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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.

The system also provided a means for physicians to work together collaboratively. The clinical email tools let physicians electronically share clinical and patient information with other physicians, laboratories, home healthcare workers, radiologists and pharmacies. By quickly transferring clinical data, physicians can conduct quick "pocket" or "curbside" consultations and participate in group discussions. Meetings now commonly occur on the Internet.

The 160 providers in Santa Cruz receive clinical information anywhere, 24 hours a day, via normal phone lines or the Internet. Our physicians are able to manage their clinical messages from the office, from home or while on vacation. From any of these locations they have tools to fully automate the processing of this data. With a few mouse clicks, they can provide instructions or annotations to staff, deposit the data in a staff member’s work queue, or forward the data to a colleague.

Step #2: Workflow processing and automation

Once electronic clinical messages were implemented, we were ready for step two: the automation of the processing of those messages.

The physician determines the disposition of each clinical message received, ultimately storing most messages in the permanent record. However, in the process of managing these messages, instructions are given to staff, messages are delivered to patients and processes are begun. For a simple test result, the process might be as basic as "notify patient of result and then permanently store result." A prescription refill might require a far more complex process of determining when the prescription was first filled, when last refilled, other medications the patient is taking and new allergies. The newly refilled prescription must be transmitted to the pharmacy, stored and, ideally, made available immediately to other providers caring for the patient.

Patient phone calls, messages or notes from other physicians require a process that is focused more on inter- and intra-office communication. Likewise, incoming authorization approvals or denials require a process that includes the office staff, the patient and often another physician.

The physicians, in turn, have the necessary automation to process those documents without the need to implement electronic medical records. At this point in the process, the paper chart remains the permanent legal repository, but the management of data, including disposition on delivery and lookup, is fully automated. Because the system is implemented across the diverse medical community, the providers work together collaboratively.

The community patient index takes on additional functions in this stage of implementation, allowing patient data to drive care management processes. As messages are sent and received, the system cross-checks the patient’s demographic data (age, sex), insurance data (carrier, primary care physician), diagnoses, stored procedures (such as "last mammogram") and current medications. The physician or staff receives current alerts or subsequent reminders based on the interaction of those variables. The specific protocols can be applied across a system of providers using standard distributed database and replication technology.

In addition to processing a high volume of incoming messages, the physician generates outgoing clinical messages, such as prescriptions, orders for laboratory tests and procedures, referrals to specialists or ancillary providers (with the necessary authorizations), and communication with other providers. The typical primary care physician generates scores of such outgoing messages each day. Some, such as notes to the staff, are straightforward communications. Others, such as prescription writing, involve pulling together appropriate data and expert knowledge to assure an error-free process.

When writing a prescription, the physician can locate drugs by diagnosis or price. The prescription writer accesses expert drug databases to check for drug, allergy, age and sex interactions and pertinent formularies. IPAs can distribute formulary "rules" for all contracted insurance plans, and the system automatically checks and alerts the physicians if the chosen drug is not on the formulary. The completed prescription request can be faxed or sent via email to the appropriate pharmacy.

Similar automation is applied to the ordering of laboratory tests. The user is immediately aware of missing or inappropriate diagnoses, and the system ensures that test results are returned in an appropriate amount of time. Similarly, the process of completing an authorization request alerts the physician or staff to the protocols currently adopted by the IPA. The management in "managed care" becomes a transparent process of alerts and reminders for physicians and their staffs.

The process of clinical message automation can be carried one step further with the automation and distribution of protocols, rules and procedures necessary to assure appropriate clinical care and patient management. These protocols provide automated alerts and reminders based on patient clinical and demographic data. The process of generating laboratory orders, writing prescriptions and creating authorizations not only is fully automated but includes the appropriate rules and checks to assure compliance with standards of care.

Care management assures that patients receive the appropriate and necessary care at the proper time. For healthy patients, this primarily involves preventive services such as mammograms, PAP smears, immunizations, cholesterol checks and cancer screens. For patients with chronic illnesses, this includes specific interventions, patient education and periodic testing for appropriate management of the disease. For a system traditionally driven by patients arriving in one of many providers’ offices, assuring care management is a difficult task. Even the full automation of a single office doesn’t achieve the goal because other specialists may be providing care.

When physicians receive a laboratory result delivered as a clinical message, they can also receive a reminder that the patient requires a follow-up test or preventive screen. When the physician generates a laboratory test order for a specific diagnosis, the system advises him or her of the appropriate protocol based on the patient’s diagnosis, age, sex, insurance plan or co-morbidity. Since the entire system was built on a distributed model, it is possible to distribute these protocols from a variety of sources.

Step #3: Electronic medical records

Once all clinical data across the community of providers is digitized, it becomes a minor step to implement the electronic repository for that data. The Elysium system uses the healthcare industry standard HL7 format to deliver clinical data.

While this data can be deposited into any electronic medical record product, Santa Cruz providers are working with Axolotl Corp. to implement an integrated, distributed clinical database with query, reporting and archival utilities. This server/repository will provide access to clinical data while maintaining data security and independent medical records. Physicians will be able to view a patient’s history and easily chart treatment progress.

When this implementation is complete, we will have achieved that elusive goal--the communitywide electronic medical record.

Making changes in stride

The automation of clinical messages has proven to be an effective method for addressing the additional responsibilities managed care has brought to the clinical environment. It has allowed our physicians and ancillary providers to develop automated systems of patient care management across the entire healthcare community. Without all the problems associated with implementing a full electronic medical record, we have been able to implement community-wide clinical automation and collaboration, and to realize productivity improvements at each step along the way.

I believe that many healthcare organizations can benefit by refocusing their clinical automation efforts into a practical step-by-step approach that can be implemented across an entire community.

By beginning with the small step of automating the delivery of clinical data, providers can incrementally add the tools necessary to meet the demands of modern medical care. They can improve office efficiency by adding electronic ordering, prescriptions and authorizations. Even without implementing a full electronic medical record, they can take advantage of clinical alerts, reminders and protocols and can distribute these protocols across a diverse group of providers.

While a fully implemented Elysium system provides an electronic medical record and a clinical data repository, effective clinical automation can be implemented at a much more basic level and still deliver tremendous benefits. Physicians are able to implement a seamless process to work collaboratively with their colleagues in assuring that a population of patients receives appropriate care.


Robert Keet, MD, FACP, has practiced internal medicine and geriatrics in Santa Cruz, Calif., for more than 20 years. He consults with Axolotl Corp.



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