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Pace Yourself!

October 1, 1998
by Robert Keet
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An independent group of providers in Santa Cruz County, Calif.

Problem:Our provider community needed to work together, share data and automate our clinical processes to succeed in the new managed care environment.

Solution:Take steps to implemement a community-wide electronic medical record system.

Results:"Axolotl’s product set allowed us to use clinical messaging to drive full clinical automation and to progressively implement change across our entire community."

Keys to Success:"Take the path to full clinical automation of the community step by step. It’s much easier and more efficient."

In my healthcare community in Santa Cruz County, Calif.,--as elsewhere in the U.S.--the move to managed care has transferred risk to provider groups, compelling them to work together and making them responsible for the health of their patient populations. Now, providers must care for patients when they are sick, and they must collaborate to ensure that patients receive proper preventive and disease case management.

A few years ago a group of physicians, two hospitals, a commercial laboratory and a radiology group in my community came together to explore approaches that would enable us to succeed in this new healthcare environment. We needed to work together collaboratively, efficiently share data and automate our clinical processes. We agreed that the ultimate goal was the implementation of a communitywide electronic medical record (EMR) system, the Holy Grail of clinical automation. We sought a solution that would allow the automation to occur across the community with a gradual, nondisruptive implementation.

The physicians in Santa Cruz County, like most physicians, maintained clinical records on paper. It was immediately clear to us that implementing an EMR system is no trivial pursuit. First of all, the economically independent physicians were not willing to have their records reside in a central repository. The repository would have to be distributed and the implementation gradual across the diverse group of providers.

In addition, the transition from paper records to EMR requires significant workflow reengineering as well as a commitment of considerable capital for hardware and software, difficult to manage across an entire community. Worse yet, implementing EMR requires a great deal of time: it’s not unusual to hear of a community spending two years installing an EMR system and having nothing to show for it in the end. Santa Cruz didn’t have two years to spare. We needed to benefit from automation almost immediately.

While we were willing to make the commitment to full EMR, we needed to make the transition as painless as possible. We believed that our path to full clinical automation of the community would be easier and more efficient if we took it step by step. First, we would automate the delivery of clinical data. Next, we would add tools to automate the management of that data and the communication between physicians. Finally, we would add the distributed electronic medical record and the tools to do outcomes analysis across the community.

After an exhaustive search, we chose to work with Axolotl Corp. of Mountain View, Calif. Their Elysium product set allowed us to use clinical messaging to drive full clinical automation and to progressively implement change across our entire community, from automated data delivery through the fully distributed data repository. Our diverse group of providers eased into the automated analogies for their current work habits and clinical procedures, achieving an unexpectedly deep level of automation.

Step #1: Moving data

As a first step to full clinical automation, we attacked the movement of clinical data between providers and their healthcare partners. Much of the work performed by physicians involves the active management of clinical documents or messages. The average primary care physician handles 50 to 150 incoming clinical messages a day. They order prescriptions, laboratory and radiology procedures, durable medical equipment, nursing services, referrals, authorizations and other services for their patients. They then analyze the resulting data, including test results, transcriptions and messages from other providers and their staff. The cycle is completed as the management of this data leads to further order generation.

Using the Elysium system, we automated the delivery of clinical data from our two hospitals, a radiology group, a large clinical laboratory and two MSOs to the physicians and their staffs. This provided a means for physician offices to easily manage this incoming clinical data. While we sought a communitywide EMR, we discovered that a great deal of clinical automation could be implemented at the document, or clinical message, level.

To automate clinical messages, each must be linked to a unique patient identifier. With the help of Axolotl Corp. we created a fully automated, distributed "community patient index" (CPI), which now contains data on more than 135,000 Santa Cruz County residents. In addition to uniquely identifying each patient’s data, this CPI carries demographic, insurance and eligibility data along with critical clinical data such as provider, drug and problem lists. This data allows the implementation of care management protocols across our community of providers. In addition, the physician and staff can access the information stored in the CPI--an easier and faster process than accessing the patient’s permanent paper chart or distributed eligibility lists.