An EMR is only as good as its electronic foundation
Computer network replaces phones, paper charts
When the University of Colorado Hospital (UCH) in Denver set out to upgrade its electronic network eight years ago, it faced a challenge quite opposite from that of many institutions. Instead of cajoling resistant clinicians to get on board, the clinicians prodded the administration to modernize an outdated network. "Fortunately, our CEO is technologically oriented," says Steve Clark, PhD, vice president and chief information officer. "Besides," he adds, "the state legislature spun us off in 1990 to be a semi-public entity, so we had to compete in the open market."
A teaching and research facility, UCH provides tertiary and trauma care. Other services include long-term care, an ambulatory care network, home care, and community-based wellness services.
"Tech-savvy" staff wanted the capacity to e-mail radiology images or download cardiology studies at the patient’s bedside. They needed quick, remote data access for consultation with primary care providers of patients who had gone home after care at UCH. Nurses clamored for a nurse management system. Clark’s task was to slow them down long enough to build an adequate electronic infrastructure for the new mode of work.
He used this analogy to help them grasp his logic: "We all want toilets that work. We want to be able to use them, flush them, walk away, and not think about them until the next time. But for that to happen, the plumbing has to be in place. Our network architecture is like the plumbing that supports all the things we want to do with our computers."
When the initiative began, UCH had a network "designed for an early vision," as Clark puts it. Built primarily for patient care software, it faltered under e-mail, and often crashed when transmitting an ultrasound. The new system runs on ATM technology (asynchronous transfer mode). It allows the user to operate phones and computers on the same line. The line handles all patient care and business support functions. The difference is stunning, he observes.
In traditional process improvement, he says, you might reduce a 10-step procedure to seven. "But the network overlayed a new set of tools on this organization. To show you the magnitude of the change — in 1992, we did not have e-mail at this facility. Today, e-mail is the standard and paper the exception. And, to some extent, telephone [communication] is the exception. It made our electronic medical record possible. When the network is down, we’re paralyzed!" Clark notes. Cardiologists used to spend one hour downloading and processing a single diagnostic study. They would postpone the task until the end of the day so they could do desk work while waiting. Now, they can access the same images at the bedside in less than five minutes. Thus, in real time, they can incorporate the results into patient work-ups and educate medical residents with vital information in hand.
In the early 90s when this initiative began, Clark met mainly with UCH’s technical types, the vendors (Santa Clara, CA-based 3Com), and consultants. The main exception, he says, were "the high-bandwidth folks from radiology and cardiology. We had to find out what they needed at that stage and where they saw their world going with diagnostic imaging." The QI people were not involved to a great extent, except to explain their vision of how the network should perform.
In designing the electronic medical record (EMR), however, quality specialists collaborated with clinicians and support staff. "We needed the input of direct and indirect users for a thoughtful, analytic approach to how the record would enable us to do things more effectively," Clark observes. The end product fetches glowing feedback from end users.
When people badmouth EMRs, Clark takes it with a grain of salt. "The electronic record is really a full family of systems you tie together that allows you to do your work," he says. One challenge to building an EMR is pulling together incompatible programs used throughout a system. UCH’s solution is a browser that ties programs together so users can connect to them through any remote computer and modem. The task is not quite finished. Clark is still working with a few vendors to make the stragglers among UCH’s applications browser ready. But that’s minor compared to what they could have faced had they not painstakingly crafted the network before launching the EMR.
"You’ll hear folks say their record doesn’t work," he observes. "But their information services people will tell you that the EMR works just fine. The network architecture underneath it doesn’t work like it should. You have to invest in the electronic network and databases of patient archives [and clinical reference data such as drug interactions] under the electronic medical record. If you wait until after you create the EMR, people will find that it doesn’t work."
With the infrastructure performing beautifully, UCH has completed Phase 1 of its electronic coming of age. They’re now in the middle of Phase 2, due to close in about 18 months. "When that’s finished," Clark observes, "the lion’s share of what the physicians want to look at will be on the EMR. Although we will still have some paper records, we will have displaced the requirement for paper."
He points out that an addition to the UCH campus, currently under construction, has no major storage space for paper archives. "We will still have a thin paper shadow chart of doctors’ notes, but that’s all." The reliable transmission of digital X-ray and cardiology images has eliminated the need for traditional film processing facilities in the new facility.
Roy Jones, MD, director of the bone marrow transplant program, already sees remarkable improvements in care, thanks to instant information exchange between UCH providers and oncologists in far-flung communities. "Managed care plans are increasingly entrusting the care of patients to people who don’t know how to do it," he contends. "A primary care physician called about one of my patients who had a complication. I could pull up her record instantaneously and tell the doctor the specific treatment she needed — instead of going to the managed care plan to authorize a visit with the patient."
Jones adds that the EMR empowers consumers, as well as providers, with data they could hardly access before. "A potential patient will ask, How did your last 50 patients do who had my condition?’ A doctor cannot keep that information in his head. But we can print it out for them according to disease, age, or whatever we want."
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