Move to electronic health records will speed up considerably in next 2 years
Once Y2K is behind them, hospitals will refocus on EHR
Are you part of a health care organization that is up to its collective ears in paper-based patient clinical records? Are you drowning in papers prepared for payers? Are you floundering in folders that hold everything — except exactly what you’re looking for?
If you answered yes to any of the above questions, you have plenty of company. If any or all of the above describes your relationship with the mounds of clinical and administrative paper generated by caring for patients and getting paid for doing so, you’re part of the vast number of health care enterprises that are still waiting to reap the full benefits of the computer revolution.
Attempts to fully implement electronic records, which are called a variety of names — electronic health record (EHR), computerized patient record (CPR), electronic patient record (EPR), and/or computerized medical record (CMR) — have been under way in the health care industry since the 1960s. The progress made in the intervening three decades has been slow, most recently due to more than two years of preoccupation with the impact of Y2K-related problems on existing computer systems.
But when New Year’s Day dawns, and the hysteria over Y2K (hopefully) fades away, look for renewed interest among health care organizations in increasing the computerization of the clinical and administrative data they generate.
In this issue of Healthcare Benchmarks, we take a look at some of the basic trends, ideas, and issues that come into play as the health care industry tries to get the full benefit of computerization. Next month, we’ll present some facts and data that can be benchmarked generated by a few of the success stories that have taken place.
Terms and definitions
Defined at its simplest, "The electronic health record is a computer-stored collection of health information about one person linked by a person identifier," explains C. Peter Waegemann. He is executive director of the Newton, MA-based Medical Records Institute, an organization dedicated to promoting the evolution, development, and acceptance of electronic health record systems, and chairman of the Healthcare Informatics Board of the American National Standards Institute (ANSI).
There are several evolutionary levels of EHRs to be found in today’s health care delivery systems, says Waegemann. Most modern health care organizations currently operate at the lowest level, utilizing what is called an "automated medical record," he notes. "At this stage, there is a substantial amount of patient information stored on computer, [but at the end of the day], there is still an ultimate reliance on the paper-based record."
The second level is known as the CMR, according to Waegemann. At this level, not yet fully achieved anywhere, he notes, optical scanning technology is utilized to capture data from paper-based systems, eliminating the need for paper records.
The next rung up the evolutionary ladder is the electronic medical record, which is envisioned as allowing "access to computerized patient information within a single health care enterprise — one hospital, one clinic," says Waegemann. The fourth level, EPR, is a true patient-focused virtual record, with the scope of availability expanded from single to multiple enterprises, "from the dentist to the doctor to the psychiatrist to the school nurse."
On the top rung of the ladder is the virtual "Holy Grail" of the EHR movement. The "true" EHR is an electronic compendium of all information pertinent to an individual’s health and well-being, according to Waegemann. "It differs from the EPR in that it is not limited to information captured by caregivers regarding a patient, but includes interaction with the patient in all aspects of data entry. Additionally, it includes wellness information and other health-related information that is not part of the traditional care delivery process," he says.
Original factors driving the EHR
The march toward a true EHR has been long and difficult, especially when compared to the advances made in computerization in other industries during the past 15 years or so. But, "health care is a different kind of entity," explains Sheryl L. Taylor, RN, manager of the Healthcare Emerging Technologies Group at Ernst & Young’s Washington, DC, offices. "It is perceived, especially by doctors and nurses, as a combination of art and science. It is not like banking, where everything can be broken down into simple generic accounts."
Several factors have driven the move toward the EHR over time, according to Taylor. "In the 1970s, the focus was definitely on charge capture. But at the same time, people started to realize that about 30% of the time, physicians were making decisions about patient care without having the information they needed — largely due to the inefficiencies of paper-based records. Patients were getting redundant care, tests were being ordered that weren’t needed, and physicians started realizing that a lot of errors in ordering medication were due to not having the information they needed, which led to the original push for computerizing patient records."
Jack Ciliberti, MD, medical director of the emergency department of Overlake Hospital Medical Center in Bellevue, WA, remembers those days well. "When I came to Overlake in 1980, there were not any records kept in the emergency department. So when a call came in about a patient, or a patient came in who had been there before, there was no information readily available. You had to send someone off to the hospital medical records department. They usually came back in about a week, and there was about a 50% probability that they would have anything you needed."
Over time, he worked to make sure that there was at least a repository for what he calls "key paper information" within his department. In 1988 Ciliberti bought a Macintosh computer and used it and the HyperCard development tool to create a "discharge instruction" program for his department. "We had a few preprinted paper forms with titles like How to Manage Your Crutches,’ and things like that," he says, "but it was pretty clear to me that a computerized system would really work a lot better."
Ciliberti’s program did a lot more than spit out discharge instructions. "To maintain the ability to interface with the hospital’s main information system, we, of course, captured patient name, demographic, and insurance information. And we would also enter who among the ER staff took care of the patient, what kind of diagnostic tests [the patient] underwent, and what the diagnosis was," says Ciliberti, "which automatically linked up with a set of diagnosis-specific discharge instructions."
The program didn’t stop there. "Whatever treatments we gave the patient — IVs, medications, splints, casts — were also entered into the program. The program would then provide a printout of specific instructions as needed — if a patient got a shot of pain medication, for example, the program would automatically tell them they shouldn’t drive for at least the next six hours," he adds.
There was still more. "We also used the program to keep track of the physicians and other health care providers we referred patients to upon discharge from the ER," says Ciliberti. "[The program] also had room for miscellaneous information, such as documentation of phone conversations. So, even back then, we had created a pretty substantial electronic medical record in our department. All it didn’t have at the time was the history and physical exam, but it was still very useful — it helped us keep track of and organize the real nitty-gritty patient information we needed to do our jobs."
A bigger picture emerges
Capture and maintain enough "nitty-gritty" patient information over time within your operation, and you’re well on the way to developing the outcomes database that is so useful in measuring quality — and marketing health care services — these days. "Without collecting and warehousing patient information in a standardized way, it is not possible to study trends or even begin to determine if the quality of care being provided is achieving desired outcomes," says Taylor.
"The computerized patient record is certainly a factor in making real-time patient care easier, but being able to come up with measures of quality is equally important," she says. "But, what a lot of VPs of nursing and provider CIOs will tell you today is that they need these record systems to be able to get the outcomes data to prove to payers that they are not only cost effective, but that they also deliver quality."
In the eyes of some, the computerization of patient records, ultimately leading to the establishment of the EHR as "industry standard," has potential impacts that go well beyond efficiency of care and gaining marketing advantage.
"Visionaries in both delivery and provider organizations in the health care industry have identified the computer-based patient record, or at least on-line access to individual patient clinical information, as a necessary component in creating a new bond between doctors and patients, allowing them to interact on an ongoing basis," says John Quinn, principal in charge of the Healthcare Emerging Technologies Group for Ernst & Young in Cleveland.
In this view, the Internet becomes the place where patients can both communicate with their doctors and access their own medical information.
"This goes way beyond e-mail," says Quinn. "I’m talking about things like having patients schedule appointments, enter their histories, access the immunization records of their children, and get information from their doctor pertinent to their health situation." Individual patient information accessible via the Internet could include items such as the results of recent blood tests with cholesterol numbers, as well as other types of data aimed at promoting wellness, as opposed to treating chronic conditions, he adds.
The future promises to be busy
Look for an increase in activity among health care organizations in attempts to more fully computerize patient records. "The industry has been pretty severely impacted by concerns about Y2K," notes Quinn. With that passing, "we now see a number of clients talking to us about bringing automated clinical systems off the back burner." For the past two years, "most of the time, effort, and money has been spent on remediating existing computer-based systems," he says. "But people are wanting to talk about computer-based patient records, casually now with an eye toward getting serious by March of next year."
And when most health care enterprises get serious about this subject, they team up with one or more of the legion of vendors in the field. Ask that segment a lot of questions, says Quinn.
"Look for a vendor that has actually successfully put in a computer-based patient record system, and find out where and how broadly it was implemented on-site," he advises. Most vendors can easily provide a list of places where they have implemented systems. "But when you dig deeper, you find out it was in a single department or specialty area. In other words, it was more like an experiment, as opposed to being an enterprisewide solution."
And just as important, "ask about the resources, in terms of time and money, it truly took to put the system in place," adds Quinn. In general, the answer to that question has been fairly disappointing when it comes from health care organizations that are taking steps toward the EHR, he notes.
"We’ve seen a lot of people go in with a lot of enthusiasm, but wind up getting bogged down in implementation," Quinn explains.
In many instances, "They get a system up and running in one part of their organization, and then they stop, largely because they are out of breath, and start to realize that they seriously misjudged the amount of time and money it takes to accomplish what they are trying to do."
[For further information, contact:
• C. Peter Waegemann, Executive Director, Medical Records Institute, P.O. Box 600770, 567 Walnut St., Newton, MA 02460. Telephone: (617) 964-3923. Fax: (617) 964-3926. E-mail: peterw@ medrecinst.com. Web site: http://www.medrecinst. com/.
• John Quinn, Principal, Healthcare Emerging Technologies Group, Ernst & Young LLP, 1300 Huntington Building, 925 Euclid Ave., Cleveland, OH 44115. E-mail: [email protected].
• Sheryl L. Taylor, RN, Manager, Healthcare Emerging Technologies Group, Ernst & Young LLP, 1225 Connecticut Ave. N.W., Washington, DC 20036. E-mail: [email protected].
• Jack Ciliberti, MD, Medical Director, Emergency Department, Overlake Hospital Medical Center, 1035 116th Ave. N.E., Bellevue, WA 98004. Telephone: (425) 688-5000. Fax: (425) 688-5959.]
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