connectivity of health information started with the 2004 State of the Union address, when President Bush called for interoperable EHRs for most Americans within 10 years. The effort accelerated later that year with the creation of the Office of the National Coordinator for Health Information Technology.

The first coordinator, David Brailer, MD, put forth a four-pronged strategy of informing clinical practice, interconnecting clinicians, personalizing care and improving population health via IT. Brailer stepped down in May after two years on the job, and was replaced on an interim basis by Robert Kolodner, MD, who is on loan from the Department of Veterans Affairs, but the strategy remains the same. Kolodner has been widely praised for helping to make the VA’s health information systems among the most advanced in the world.

Brailer touted the regional health information organization (RHIO) as a centerpiece of interoperability plans, while also advocating for quality-based reimbursement rather than the prevailing model of payments based on volume. The administration has taken several steps intent on changing the system and promoting IT adoption in 2006.

Last summer, Bush signed an order requiring federally sponsored healthcare programs — primarily Medicare, the VA, the Military Health System’s Tricare and health plans for federal employees — to provide enrollees with information about how much healthcare providers are paid for certain services. The executive order also requires federal agencies to establish standards for measuring quality.

Both programs, which must be in place by Jan. 1, are intended to promote transparency in healthcare, with an eye toward expanding “pay-for-performance” and other quality-focused reimbursement schemes. Information technology is supposed to be the enabler.

Meanwhile, a federally funded, private organization called the Certification Commission for Health Information Technology (CCHIT) has given its stamp of approval to 33 commercially available ambulatory EMR and EHRs, certifying that each product meets a minimum set of standards for functionality and interoperability.

Certification will expand to inpatient records next year and to community-wide networking software in 2008, and the list of certified ambulatory EHRs should grow with each new, quarterly testing period.

In a related move, the Department of Health and Human Services this year created safe harbors under the Medicare anti-kickback provisions and the Stark rules governing physician self-referral, allowing hospitals to donate up to 85 percent of the cost of electronic records to medical practices. In order for the exemption to apply, donated software must be certified as interoperable.

Certification is meant to demonstrate that an EHR can handle certain tasks, such as clinical documentation or results reporting, not that a particular product is suitable for any given hospital, department or physician office. “We don’t substitute for due diligence,” says CCHIT Chairman Mark Leavitt.

According to Tim Eggena, executive vice president for research and development for NextGen Healthcare Information Systems, an ambulatory EHR vendor based in Atlanta, certification is helping to weed out some of the weaker players in the market, but it should not be the final determination in a purchasing decision.

“For the providers out there, they need to look beyond just certification and look deep into actual functionality,” Eggena says. “It’s not just buying from one of the certified vendors.”

Indeed, Janet Marchibroda, chief executive of the eHealth Initiative, a coalition of IT supporters across the entire healthcare spectrum, says that the purchase of software represents only one-fourth to one-third the total investment in electronic records. There is computer hardware to buy, training of staff and ongoing maintenance of installed systems. Above all, though, EHRs represent an entirely new way of practicing medicine.

“Regardless of the state of the software, the biggest issue is process redesign,” Marchibroda says. Depending on the features of the particular EMR system, physicians, nurses and office staff alike may have to learn new ways of communicating with patients and with each other. Methods of billing and clinical documentation change, as does the referral process.

The University of Pittsburgh Medical Center’s St. Margaret Hospital had a short-term reduction in efficiency when the EMR came online, but it definitely was short. “After six weeks, everybody was much, much faster,” says Joel Diamond, MD, the hospital’s chief medical information officer.

Diamond’s own seven-physician practice reports a net gain of $95,000 in the year after installing a Misys Healthcare Systems EMR in 2002. After two years, the practice had reduced support staff by four full-time equivalents, eliminated all chart-pulling and dictation costs, improved coding and reduced overtime expenditures.

The money saved was reinvested in the practice by raising salaries, which, in turn, boosted job satisfaction and staff retention.

Integrating the EMR

Diamond’s practice was far ahead of the curve in 2002. Even two years ago, the idea of an EMR or EHR was somewhat of a foreign concept to all but the most advanced medical practices, though this was less true for hospitals with large IT departments.

“It’s kind of an alien. People are trying to figure this out,” NextGen R&D chief Eggena says of electronic records. But like electronic practice management systems two decades ago, healthcare will grow more comfortable with the technology, he predicts.

“We’re making progress,” says Charlene Underwood, director of government and industry affairs at Siemens Medical Solutions, and president of the HIMSS EHR Vendors Association. However, Underwood adds. “We’re still lacking the right [financial] incentives.” Payers and employers need to do more to effect change, Underwood says.

At least one business heavyweight, namely Intel Corp. Chairman Craig Barrett, is challenging the healthcare community to stop worrying about what things will cost and just take the plunge already, seeing that healthcare is two decades behind other major industries in adopting information technology.

“When we have hospitals and doctors and interest groups saying, ‘I can’t possibly do this, I can’t possibly do electronic prescriptions because the PCs are so expensive,’ you just can’t look at these people with a straight face. You have to laugh at them. You have to say, ‘Join the real world; look around,’” Barrett said in a September speech to health IT leaders at the Third Health Information Technology Summit in Washington, D.C.

At the same time, the Intel boss admonished the business community to demand quality rather than negotiating healthcare coverage based on price alone. “We’ve got to change the debate. The debate can’t be who pays,” he said.

“I don’t think the current situation, the status quo, is acceptable. We have to see a major change, and that major change has to come from my community,” Barrett continued. “The people with the purchasing power have to provide the incentives because, frankly, I don’t think the [healthcare] industry is capable of modifying itself.”

Which leads to a bit of a chicken-and-egg conundrum in healthcare: It’s hard to purchase based on quality without accurate data on quality.

While the presidential order on transparency was intended to enable quality measurement and Medicare and some private payers have sponsored a number of small-scale pay-for-performance efforts, U.S. healthcare still is based on volume and production. That is unlikely to change as long as paper records predominate.

“You can’t wait until pay-for-performance to put in an EMR,” says UPMC’s Diamond. “Viable pay-for-performance is absolutely impossible without an electronic record.”

Health plans have tried to measure outcomes in much the same way they have identified candidates for disease management programs, namely by examining claims data. But after comparing actual hemoglobin A1C levels of diabetic patients in his own family practice to what payers provided, Diamond determined that claims-derived information was less than accurate, and was costing the practice money. He showed the information to a couple of large payers and was able to justify higher coding levels and recoup lost revenue.

“For the first time in my life, I felt like I owned the data,” Diamond says. “It was a very empowering moment.”

Diamond felt equally empowered when he was woken up in the middle of the night by an emergency physician in San Francisco who was treating one of his patients. With the EMR, Diamond was able to log on to the EMR from home, view the patient’s chart and provide the ER doctor with relevant test results, saving valuable time and averting duplicate testing.

As he recalls the exchange, the other doctor said, “Dr. Diamond, I noticed it was almost 2 a.m. in Pittsburgh. What are you doing in the office?” Diamond responded, “I’m in my bed, dude.”

The crystal ball

If RHIOs ever take off on a wide scale and form the basis of an envisioned national health information network, the distant ER physician might not even have to call Diamond for such information. An electronic key provided by the patient would unlock the patient’s record — or at least a clinical summary listing chronic conditions, medication history, allergies and recent lab reports — to help avert medical errors.

Two-and-a-half years into the national effort, there are something like 300 entities that could be labeled RHIOs or a similar form of health information exchange. Perhaps a half-dozen of those are financially self-sustaining.

“We’ve seen the field mature a lot…but this is hard work,” says the eHealth Initiative’s Marchibroda. “It moves counter to the way the health system operates.” Sharing information with competitors is not exactly intrinsic among hospitals or insurance companies.

Marchibroda sees imaging exchange as one means of breaking the impasse. “I think it’s an area that is ripe for advancement but it hasn’t been talked about a whole lot, and I’m not exactly sure why.”

A recent eHealth Initiative survey showed that 12 percent of health information exchanges were moving images and 20 percent were sharing radiology results. The latter number is not far off the 26 percent exchanging inpatient laboratory results and 22 percent electronically transmitting inpatient lab values.

Anecdotal evidence reported last year by M.D. Anderson’s McEnery suggests that further interorganizational exchange of electronic images is taking place not over electronic networks but via physical media such as CD. Those movements would not show up in the eHealth Initiative poll.

“Users benefit quite a bit from the transfer of images electronically, clearly,” Marchibroda says. The fact that standards have been in place for some time also puts health imaging ahead of other clinical information.

All the large vendors of filmless radiology equipment came together years ago and agreed on guidelines for data exchange, Digital Imaging and Communications in Medicine (DICOM). “The vendors stood together,” Underwood says. “They recognized the value of a single standard.”

In contrast, the healthcare industry still has not agreed on a common definition of an electronic health record.

Marchibroda still believes that the EHR is advancing, in part because progress is being made in a series of federal contracts supporting regional interoperability and the development of a national electronic network for biosurveillance.

“I think this movement towards quality also will have impact. We didn’t see that last year,” Marchibroda says.

“Folks are understanding that this is here to stay and we’ve got to figure it out.”

By Bush’s target date of 2014, Underwood believes that patients will have started to see the value of interoperability. “We will see the sharing of patient data at least in some areas.” 

“You would hope we’d have the surveillance network,” she adds.

As for wider, routine sharing of health information, “I think that in the marketplace, we’ll see consumers more engaged with personal health records,” Underwood says. But a lot will depend on leadership at state levels. “There’s going to be some regional success at this,” she predicts.