The State of the EMR: Gaining Traction, Showing Results

Healthcare facilities and physician practices large and small are investing in electronic medical records to improve patient safety and quality of care while cutting cost and putting behind them the inefficiencies of paper records. A variety of facilities tell how they've taken the plunge - and offer advice for those ready to make the jump.

The concept of an electronic medical record (EMR) has existed for more than 20 years. Yet U.S. healthcare providers have been slow to embrace the idea. Economics is a major barrier, says Peter Waegemann, CEO of Medical Records Institute (Boston). "While we need the EMR for a variety of reasons - patient safety, costs, quality of care - individual physicians, clinics and hospital don't realize an immediate return on investment (ROI) with an EMR," explains Waegemann.

Economics extends beyond the micro level; British and Australian governments have invested $12 billion in EMR projects. The U.S government commitment of $100 million over a decade seems paltry in comparison. The big picture in the U.S. shows that only 9 to 12 percent of U.S. providers have invested in an EMR, says Waegemann. Other estimates go as high as 15 to 20 percent infiltration in physician offices and 20 to 25 percent for hospitals. But things are looking up as a recent study in Health Affairs shows that one-third of small practices have an EMR in the plans over the next two years.

Deane Morrison, CIO of Capital Region Healthcare and Concord Hospital in Concord, N.H., agrees that nearly no one has a complete EMR portfolio. But most U.S. healthcare providers have deployed components of the EMR, says Morrison. "In the acute care/hospital setting, the EMR consists of a collection of applications that work in concert to bring all of the pieces of the paper medical record into what appears to be a single system." The applications include nursing assessment and medication administration, transcription, radiology images and reports, historical documents and physiological monitoring and may include decision support and computerized physician order entry. On the other hand, the electronic health record (EHR) - a term often, but wrongly, used interchangeably with EMR - consists of many EMRs across different hospitals, clinics, pharmacies and health insurance companies, explains Waegemann.

This month, Health Imaging & IT visits with a handful of providers that have embarked on the EMR process to learn more about the hows and whys of the EMR. We're also taking a look at some of the challenges - and finding there is plenty of good news.

Consider:

• Healthcare facilities earn an ROI as medical records staff and transcription costs are cut.
• Patient safety is greatly enhanced via the elimination of the stereotypical chicken scratch notes and medication orders.
• Information is available in real-time and in multiple locations, allowing physicians to maximize their time while providing better patient care.
• The EMR is a richer, more complete picture of the patient. It can be mined to alert patients, such as following the Vioxx incident.
• Electronic records can advance care as on-call clinicians have a better knowledge of the patient's condition. For example, if a cardiac patient is admitted to the hospital on Friday night, an EMR-equipped cardiologist may release him sooner than a conventional provider as he has a more complete understanding of the patient's condition.

While the benefits are real and fairly consistent, the EMR selection and deployment processes are not standard. "There is not one straight avenue to success. Every experience is different," cautions Waegemann.

The rationale

Although the federal government is touting EMRs and could create incentives or disincentives to spur on adoption, there are a variety of other reasons for implementing an EMR.

Take for example Associated Cardiology Consultants, a six-site cardiology practice in New Jersey. The practice grew out of a 1994 merger of three practices, each with its distinct charting processes; some placed x-rays and labs in the front of paper charts. Others put them in back. "It was confusing," recalls Executive Director John Morris. Hence the first EMR goal: a standard chart. The practice also aimed to provide access to patient charts across its offices, decrease transcription costs and search the medical record for research purposes. Improved billing and collections also was key. "Doctors tend to undercode. An EMR provides clear documentation of the patient visit, so that we can code appropriately," explains Morris. The practice deployed Amicore Clinical Practice Management on tablet PCs in December 2000.

Alegent Health, a nine-hospital regional integrated healthcare delivery system in Omaha, Neb., has implemented a series of Siemens Medical Solutions applications including Soarian Clinical Access, INVISION bedside charting system, Soarian HIM (health information management), Siemens Pharmacy and SIENET PACS to create a comprehensive EMR solution. A new all-digital hospital provided the impetus for an EMR that could be gradually rolled out across the organization to provide real-time access to the latest clinical information to provide better quality, more efficient care. "We can hardwire quality with this system by building evidence-based order sets into Soarian," says CIO Ken Lawonn.

Concord Hospital has taken a gradual approach to the EMR process. The process began about 10 years ago with online nursing assessments, bedside barcoding and electronic medication administration via McKesson's Care Manager. Since then, it has expanded to include McKesson's Horizon Medical Imaging PACS and Horizon Physician Portal as core EMR components. Morrison explains the rationale for this approach. "The EMR is not just about getting the information online, which does not transform data into usable information. It's about re-engineering processes and changing the way information is collected."

Poudre Valley Healthcare in Fort Collins, Colo., decided to deploy an EHR, rather than an EMR, across its hospital and outpatient clinics as well as some local private offices. The implementation includes Meditech's Enterprise Medical Record for the hospital and Meditech LSS for outpatient clinics and private practices. CIO and incoming College of Health Information Management (CHIME) President Russ Branzell explains, "This provides one integrated health record across sites. If a patient visits an outpatient clinic, the core elements of the visit - allergies, treatments and medications - are shared and available."

Benefits & results

Benefits of the EMR come on multiple fronts. There are clinical benefits, workflow gains and even financial pluses. "The No. 1 and 2 reasons for deploying an EHR [or EMR] are patient care and patient safety," states Branzell. "Doctors practice better medicine with an EMR. There is so much more information in a more organized way," sums Tom Goodwin, director of clinical information systems for MIT Medical of Boston, which uses Allscripts TouchWorks.

For example:

• Physicians can graph lab results for a high cholesterol patient over time.
• Legible prescriptions reduce medication errors.
• Anytime/anywhere access to the complete patient record eliminates guesswork.
• Compliance with clinical guidelines increases. For example, facilities can electronically review charts of heart attack patients to make sure they are on aspirin therapy.

Workflow can be transformed with the EMR. Morris points out, "Today's doctors want a life. With an EMR, they can complete paperwork at home late at night." Practices are more efficient. Associated Cardiovascular Consultants increased physician staff by 33 percent with no increase in support staff.

Conventional wisdom does not equate the EMR with immediate ROI. Indeed, Morrison cautions, "For many components there is no return until all of the pieces are in place." Associated Cardiovascular Consultants touts a three-year ROI due to $150,000 annual reduction in transcription costs. The practice also saves $25,000 annually on malpractice insurance because its provider realizes the value of clear notes and electronic prescriptions. MIT Medical reduced its medical records staff from 12 FTEs to eight and reassigned two of the remaining employees to other duties.

There are miscellaneous benefits, too. Concord Hospital was able to mine its EMR to determine the number of patients with diagnoses that require wound care to clearly establish the need for a new wound care center.

Lessons from early adopters

Although there are multiple paths to EMR success, there are some guidelines that can boost the odds for a successful implementation. Clinician buy-in is essential. "Resistance to change can come from all corners including physicians, clinicians, transcriptionists, pharmacists and IS," notes MIT Medical's Goodwin. Branzell suggests a proactive approach. "A successful implementation is clinically led, owned and designed and IS-supported," adds Branzell.

"Define your goals," says Morris. "This will help steer the decision-making process." For example, if access is a goal, the solution should provide web access, which is not universally available.

There are IT challenges as well. With an EMR, dependence on technology skyrockets. If an interface goes down, users can lose their only access to information. "The system must be architected for high-availability and redundancy. It's important to realize the interdependency of systems and think through batch environments" says Alegent Health's Lawonn. He recommends redundancy at all levels - including power, data center cooling and networking. Alegent Health relies on SAN (storage area network) storage in multiple locations. The hospital also beefed up its clinical support staff, relocating some help-desk analysts to the floor and offering one-on-one bedside training. Other new staff members include a medical director of informatics and a clinical informatics specialist.

Hindsight can be 20-20. Take the example of Associated Cardiovascular Consultants. The practice opted not to hire additional staff to enter initial data into the EMR. "There was a lot of wailing and whining among physicians that first year," says Morris. That's because the bulk of the data such as family history and medication information are entered on initial patient visits. Therefore, benefits aren't apparent until the physician sees the patient several times. "It was penny-wise and pound foolish," sums Morris.

Finally, integration is key. Alegent Health made a fundamental decision to deploy best integration instead of best-of-breed solutions, says Branzell. Concord Hospital also employed the integration approach. McKesson Physician Portal is open and standard, so other vendors' products like EKG and fetal monitoring solutions work within the portal, says Morrison.

Future directions

Most sites refer to the EMR as a process rather than a product. Organizations on the leading edge of EMR technology are looking forward to the next levels, which include evidence-based medicine, richer data mining and improved access for referring physicians and patients.

"One deep benefit is the transformation of care processes," states Branzell. At Poudre Valley Healthcare, clinicians across the enterprise are building plans of care that accommodate best practices in documentation. For example, orthopedic surgeons can create standard processes for a hip replacement including items such as timing and length of physical therapy.

Currently, Associated Cardiovascular Consultants manually returns to the EMR to review charts to ensure that all heart attack survivors follow an aspirin regimen. The next version of Amicore Clinical Practice Management will flag the record on the front end to electronically facilitate evidence-based medicine.

MIT Medical is focusing on patient connections. It plans to deploy a web portal that offers secure messaging to physicians. Other applications include online prescription renewals and tracking tools for items like blood sugar and cholesterol readings. Associated Cardiovascular Consultants plans to offer referring physicians access to charts, which will be critical as snowbird patients shuttle between southern states and New Jersey. The practice also plans to enhance patient access, allowing them to check medications and make appointments online.

Conclusion

The EMR could be healthcare's Holy Grail, promising to enhance medicine by enabling doctors to make best practices the standard of care. Decision-making is facilitated by the availability of real-time information at the point of care and anywhere it is needed for decision-making. And medical errors plummet as electronic text replaces handwriting.

Despite its promise, the EMR is not a slam dunk or immediate profit center. It is best implemented gradually according to a well-developed plan that involves all stakeholders from clinicians to pharmacists to IT staff. Successful facilities plan extensively, anticipate roadblocks, provide hand-holding and training for staff and are proactive and future-oriented about the EMR, continuing to look for ways that it can be used to drive improved patient care. 

Rethinking EMR Disaster Recovery After the Storm: Lessons from Katrina

When Mary Bird Perkins Cancer Center in Baton Rouge, La., deployed IMPAC ViewStation as its EMR several years ago, the radiation therapy cancer treatment facility had not imagined the devastation its state would realize in the wake of Hurricane Katrina. The hurricane not only demonstrated the value of the EMR - but also revealed some holes in EMR disaster recovery plans.

The three-site cancer center runs ViewStation over a wide area network via Citrix. The application is hosted out of Baton Rouge via a T1 line and handles front- and back-office functions, transcription, dictation, imaging and medication.

"We believed our disaster recovery plan was solid pre-Katrina, but we will add several layers in the future," says President and CEO Todd Stevens. The plan consists of mirrored servers, RAID 5 architecture and nightly backup to the tape library. But the center's proximity to New Orleans, just one hour away, pinpointed some areas for internal improvement.

External EMR disaster recovery plans require improvement as well. "Conventional EMR thinking may not provide any different access to records than to paper," reveals Stevens. That's because New Orleans hospitals' servers were down and staff had to evacuate, so both the IT infrastructure and manpower to push EMRs to other sites had disappeared. For example, EMRs for 50,000 patients treated at New Orleans Veterans Affairs Medical Center were airlifted to Houston, where they could be accessed about four days after the hurricane.

After the storm, Mary Bird Perkins Cancer Center lost all T1 lines for several days and did not expect them to return. The center planned to set up satellite operations for its sites, but there was no way to autoregister EMR data across the three copies of its database, and staff would have had to manually update its main database. Fortunately, T1 lines were back online sooner than expected, so the center avoided the arduous task of manual updates.

On the upside, Mary Bird Perkins plans to convert to Microsoft SQL early in 2006. "This will allow us to use transaction logs in the event of a satellite failure from our main office," reports Stevens. SQL also provides an electronic mechanism for transfer if a T1 line is lost; the real-time switch means no interruptions to the server.

On the clinical side, the center has treated about 75 displaced cancer patients, who had no time to gather medical records prior to evacuation. The center relied on patients to share information and set up a website and 800 phone number to track physicians who treated patients, so that patients could resume treatment. One of the real EMR payoffs will come as displaced patients exit treatment. "The electronic record ensures that we will have an easy time communicating with other providers," says Stevens.

Electronic records are facilitating care for other evacuees as well. The Department of Health and Human Services is creating a database to help evacuees access prescription drug records. The system could contain records for prescriptions filled at large retail pharmacies up to 90 days prior to the storm. Another program tracks patients' care at shelters such as the Astrodome; the Astrodome program also communicates lab results to offsite providers.

"The real advantage to the EMR is the ability to move thousands of charts on tape," adds Ronnie Meadors, director of MIS for Mary Bird Perkins Cancer Center. When the practice's Hammond and Covington facilities closed their doors because of downed trees, patients were easily able to continue treatment on Baton Rouge because all data were electronically available.

Healthcare providers, like everyone in the Gulf region, are learning and re-building, after the storm. "We need a distributable, portable, secure EMR," states Stevens. Mary Bird Perkins Cancer Center may assign a staff member to go to a secure offsite database to take calls and electronically transfer information to other sites in the event of another disaster.

"Katrina exposed short-sighted thinking about the EMR. The EMR is not enough. Healthcare cannot take a laissez faire approach to disaster recovery; it must be thought through to a higher level than most sites have," concludes Stevens.

The EMR in Private Practice

One-third of small practices plan to implement EMRs in the next two years, according to a study published recently in Health Affairs. Other research indicates that financial gains are not necessarily a given for small practices that deploy an EMR. The average practice recoups its investment in 2.5 years and then begins to accrue profits, but a few have experienced financial struggles after implementation. And gains in quality are modest, says the study.

Successful small implementations are possible. Take for example Goshen Medical Practice, a single physician internal medicine practice in Goshen, Ind. Dicky Bhagat, MD, says eClinicalWorks EMR facilitates enhanced efficiency and paperless operations. The EMR incorporates all front- and back-office operations as well as progress notes, labs, diagnostic tests, medications and treatment plans.

"It's unimaginable to return to paper," claims Bhagat. He calculates he receives 20 to 40 daily prescription refill calls daily. With eClinicalWorks, a staff member clicks on the patient summary and a prescription can be auto-faxed to a pharmacy in 30 seconds. The corresponding paper process takes 5 to 15 minutes per refill or the equivalent of one FTE, says Bhagat. The EMR also copies historical notes forward to facilitate efficient and complete coding. "I've realized a substantial jump in income due to correct coding [vs. undercoding]," explains Bhagat.

Bhagat offers a bit of financial advice. "Make sure you understand what you are signing when you purchase an EMR." Some vendors require practices to purchase hardware from them. "An off-the-shelf server might cost $12,000, but a vendor might mark it up to $56,000," states Bhagat. Support and services contracts warrant close scrutiny as well, says Bhagat.

Diamond, Fera & Associates, a seven-physician, four-office practice in suburban Pittsburgh, recently deployed a Misys EMR. "We wanted to provide physicians with access to data from multiple offices, homes and hospitals. Before the EMR, we dealt with significant problems as charts were stored in different offices and frequently needed to be faxed or transported to other sites," explains Joel Diamond, MD. "But the major driver for the EMR was the promise of dramatic quality improvement."

The practice has seen hefty gains in quality. Medical errors - especially those caused by hastily scribbled prescriptions - misinterpreted data or lost or misplaced charts have dropped. The practice has implemented decision support by incorporating drug-drug interactions and allergies in Misys EMR.

Diamond, Fera & Associates has built best-practices templates, too. The templates like one for sports physicals not only standardize care but also boost workflow with one-click documentation. "We completed a study with our local Blue Cross carrier that showed our documentation of smoking has increased from 15 to 70 percent," continues Diamond. Consequently, the practice can provide smoking cessation counseling every three months to affected patients.

Misys EMR offers full integration of several applications including practice management, document management and claims processing. Like other EMRs targeted to small providers, the EMR does not integrate with PACS for viewing of digital images. "I don't think I would want PACS images in the EMR because of the storage space requirements," says Diamond. Instead, he and his colleagues access the hospital PACS via the web and radiology reports are scanned into patient charts. The practice has utilized its EMR for other forms of digital imaging. Each patient's chart contains a personal photo, so physicians can recognize patients, and the practice also takes wound care photos and imports them into the EMR.

Diamond looks forward to the next steps. Misys Patient Portal will allow the practice to share information like lab or blood sugar results with patients. "This should further improve quality and outcomes," opines Diamond. And Misys Connect will integrate hospital data such as radiology reports and other digital information into the EMR, eliminating some scanning.

The quality improvements are clear for Diamond, Fera & Associates. The financial results are equally favorable. "We've seen a significant return on investment. The EMR has more than paid for itself. The staff goes home earlier and can not imagine practicing [medicine] without the EMR."

An EMR Alternative?

The EMR field is large and ripe with options. It increased again this fall with Dictaphone Corp.'s launch of mdEssential. The company dubs the solution as an alternative to the traditional EMR.

The new system allows physicians to document encounters via dictation and also produces structured patient data that becomes readily available at the point of documentation. mdEssential uses speech recognition technology to convert dictation to text documents. Then, national language processing finds and extracts key clinical data from the finished text documents. This information is placed in a database that can be accessed, searched and organized.

Guthrie Clinic/Robert Packer Hospital deployed the precursor of mdEssential - Enterprise Workstation - in January 2004 as a forerunner to the EMR. The query-able system allowed the clinic to identify all patients on Vioxx within 24 hours. The system, however, is not quite a true EMR, says Frank Belardi, MD, program director for the Family Practice Residency Program. It does not interface or download lab results or digital images, and it does not incorporate medication reconciliation. The clinic will integrate other EMR functionality such as disease management protocols into Enterprise Workstation in the next few months. It plans to deploy a full EMR by 2006 and will consider options from multiple vendors.