BUSINESSThe Winona project: Developing an electronic linkThe city in southeast Minnesota becomes a test site for a first-of-its-kind integrated techonology network.By Tyler Chin, amednews staff. March 11, 2002. In 2000, Cerner Corp. asked the medical community in Winona, Minn., to help develop Internet-based technologies and participate in a study to determine the benefits of linking consumers with doctors and hospitals. The medical community in southeastern Minnesota jumped at the offer. And the ambitious effort to connect consumers to their doctors also led the physicians to consider getting an electronic medical records system to improve care and efficiency. The doctors, most of whom work at two independent clinics, and the town's only hospital system, Winona Health, agreed to implement and share the cost of the communitywide system that would enable them to share patient records. Today, though, Winona Health Online isn't fully functional, and implementation of the EMR began just last month. The hangup: problems that typically crop up whenever technology is introduced in a clinical setting -- lack of physician automation and integration issues. Winona's experience provides a lesson for others who are exploring online communication between consumers and physicians or an EMR. Large group practices and health systems could have an even tougher time implementing those projects. "We're really just now starting to implement the EMR, and it will be 2003 before all the components will be up and running," said William E. Davis, MD, a family physician with Family Medicine of Winona, an independent four-doctor practice. "Many people have the idea that buying an EMR is kind of like buying Microsoft Office -- buy the box, open it and throw the disk in, and you're up and running. It's much more complex than what a lot of people realize when you start thinking of all ... the information that has to be built into the system before you can start." On Feb. 26, Dr. Davis' group and a two-doctor group owned by Winona Health were scheduled to become the first two sites to use the EMR. The system from Kansas City, Mo.-based Cerner is expected to be rolled out to the hospital and the 35-doctor Winona Clinic in the next two years.
People in Winona use the Internet 20% more than the national average.
One of the main challenges has been the physicians' lack of experience. They and their employees had to be trained, said Dr. Davis, who serves as the information technology liaison between physicians and the hospital. Dr. Davis expects his group to have an easier time making the transition to the new electronic records, because the practice has been using an EMR for 13 years. Why Winona?Cerner chose Winona as a test site for its IQHealth product line because it was small, it had a single health system, it had a small number of physicians and it had a fiber-optic network already in place. Plus, its residents' Internet usage exceeded the national average by 20%. Those factors made the task of connecting the hospital, clinicians and consumers less daunting than it would have been elsewhere, said Kathryn Bingman, vice president and general manager of Cerner and president of Cerner IQHealth. The technology company is marketing IQHealth to health systems and employers. Winona is well-wired because a local educational foundation built a fiber-optic network connecting all schools, including universities, to the 99-bed community hospital. Also, there is more than one company offering telephone, data, cable television and Internet services. Using IQHealth applications, consumers can create their own personal health records over the Internet. They also can use them to fill out and receive a health risk assessment, obtain laboratory results, ask questions, request prescription refills and access other health information. The three partners in Winona Health Online -- Winona Health, Cerner and Hiawatha Broadband Communications -- won't disclose the cost of the project. Physicians haven't had to pay for Cerner's IQHealth technology, but they had to provide their own computers and Internet access. The online service is free to consumers. While the physicians aren't paying for IQHealth technology, Winona Health and community physicians signed a multiyear, multimillion-dollar contract for Cerner's inpatient and outpatient EMR software products. Cerner is selling that software as a service to Winona's hospital and clinics under a model that allows users to remotely access the software over the Internet. The decision to share costs for a common EMR wasn't that difficult, partly because competition among local physicians isn't that heated and they enjoy good working relationships, said Charles A. Shepard, MD, an internist at the Winona Clinic and the health system's medical director. Winona Health and Winona Clinic declined to disclose how much they are paying for the software. Dr. Davis said the EMR will cost his group $30,000 annually. Insurers aren't involved in either project. However, physicians hope that they will be able to prove that the technologies improve patient care, which in turn could enable them to receive or negotiate better reimbursement. A slow startAlthough it has been available since October 2000, Winona Health Online is lightly used today in large part because it falls short of what was initially touted. Consumers who sign up to use the network cannot automatically receive test results, said Dr. Davis. To get those results "electronically," the consumer e-mails a request to Dr. Davis, who then has to find the paper record and then input the results and his interpretation of them on a computer. The test-result notification service won't come online until Cerner begins integrating its EMR and IQHealth products this year. But the biggest reason Winona Health Online and the EMR projects have been slow out of the gate is that it takes time to develop software that lets those systems talk to the hospital's billing and ancillary systems, Dr. Davis said. For example, the hospital laboratory system is set up so that test results are automatically printed at Dr. Davis' office, which is next to the hospital. Doctors want the new EMR system to send results to their e-mail box so that they can read, interpret, sign and forward them to patients. "Oftentimes you have several layers of computers involved in that processing, so each step requires that you build interfaces," Dr. Davis said. "I think that really slows it down." To address interface and other implementation issues, a 12-member physician advisory committee has been formed that meets regularly to discuss and review improvements and to share information with other doctors. Some, however, have skipped the meetings because they say Cerner is asking them to develop "views" -- how doctors retrieve information from the EMR's database -- without paying them for work that they think Cerner should have done. But the work, which is almost complete, is necessary because the data must be formatted and retrieved from the database in a way that is useful, relevant and searchable, Dr. Shepard said. The hospital also is trying to design an EMR system that fits its needs and physicians' needs rather than accepting what Cerner may have designed for another customer, he said. A cultural shiftAlthough physicians have been cooperative, their reactions to the upcoming EMR are mixed. "There are physicians who can hardly wait until we have a more efficient electronic system," Dr. Shepard said. "There are other physicians who are really very fearful of the whole project, and probably a large group in between who have a wait-and-see approach but are willing to work to make it as good and functional as we can." Whatever their reaction, his colleagues realize that using an EMR is the way to go because they "are struggling with increasing demands that are made on us to manage information over extended periods of time for people with diabetes, heart disease, elevated lipids and [other problems]," Dr. Shepard said. "The paper chart doesn't lend itself to retrieving data over a couple of years. While [the EMR] will be a cultural shift for physicians, I think there will be a very strong upside in terms of doctors being able to do their work easier and being able to do a better job." Lyle Torguson, MD, a family physician at Winona Clinic, agrees. "I'm desperately looking forward to getting the EMR, because for seven years that's all I used" while working at the North Memorial Medical Center Clinics in the Minneapolis area, said Dr. Torguson, who joined the Winona Clinic in July 2001. The system he used at North Memorial made it easier for him to find patient data and refill prescriptions. And it automatically checked for drug interactions whenever he entered a new prescription on a computer, he said. While Dr. Torguson is sold on using the system, he admits that the EMR reduced his productivity. "In the Twin Cities, we found out the system there slowed down our production by 10%, but it depended on how much support staff you had," he said. "It's definitely a slightly more inefficient use of your time in general, but I think the advantages far outweigh the disadvantages. Ultimately patient care is much, much better with an EMR. Patient care without it is not as good." ADDITIONAL INFORMATION:Winona, Minn., at a glanceSize: 25 square miles
Source: Winona Convention and Visitors Bureau Building linksThe health system in Winona, Minn., is implementing two Web-based electronic records initiatives. One targets consumers and the other clinicians. The projects are separate, but their technologies will be integrated. Here is what makes each project unusual and what it does: Cerner Corp.'s Millennium system:
Winona Health Online project:
TimelineJune 2000: Winona Health, Cerner Corp. and Hiawatha Broadband Communications announce plans to connect Winona, Minn.'s, hospital, physicians and consumers in a bid to improve community health and let patients create their own Web-based personal health records.
WeblinkWinona Health Online (http://www.winonahealthonline.org/) Cerner Corp. IQHealth division and product line (http://www.cerner.com/iqhealth/) City of Winona, Minn. (http://www.cityofwinona-mn.com/about/) Copyright 2002 American Medical Association. All rights reserved.
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