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Electronic medical records

February 1, 2006
by Mark Hagland
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EMR, EHR....At times, the debate over what to call the various types and versions of automated records now being developed threatens to overshadow the progress being made in facilitating electronic records-based patient care. But a wealth of initiatives—including the federal government's recent standards harmonization, product certification, and national health information network initiatives, as well as a variety of organizational and regional efforts—signal that a new era is dawning for electronic medical records (EMRs). The technology is largely ready for prime time, observers say, and the payer/purchaser demands for higher-quality, more efficient healthcare are moving implementation forward.

Inevitably, the road ahead will be a long one. The EMR is the core component around which the totality of clinical care IT progress will necessarily revolve, many say. And clinical informatics pioneers see a series of distinct phases ahead, stages that will extend over decades rather than months.

One such pioneer is John Haughom, M.D., senior vice-president for healthcare improvement at PeaceHealth, a six-hospital system based in Bellevue, Wash. PeaceHealth, with facilities spread out across Washington, Oregon and Alaska, went live with its first-generation EMR as early as January 1996, and has been innovating ever since. Based on the experiences of organizations like his own, Haughom has developed his own schematic for EMR progress, one that involves three distinct phases. According to his theory, Haughom sees "three iterative phases of the evolving EMR concept," and he adds, "We're very clearly right now in Phase 1 of that evolution. Essentially, we're automating the paper chart, putting it into a digital format." While that step is fundamental to everything else, he sees Phase 2 of the EMR's evolution moving beyond one that offers "passive decision support" where "doctors and nurses know that it's there, but they've got to go to a clinical workstation to find it."

An "active EMR," as Haughom sees it, will help patient care organizations to use the power of advanced information technology "to actually mine the data to identify important clinical information," which can range from potential drug-drug interactions to patient condition trending. Once the core infrastructure has been developed, Haughom emphasizes, clinical information systems could parse terabytes of clinical data in seconds, proactively identifying opportunities for clinical intervention, and enabling a more comprehensive decision support strategy. Phase 3 will involve coupling all the information in prior phases with an individual patient's genomic information, to create the "personal EMR," which will tailor care regimens to individual needs.

The timeframe for all this progress? Haughom predicts that hospitals that are now implementing Phase 1 EMRs will complete that step in the next three to five years, while a handful of early-adopter organizations like PeaceHealth will have built their Phase 2 "active" EMRs in that time.

Haughom also cites the predictions of the San Francisco-based Health Technology Center (where he is a governing board member), which foresee pioneering organizations reaching Phase 3 sometime around 2014 or 2015.

Full-court press in Massachusetts
According to a study performed last year by executives at the Chicago-based Healthcare Information & Management Systems Society (HIMSS), only 10 percent of hospitals had comprehensive EMRs as of the beginning of 2005. But some in the industry are pushing ahead aggressively. Most notably, industry leaders in Massachusetts are pushing a statewide initiative to ensure that every hospital in that state has an EMR by a targeted timeframe of late 2009. Using the vehicle of a new Boston-based organization, the Massachusetts CPOE Initiative, leaders from all stakeholder groups statewide are funding a bold initiative to rapidly advance EMRs with full computerized physician order entry (CPOE) capabilities.

"For Massachusetts, it's critical—the cost of healthcare here is higher than anywhere else on the planet," explains Mitchell Adams, executive director of the Massachusetts Technology Collaborative (MTC), Boston—the initiative's leader organization. Adams helped form the Massachusetts CPOE Initiative and obtain funding for its work after the MTC released a study two years ago that estimated that using seven information technologies in clinical care could lower health costs by $2.5 billion a year in Massachusetts, with CPOE accounting for the bulk of that projected savings.

By June, Adams notes, the CPOE Initiative will have spent $1.7 million on consultants, studies, and support for the project. Its initial study found that of the 50 of the state's 70 hospitals without CPOE, 12 were ready to begin implementation. Since then, initiative-funded consultants have been creating practical "roadmaps" for each of those hospitals in order to help them begin the implementation process. Those roadmaps encompass comprehensive budget plans, preparedness reports, and consultation from an executive group drawn from each of the 12 hospitals and from several major health plans and government agencies. The initiative, Adams says, shows that when stakeholder leaders from across the industry put their heads together, rapid progress on EMR implementation is possible.

An environment in flux
Rick Skinner, a well-known industry expert and former CIO of the Portland, Ore.-based Providence Health System, says he sees attitudes and the operating environment changing rapidly. "The biggest trend or environmental change is that today, just the concept of working from an electronic representation of a patient's information is accepted" by clinicians across the industry, says Skinner, who is now vice president of the client services organization at the Long Beach, Calif.-based First Consulting Group. The second shift, he says, is that EMRs are no longer viewed as experimental—many EMR implementationshave been completed or are in advanced stages. Still, he says, most hospitals are still in the relatively early evolutionary phase of building robust clinical data repositories on top of the basic documentation and ancillary systems, while only a small minority have begun to take full advantage of clinical decision support, rules engines, and physician order entry. In fact, he sees most hospital leaders holding off on CPOE until their organizations have more robust clinical documentation, pharmacy information systems, barcoding, and other systems, in place first.

Meanwhile, although financing remains a major concern, particularly on the ambulatory/medical group side, other barriers to EMR development are falling away quickly, says Sarah T. Corley, M.D., chief medical officer of the Horsham, Pa.-based NextGen Information Systems. Corley, who also represents the American College of Physicians on the Washington, D.C.-based Physicians Electronic Health Record Coalition, says that physicians' historical resistance to EMRs is rapidly falling away, as physicians use computers more often, access EMR systems in hospitals regularly, and engage in e-prescribing more frequently. And on a wider scope, she says, "There's a recognition among physicians that pay for performance is coming, and that quality is lacking," and that automation offers the opportunity to provide better care. The fact that EMR products have improved dramatically and that standards harmonization and product certification are on the way will only enhance physician acceptance and adoption, she adds.

John Glaser, Ph.D., CIO of the greater-Boston healthcare system Partners HealthCare, agrees. He emphasizes that product certification will be a major factor in adoption both on the inpatient and outpatient sides of the industry in the next few years. Glaser also says he believes that pay-for-performance arrangements springing up between payers and providers will accelerate EMR adoption."The incentive context is changing rather rapidly."

Mark Hagland is a contributing writer in Chicago.


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