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Electronic medical records: Mastering the maze

Physicians who have overcome the obstacles of integrating an EMR system into their practices see the benefits to their patients and their communities.

By Tyler Chin, amednews staff. Dec. 24/31, 2001.

Can the Sept. 11 terrorist attacks and subsequent anthrax threat lead to wider deployment of electronic medical records? After the attacks, a number of health care technology companies and other observers called for broader use of technology to help ensure a more effective response to bioterrorism threats and mass medical emergencies. They say electronic medical records could help save lives in an emergency because important patient data could be transmitted quickly to doctors and other providers.

Tech-savvy physicians don't necessarily agree with that assessment. Electronic medical records, or EMRs, would be useful in typical emergencies or routine patient encounters, but not in a mass emergency like the one caused by the attack on the World Trade Center, they say.

On the road to records
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That's because electricity and telecommunications could be down and conditions would be so chaotic that doctors wouldn't have the time or the ability to access electronic records, much less paper files, said Brian Keaton, MD, an emergency physician at Summa Health System in Akron, Ohio. "In that kind of environment, I'm not sure an EMR would help you," said Dr. Keaton, director of the provider's Summa Center for Emergency Medical Informatics.

He and other physicians expect terrorism fears to spur federal efforts to establish a national data-sharing network for public health surveillance. But those fears won't drive practicing physicians to adopt electronic records, they say.

Still, physicians say it's only a matter of time before they routinely use electronic records to deliver better care to patients. They don't know when that will happen, but a number of developments, including high-profile pressure to reduce medication errors, are expected to lead doctors -- willingly or not -- to widely adopt electronic records.

"We're practicing in a much more complicated health care environment than before," said Richard Roberts, MD, a family physician at a six-doctor group in Belleville, Wis., owned by the University of Wisconsin Medical Foundation. "A lot of people deal with the patient, not just the family doctor. You've got to share the information, put it in a format that is understandable, easily retrievable and can relate to other data."

Only 5% to 22% of physicians use electronic medical records.

Employers, insurers, technology companies and others are beginning to address some of thorniest obstacles that have deterred most doctors from implementing clinical information systems in their practices.

The number of physicians using some form of electronic records ranges from 5% to 22%, according to several surveys.

One of the main reasons relatively few doctors use EMRs is that most systems are proprietary and don't talk to each other.

"The vendors that make the software don't make them easily compatible or transferable," said Richard Hellman, MD, an endocrinologist at a three-doctor group in Kansas City, Mo.

Another hang-up is privacy. Physicians worry about the security of records stored in an electronic format. That concern has been further heightened among some physicians who aren't certain how to comply with the federal Health Insurance Portability and Accountability Act of 1996, Dr. Hellman said.

HIPAA does not require doctors to use electronic records systems, but if they do they must take steps to comply with the law's privacy and confidentiality provisions by April 14, 2003. Violators face stiff penalties.

A fragmented system

The nature of the American health care system and variety of practice arrangements also make it difficult for doctors to implement electronic records systems.

"It's so all over the place that nobody has been able to develop a standardized computer platform that everybody could work from, because what a hospital system may need is going to be different from what a solo doctor may want or need," Dr. Roberts said.

In contrast, in New Zealand -- where primary care physicians are typically in solo or two-doctor practices -- that nation's health system is "built on primary care and community health rather than the subspecialty care and fragmented system we have," Dr. Roberts said. "So they do a much better job of putting computers in place and communicating with each other." The result is that most primary care physicians in New Zealand use electronic records.

Because the American health care system is so fragmented, Dr. Roberts said, an EMR ultimately will have to be Internet-based, because the Internet offers a pervasive and flexible technological platform.

But other physicians see promising alternatives to Internet-based records, including smart cards, which contain computer chips embedded in plastic.

Another alternative is a standard known as CCOW. When a physician logs on to a computer and enters his ID and password, CCOW pulls data from disparate information systems and "visually" integrates the data at his desktop as long as those information systems accommodate the CCOW technology, Dr. Keaton said.

CCOW is less expensive than technologies used by large provider organizations and others to feed data from information systems into a central database, said Dr. Keaton, who also is a member of the board of directors of the American College of Emergency Physicians.

CCOW is not something that a doctor can buy or download off the Web. It is a standard that was initially developed in 1996 by a consortium of health care providers and software companies formerly known as the Clinical Context Object Workgroup.

How much does it cost?

An EMR can cost millions of dollars, a major stumbling block for physicians. If that hurdle is to be overcome, everybody will have to directly or indirectly bear the cost, Dr. Roberts said. That sounds like a lot to ask but it can be done, he added. For example, his group last year installed an EMR from Physician Micro Systems Inc. that so far has cost about $350,000, including ongoing costs.

The group used a combination of methods to pay for the system. Those included requesting and receiving a grant from Sun Microsystems Inc. for the hardware, amortizing $250,000 over five years and getting the University of Wisconsin to pay $50,000 over two years for a physician to champion the project and work on it, Dr. Roberts said.

The group also raised $30,000 from community organizations, an impressive feat considering that the community in question, Belleville, has a population of 1,500, he said.

"We said, 'Look, we will be able to give you back information about the community. If you want to know what percentage of people in Belleville who are on beta blockers have had heart attacks, which is an important quality indicator of your chances of having another heart attack, we will able to tell you that,' " Dr. Roberts said. "The community understood that and was very supportive."

Dr. Hellman said physicians shouldn't expect the government to help pay for EMRs, particularly as Congress tries to pass an economic stimulus package and establish funding to fight terrorism. But the government can offer tax credits to encourage physicians to implement EMRs, he said.

Doctors in small practices also don't necessarily have to spend hundreds of thousands of dollars for a system, Dr. Hellman said. Small groups can buy Web-based systems costing a few thousand dollars per user versus the $40,000 to $50,000 per user that larger entities pay for their EMRs, he said.

Just do it or else!

But affordability alone isn't always enough to compel groups to implement electronic records.

"I spent six years successfully using an EMR in practice and have been trying to get my new group to utilize the software to no avail," said L. Scott Fox, DO, who works for an emergency medicine group of more than 100 physicians serving hospitals in the Pacific Northwest.

The Tacoma, Wash., physician, who also sells electronic records software from ER Records Inc., said the company had given him permission to let the group use the company's software free for six months. Dr. Fox installed the system at one of the group's client hospitals, but colleagues preferred to stick with paper.

The main reason doctors failed to use the technology was that administrators didn't order them to, he said.

"The institutions where I've gone out and installed the system, the ones that have been successful, have been the ones that mandated physicians to use it for a three-month, 100% pilot [period]," Dr. Fox said. "The ones that failed are the ones that gave physicians a choice."

While many organizations say that doctors can't be ordered to do anything, including use technology, Dr. Fox vehemently disagrees.

"Administrators tell me all the time, 'I can't tell doctors what to do,' " he said. "I say, 'What do you mean? Doctors are told what to do when they go to medical school and during their entire training.' You can tell them what to do, especially in light of the fact that business runs medicine now. Somebody's just got to have enough gumption to do it."

The key to successfully implementing an EMR is persuading physicians to use it for a short period so they can get over the learning curve, Dr. Fox said. After that, physicians will see the benefits and will use electronic records after the testing period is over, he said.

Some say that employers, insurers or the government will mandate that doctors use technology to improve patient care. Already, several Fortune 500 companies who spend billions on health care services have said they will favor hospitals that implement computerized physician order entry systems to reduce medical errors.

"Computerized order entry will be mandatory," Dr. Keaton said. "That will be the driving force that will push the people who have been dragging their feet to go to the next step."

Physician use of electronic records will grow too, as younger doctors who grew up with technology come along.

"I don't think you can walk down the hallway in my hospital any time of day or night and not see somebody using a Palm Pilot," Dr. Keaton said. "So from that standpoint, I think it's moving forward a whole lot more."

ADDITIONAL INFORMATION:

On the road to records

Obstacles

Some of the hurdles that have slowed down physician adoption of electronic records:

Information systems have historically been proprietary, expensive and hard to use.
Lack of a standard clinical vocabulary and definition of an electronic medical record.
Privacy and confidentiality concerns.
Physician resistance and inertia.
Fragmented nature of health care system.

Work-arounds

Developments, trends and forces that likely will lead to greater adoption of electronic records:

Computer systems are more sophisticated and powerful.
Companies are developing Internet-based systems or making information systems accessible over the Internet, making electronic medical records software more affordable and easier to use.
Employers are pressuring hospitals to implement computerized physician order entry systems to reduce medical errors. Some expect employers, insurers and others to mandate that doctors use those systems.
Younger physicians are comfortable using technology and will expect or demand that it be made available to them in their practice.
Organizations are trying to promote standards to facilitate data exchange and interoperability between information systems.

Weblink

CPRI-HOST, Computer-based Patient Record Institute and Healthcare Open Systems and Trials (http://www.cpri-host.org/)

Medical Records Institute (http://www.medrecinst.com/)

Interim report, "Toward a National Health Information Infrastructure," National Committee on Vital and Health Statistics, June 2000 (http://www.ncvhs.hhs.gov/NHII2kReport.htm)

HL7's CCOW page (http://www.hl7.org/special/committees/visual/visual.cfm)