Record Time

Health care providers are slow to institute expensive electronic medical records systems, but government mandate and industry experts say it’s crucial

The effect of Hurricane Katrina was catastrophic on many levels, but it was disastrous for health care providers and patients whose traditional paper medical records were destroyed in flooded buildings.

The effect of Hurricane Katrina was catastrophic on many levels, but it was disastrous for health care providers and patients whose traditional paper medical records were destroyed in flooded buildings.

On a less epic scale, Washington Health Care Authority Health Policy Director Richard Onizuka spent some time caring for his mother before her death. He noticed a trend.

With her to every medical appointment, she carried a canvas bag that contained pieces of paper on which she taped the label of every single medication she was taking.

Her memory fading, she had no other choice.

In an increasingly electronic age, the scenarios seem baffling.

Over the last few years, health care providers and have been eyeing electronic medical records (EMRs) as a solution – computer-based patient record databases that are easily accessible by providers.

There are pockets of providers across Washington that have implemented their own EMR systems, and some are attempting to take it a step further – sharing information with other providers.

Built-in intelligence

Electronic medical records allow authorized medical staff and providers immediate access to a patient’s medical history, current medications, allergies, test results, clinical notes and discharge orders.

Many systems have the ability to raise red flags if a physician prescribes an improper medication or provide them with the most current medical research and order sets.

Building an evidence base into the system is one of the core benefits of EMRs, said Jonathan Avery, Legacy Salmon Creek Hospital administrator.

Legacy Salmon Creek was built as one of the few paperless hospitals in the country with 100 percent computerized physician order entry.

"The real power is our ability to build in the latest evidence-based orders for any given diagnosis or procedure so physicians are automatically guided within the system based on the latest research," Avery said.

The hospital now has about 500 order sets built into its system.

The potential for errors due to illegible orders is eliminated, processes are streamlined and treatment is standardized hospital-wide, said Todd Guenzburger, sight director for adult inpatient medical service at Legacy Salmon Creek Hospital.

"The key is that all of the medical information is immediately available anywhere the physician is," Avery said. "From the moment the patient is seen and test results are entered, any other clinician in any other location can access the information from a physician portal."

No more faxing paper records requests to a records clerk and waiting for days while the record is pulled and makes its way back to the physician. And, Avery said, some clinicians have taken to accessing their patient records remotely before coming into the hospital, so that when they arrive, they are up to date on their patients’ conditions and are ready to care for them.

On the downside, EMRs require mammoth start-up costs and the learning curve can be steep, which can lead a decline in efficiency, said Guenzburger, a proponent of EMRs.

Establishing an EMR system with servers on-site can cost $15,000 to $30,000 per physician. A web-based system can cost a few thousand dollars per provider, but with that reduced cost, come increased security issues, Onizuka said.

"It takes a long time to make an EMR do what you want it to do, which is why places like Legacy Salmon Creek are few and far between," Guenzburger said. "It is difficult, costs a lot of money and until you get it polished, it may be more efficient on paper.

"That doesn’t mean it’s not a better thing to do."

Avery said a common complaint from hospital staff is that the system’s screens and workflow are not intuitive, but the hospital is working to make the system more user-friendly.

Connecting the dots

Ultimately, many providers and state officials would like to be able to make EMRs available across the state, creating a more efficient, streamlined and less expensive health care system.

There are several groups in Washington that have invested in electronic information sharing technology, but the trick is trying to link them together, Onizuka said.

A state-established group, overseen by the Health Care Authority, is now working to design an interoperable system with a set of standards for storing and transmitting EMRs statewide when needed.

"Health care is incredibly uncoordinated, which adds to expense and frustration with the system," said Joeseph Kortum, president and CEO of Southwest Regional Medical Center at a public forum in late March. "We need to agree on a uniform health care system, including how to transfer information."

Providers are spending tens of millions of dollars installing highly sophisticated information systems, but can’t coordinate with other providers because they can’t agree on how to share information, Kortum said.

"It’s politically terrifying to deal with health care, and it’s going to cost billions of dollars for everybody to have to transition, but I think it’s worth billions of dollars," he said.

In 2005, the legislature passed a bill directing the state HCA to establish and collaborate with a Health Information Infrastructure Advisory Board to develop a strategy for adoption and use of EMRs and health information technology statewide.

The HCA and the advisory board, along with the Health Information Infrastructure Stakeholder Advisory Committee, examined Washington’s existing infrastructure, looked at other states’ efforts and developed a detailed set of evaluation criteria for possible solutions.

The board released its report in December recommending the creation of health record banks and has since secured $3.4 million in state funding to complete the initial design work and set up several www test sites. The initiative was included in the health care reform plan that sprang from Gov. Chris Gregoire’s Blue Ribbon Commission, which she signed into law in May.

In its report, the advisory board estimated $8 million to $11 million was needed for the initial design work.

This proposed health record banking model will allow consumers to designate their information bank of choice and the type of records to be shared, when needed, with providers across the state.

"There is no easy way for medical record information to be transferred," said HIIAB Chairman Mark Droppert.

If consumers move, go on vacation, switch doctors or visit a specialist, they pull out a clip board and start over every time. As a result, people can be over medicated, under medicated or improperly treated, he said.

"We’re all looking at ways to reduce the cost of care," said Dave Wasser, public affairs director for the HCA. "If you’re treated by somebody then sent to a specialist, they’re not sure if you had XYZ test and you’re not sure, they’re going to do another XYZ test just to be sure."

It all adds up to wasted health care, Droppert said.

The banking model takes advantage of the EMR infrastructure that individual providers have already put in place. The problem is that many existing systems hold data differently, Onizuka

The state must establish a set of standards for data elements and how data will be held and transmitted.

"The standards will create connectivity so you can essentially watch a VHS tape on your Betamax," Wasser said.

Droppert said Washington is relatively advanced. The national average for adoption of EMR systems is 20 percent, about the same as Washington’s rate, Onizuka said.

But is it really a state issue, or should an edict be coming from the federal level?

"The answer is yes, it’s state and federal," Droppert said. "Health care is inherently regional, but the population is not static. It goes on vacation, business trips, it moves."

In the long term, there needs to be a level of systemization, and the standards need to be national, but Onizuka said a federal set of standards are not going to materialize anytime soon. However, if states are able to demonstrate that an electronic interface can work, federal policymakers should pay attention.

The HCA has discussed possible pilot programs with the state of Oregon to test cross-border information sharing, likely in the Vancouver area, he said.

"With the Internet, there’s no reason a doctor can’t access healthcare records at a bank in Tacoma from Duluth if you’re at an ER in Duluth," Droppert said.

But at this point, cost is the great unknown.

Training has already begun

An operational electronic medical records system requires technicians who know how to use it.

At Clark College, leaders are aware of the trend toward electronic health records. In early March, the advisory committee to the medical office technology program set up a subcommittee to examine this very issue.

Providers said they want employees to be comfortable with a computer and have some experience with medical office software and current practices in hospitals and doctor’s offices directly related to electronic health records, said program director John Clausen.

But providers requested that students continue to learn to work with paper records to understand the work flow.

In labs, students work with paper records but discuss application of the same record in electronic format, Clausen said. They’re trained on Medisoft, an electronic system of identifying patient information in labs.

The committee requested increased use of the system, and the college is looking to incorporate an actual EMR system in the lab so students learn to enter data into the system as they’re examining patients.

"One of the things we have to get students, doctors and people like me to understand is that it’s just a different medium and it’s not that different," Clausen said. "A lot of the things we did on paper, we still do, now we’re just looking at a monitor, not a sheet of paper."

Clinic & hospital to share info

The Vancouver Clinic and Southwest Washington Medical Center recently joined forces to share electronic medical information.

The Vancouver Clinic has had electronic medical record systems for several years and added a picture archiving communication system (PACS) to its radiology department in 2005. The hospital recently installed the same PACS system, said Brett Windsor, director of ancillary services at The Vancouver Clinic.

On May 9, the two entities, with the McKesson Corp., began allowing each other access to each entity’s PACS system. Known as Dicom Query Retrieve, the link allows both institutions to request and almost instantly receive copies of diagnostic images, rather than delaying patient care.

It also ups efficiency, as staff is able to spend time on work other than requesting images.

"It is an absolutely massive boon," Windsor said. "Politically, it’s very difficult."

Until now, institutions in Southwest Washington have been unwilling to share, Windsor said.

A big fear is competition, he said.

"I think institutions are scared other intuitions will try to steal their patients," Windsor said.

He also said there is false fear where the federal Health Insurance Portability and Accountability Act is concerned.

"I think institutions are using it as a reason not to exchange information," Windsor said. "HIPAA was not designed to prevent sharing, it was designed to prevent inappropriate access."

There are some privacy dangers that come with electronic information transfer, Windsor said, adding that those same dangers exist in traditional paper records systems.

"People can be irresponsible and look for information they don’t have access to," he said. "We know who at the hospital has access to our records and we’re able to see what they’ve been doing. With any medical records, you rely on people to be appropriate."

Firewalls are in place, and the clinic is able to lock down the system.

Windsor said the clinic is willing to share with any institution willing to share with it.

Setting up the partnership took about six months of planning.