The State of the Electronic Medical Record

The quest for more immediate access to patient images and information to enable faster, critical diagnostic decisions is the goal of all healthcare providers. Anytime, anywhere access to all patient information is the newest Holy Grail across the healthcare enterprise.

To help in that crusade, radiologic images increasingly have become an integral part of the electronic medical record (EMR), progressing from the EMR's traditional use as a text-based diagnostic report with few, if any, patient images.

"Today, the EMR includes that [text-based] component, plus images from radiology, cardiology and other 'ologies' that have imaging modalities," says Richard C. Howe, Ph.D., vice president of IT consulting for VHA Inc.

Howe credits the Integrating the Healthcare Enterprise (IHE) initiative - the joint venture between the Radiological Society of North America (RSNA) and the Health Information and Management Systems Society (HIMSS) - for heightening awareness among healthcare providers beyond the radiology department to the value of electronic images in a patient's EMR.

"The vendors also have developed open architecture systems, which include PACS that allow all physicians to view images, not just radiologists," Howe adds.

EMR ADOPTION

The ultimate goal for many practitioners is to have EMRs become a cradle-to-grave record of a patient's medical history. As is the case with all technologies, healthcare institutions prioritize available dollars with the most immediate need. Providers that can invest in EMR technology see it as a vehicle to more informed patient-care decisions.

"It speaks to how we spend the money as a community, a country and a people," says G. Daniel Martich, M.D., executive director of the EMR initiative at the University of Pittsburgh Medical Center (UPMC). "We have limited resources. We need to be smarter about them. We want to provide the best care possible without overtly rationing healthcare. One of the ways of doing it is being more efficient as doctors, nurses and hospitals."

UPMC plans to allocate some $400 million over 12 to 14 years to implement its IT infrastructure, which includes EMRs. The hospital is four years into that plan and has approximately 500,000 patients in its EMR data banks.

UMPC's Children's Hospital has created EMRs for its young patients, not necessarily from birth, however, because it is a children's, rather than obstetrics, facility. While it may not be the cradle-to-grave approach per se, Martich said it is at least the beginning of a life-long patient record for children who are two- and three-years-old.

"I think the potential [for a cradle-to-grave patient record] is there and it is starting to get that way," he adds. "Unfortunately, only time will fully bear that out."

EMR SAVINGS

Needless to say, not every healthcare provider has the financial fortitude to install a systemwide EMR. Capital budgets are based, in part, on - like it or not - the return on the hospital's investment (ROI) in a particular technology.

"There is a limited pool of capital dollars and constituents are competing for those capital dollars," says Patricia Whelan, vice president of IT for Shields Health Care and partner in Shields Consulting for radiology informatics. She also is the former director of radiology informatics at Massachusetts General Hospital (MGH) and former CTO of MGH's Radiology Consulting Group. "[An EMR] is often looked at differently than other initiatives, because it doesn't have a direct positive ROI from the system's implementation. It competes with initiatives, such as adding a new MRI, which will bring hundreds of thousands of dollars into the organization."

What are the potential financial benefits of an EMR? About $86,400 net benefit per provider (physician), according to a study in the April issue of the American Journal of Medicine. The cost-benefit study by Samuel J. Wang, M.D., Ph.D., of Partners HealthCare System in Boston, evaluated the EMR in the ambulatory primary-care setting, comparing the technology to paper-based medical records over a five-year period.

The estimated net benefit of $86,400 per provider (physician) includes savings realized in drug expenses, improved utilization of radiology exams, better collection of charges and fewer billing mistakes. In cases where a patient's care was capitated, the net benefit ranged from $8,400 to $140,100.

START WITH THE GP

If, in fact, the EMR is to reach its cradle-to-grave mission, John Quinn, chief of technology for the healthcare practice at consultants Cap Gemini Ernst & Young (CGE&Y), says that the technology should be based in the general practitioner's (GP) office. In the United States, it is "probably the most underserved portion of the EMR market," he says. "It's the most likely place you'll walk in and still find someone using pencil and paper."

Based on dollars and cents, Quinn adds that the cost to implement an EMR generally is "prohibitive" for GPs.

"There is a fundamental incongruity or disconnection with the vision vs. how do you apply it to primary care as well as secondary care in the U.S.," he says. "It is difficult to match the vision of an EMR to how we organize healthcare in the U.S. - which is largely hospital and integrated delivery networks that tend to look at the secondary side of healthcare, as opposed to the primary care where most of our electronic medical records would lie."

Quinn says that while hospitals allow family GPs to look at information generated in the hospital, it is still a "distant, hands-off type of approach, as opposed to an integrated EMR in the GP's office."

The true value of an EMR, he says, is its ability to make physicians more effective in delivering care by automating processes, making procedures and medication distribution safer and, ultimately, reducing costs by eliminating duplication.

THE SOLO PRACTICE

Tom Landholt, M.D., has taken that approach in his one-doctor, two-year-old PatientCare Clinic in Springfield, Mo. Landholt has two employees, sees 15 to 20 patients a day and has some 2,000 patients in his EMR system. When he receives a patient image, it is never on film; it is always electronic.

"The only way for me to write a business plan and afford an office as a solo practitioner is to automate the efficiencies that you gain in the day-to-day operations so they far outweigh the investment you make upfront," he says. Landholt invested $40,000 to install his EMR system and has allocated some $20,000 in each of the last two years to keep the technology current.

"From the aspect of the EMR itself, it is an expensive way to keep medical records compared to other systems, but when you look at it as a re-engineering tool and how you can run a better office, then it starts to make sense," Landholt says. "The keys are the interfaces that go into the EMR. If you have evaluated the EMR as a standalone, it is never affordable."

When Landholt refers a patient to a hospital's radiology department, the EMR helps fill out the form, saving time and human resources. The data then is transmitted to the hospital and Landholt's office notifies the radiologist in advance about the requested scan and patient information relevant to the exam.

"Physicians look at EMRs and say 'What's in it for me?'," Landholt says. "When you look at the overall workflow, most of the work is not done by the doctor. We think for a living; others do the [paper]work. Filling out forms, looking at schedules, every time they talk to a patient, they have the EMR chart in front of them."

SAVING LIVES

A recent report from the Institute of Medicine estimates that 7,000 people die annually as a result of medication errors, while another 100,000 patients die each year because of other medical errors.

UPMC's Martich has seen EMRs prevent errors within his system. "We have had some success at our Children's hospital, in terms of medication error reduction and call backs from the pharmacy from physicians," he says.

Children's Hospital has implemented computerized physician order entry (CPOE) modules and currently is installing the technology in two other UPMC facilities. Martich says the technologies have provided for "a fluid handoff between specialist and primary-care provider or between inpatient and outpatient or doctor and nurse."

The EMR also is helpful when patients are moved to a rehabilitation center or nursing home within UPMC's network. The patients "may still have some issues going on, if they are sent to a rehabilitation facility," Martich says. "The physicians know about the patient before the patient arrives. They can look at lab reports, microbiology reports, x-ray and operative reports before the patients hits the door."

INFORMATION ACCESS

Intermountain Health Care (IHC) has 21 hospitals in its integrated delivery network (IDN), which stretches from southern Idaho to southern Utah. IHC started in 1995 to implement a picture archiving and communications system (PACS) on a facility-by-facility basis. The individual hospitals used their own budgets to install their respective PACS.

"If we were to accomplish our vision - which is making this electronic medical record available to a physician anywhere in the system from any facility in the system - we needed to also cut down those [regional] boundaries so they wouldn't be tied just to one region," recalls Deanna Welsh, IHC's administrative director of imaging services. "So, we went from a facility to a region and then to a central solution."

The central solution included deploying a long-term archive and web distribution system at IHC's IT facility, which came online about 18 months ago. The server in the IT center links directly to IHC's EMR system.

"It provides redundancy from all of the PACS in the regions and it also provides one central link into our electronic medical record," Welch adds. Initially, the EMR provided text-based patient reports across the enterprise, but since then, radiology images have been added to patients' EMRs and are available at any IHC facility.

"Now you can be in our hospital in St. George (Utah), have a chest x-ray done and then come to Salt Lake City 350 miles away and have an x-ray done here," says Welch. "A physician can pull up the x-ray from St. George and compare the one done here [at Salt Lake City]. It really is a single patient medical record, no matter where your procedures are done in the system."
Quick access to a patient EMR and electronic images not only provide better care for the patient, but can prove a competitive advantage for a healthcare provider. Such is the case for Shields Health Care and its 18 medical imaging centers across Massachusetts and Rhode Island, as they perform approximately 150,000 MRI, CT and positron emission tomography (PET) scans annually.

"We are currently rolling out so we have several hundred providers with the ability to have access to results at their fingertips," says Whelan. "The idea is 'he who has the information and can get it to the physician's desk top wins.' Here we are constantly competing with a number of different facilities for that referral."

EMR CHALLENGES

The technological fact of the matter is that the installation of an EMR is considerably easier said than done. To have any relevance, EMRs must contain information from a variety of sources, such as radiology departments, cardiology cath labs and the clinical laboratory.

"That's a good thing," says CGE&Y's Quinn. "The bad thing is that it makes it very difficult to implement. [EMRs] take a long time to reach a position where they are supporting the processes the institution wants supported. There are some fairly complex interfaces that need to go both ways."

Another reality is that the medical equipment within hospitals and healthcare systems is never all the same age.

To solve the dilemma of divergent interfaces, facilities turn to DICOM and Health Level 7 (HL7) to allow the different technologies to exchange information. A new version of HL7 messaging Standard, v.2.5, was unveiled in October. The edition stems from version 2 - the Application Protocol for Electronic Data Exchange in Healthcare Environments - the standard for communicating clinical data supported by major medical informatics systems nationwide.

The new modifications include improved documentation of the data types, the definition of a message profile methodology, better support for imaging by means of a new segment and a new order message, a new message that supports diagnoses/procedure messages in 'update' mode and a new specification of claims and reimbursement messages. (Additional information is available at www.HL7.org.)

EMR STRATEGY

VHA offers a six-phased approach for its member facilities implementing an EMR system. It begins with a planning assessment, evaluating a facility's workflow needs to increase efficiency and productivity. The process then moves to vendor selection and request for proposal (RFP), contract negotiations and plan implementation where adherence to the workflow plan is critical.

VHA aids with the implementation and an acceptance plan, which evaluates how the EMR and/or PACS should work and interface with a radiology information system (RIS) or hospital information system (HIS). The success of the system determines if and when the vendor is paid.

"It's not just that the EMR and PACS turn on; that's the easy part," says VHA's Howe. "Does it interface? Does it work well with the scheduling system? Does it work with the RIS or HIS? That's part of the acceptance plan."

EARLY COMMITMENT

St. Francis Health System in Tulsa, Okla., set out on its EMR path in 1995, as lab technicians and radiology and pharmacy departments campaigned for new integrated information systems.

Today, St. Francis' 1,000-bed hospital, inpatient facilities and outpatient clinic produce approximately 250,000 radiology exams per year. The system also enrolls approximately 110,000 new patients annually, adding to the more than 1 million names already in its EMR system.

To stay ahead of the curve, Dave Paulsen, manager of clinical systems, says St. Francis has allocated what he describes as "appropriate resources" to avoid problems with bandwidth and storage.

"I guess for an IS person to say 'appropriate resources,' other people might say 'extravagant,'" Paulsen adds. "I have not heard any physicians complain about the accessibility of the images or delay in retrieving images."

TALK THE TALK

CGE&Y's Quinn also recommends standardized terminology and vocabulary - at the very least within the same IDN - to make the EMR worthwhile.

"We're not just talking about standards like HL7 for moving the data," adds Quinn, who also chairs the HL7 technical standards committee. "We're talking about the values that are inside those messages to perform an accurate diagnosis to avoid prescription failures and missed diagnoses."

Quinn says an interface takes about three months on average to install, test and successfully implement. The interface must be verified that it can take an order from the EMR, transmit it to, say, radiology, provide a status update, cancel an order, and receive a finalized result in return.

"Each of those [functions] are different messages that need to be tested separately. That's the reason for the cost and the time," he says. "When you successfully address all those things, you have successful implementation. It's not like opening the package under the Christmas tree and an hour later having your toy put together."

With various sizes of electronic images flooding the EMR pipeline, facilities also must make provisions to accommodate larger datasets, evaluate bandwidth and provide adequate storage capacity. Generally speaking, radiology IT people use 10 megabytes per image as a standard rule of thumb to calculate needed storage.

NEXT GENERATION

In the near future, Whelan believes more vendors will develop products to solve the interface issue and there will be more choices for integration.

"I think there will be independent organizations that will drive the vendors to better adherence to standards, whether they be HL7, DICOM or otherwise," she opines. "Many organizations will realize that if they can't push, pull or move this data around in a way that is efficient, they will be behind their competition. If they're still producing paper, they won't be able to take advantage of software and other technology advancements that we haven't yet begun to think of."

Whelan also sees EMR technology "as a baseline on which all future technologies will be built," fostering the ability to connect departments within the same hospital or IDN as the common point for all available patient information.

"The electronic medical record, I believe, will be the Holy Grail of healthcare informatics," she adds. "Some people, through the technology itself, will do it correctly. Other people won't leverage the standards and won't adhere to protocols as closely as they should. However, this is a start."

Some IT-savvy healthcare providers are writing their own EMR technology, as is the case at MGH's Partners Health Care System. Partners has an EMR system called the Clinical Application Suite (CAS), which was developed to garner all patient information in
different locations into one EMR.

At PCC, Landholt sees the concept of e-visits to the doctor's office as becoming a reality with the help of the EMR.

"We will be able to better fit our services into people's lives using electronic means, rather than trying to fit people into our clinic," he adds. "There is an access problem with doctors these days and there are a lot of things that don't necessarily require me to be one-on-one with a patient."

If a patient has back pain, Landholt can schedule an MRI of the spine without a patient physically coming to his office. In the case of surgery, the hospital and patient need to be contacted and the radiology study needs to reach the appropriate physician.
"As a solo doctor," Land holt says, "the technology is the only thing keeping me independent."