With inpatient data increasingly online, can widespread EMRs be far behind?
With inpatient data increasingly online, can widespread EMRs be far behind?
When Mark J. Fleschler, a Dallas internist, rounded on five patients one recent morning, he discovered that lab results for three of them hadn't arrived. At one time, this would have meant a return trip to the hospital later that day or an effort to reach one of the ward nurses via telephone. But Fleschler, who had to make some clinical decisions quickly, knew neither would be necessary.
"By the time I returned to my office and got on the computer, the results were there. So I was able to take care of things immediately."
The internist pulled up these vital results via the CareGate Web site of Texas Health Resources, a 12-hospital system. Like similar services in many health care systems across the country, CareGate gives doctors online access to patient demographic and insurance data, lab and radiology data, discharge summaries, and other transcribed reports.
Online access benefits physicians in several ways. First, it allows the doctors to see results when they need to, whether they are in the hospital, the office, or elsewhere. Second, they can read and sign off on hospital reports and test data at their convenience, from any location. Third, staffers can handle billing questions about hospital charges or patient calls about test results without pulling charts or playing phone taga great time and money saver.
Physicians seem to like these services. Nearly 1,300 of Texas Health Resources' 3,200 doctors use CareGate. And in the large University of Michigan Health System, virtually all house staff and attending physicians use the similar CareWeb site.
After decades of talk about the need for electronic medical records, only about 5 percent of doctors are using a comprehensive EMR system. Approximately the same percentage of hospitals have all inpatient data on EMRs, say experts. But progress is being made: Nearly half of all hospitals give doctors some patient data online, estimates Peter Waegemann, executive director of the Medical Records Institute in Newton, MA. While much of it is limited to patient histories, 25 to 30 percent of hospitals let doctors tap into some current clinical data, says Suresh Gunasekaran, a senior analyst with Gartner Research in Mountain View, CA.
At some institutions, office-based physicians have to go through the time-consuming process of dialing up hospital computer systems and then logging onto separate databaseslike lab or radiologyto search for patient-specific data. But many others allow physicians to access all databases on a secure Web site with one logon and password.
Why are hospitals investing in this information technology? For one thing, it saves money on couriers and postage. More importantly, hospitals are trying to build loyalty among staff physicians by providing a service that competitors might not offer.
Of course, the acute care record is incomplete without medication lists and daily progress notes. But there are moves afoot to close this gap. Some Texas Health Resources doctors, for example, are dictating instead of writing daily notes to get them into the online record. And Tallahassee (FL) Memorial Hospital plans to add med lists and progress notes to the online records it provides to doctors.
The Florida hospital's information technology vendor, Cerner Corp., is helping it design a computerized physician order entry (CPOE) system that can be used in the office as well. That would allow an FP, for instance, to order a continuation of current medications when he hospitalizes a patient, notes vascular surgeon Lawrence D. Kaelin, who's helping the hospital upgrade its clinical information system.
A growing number of hospitals are implementing CPOE, partly in response to pressure from The Leapfrog Group, a coalition representing large health care purchasers that view CPOE as a key to reducing inpatient medication errors. It stands to reason that, as this trend gathers momentum, more institutions will supply physicians with lab and pharmacy data online, and, down the road, enable them to enter inpatient orders from their offices.
Privacy concerns have created obstacles to online data, though. Until recently, physicians with Texas Health Resources had to get the permission of colleagues who were treating their patients before they could see the other doctors' notes on CareGate. Now, however, physicians can see any report as long as they identify their relationship with the patient. An electronic audit trail lets THR monitor who has viewed what.
Once you're able to access inpatient data online, the next step is consolidating it with outpatient information. Some health care systems allow you to enter outpatient notes on the same Web site that holds inpatient data, if the patient has been in the hospital or one of its ambulatory facilities. And if outpatient tests are done in the hospital lab, you can get those results online. But online hospital data doesn't usually include results from commercial labs.
Hospitals owned by large groups are more likely than hospitals staffed mostly by private-practice doctors to host clinical information systems that encompass both inpatient and outpatient elements. Examples include the Carle Clinic in Urbana, IL, the Mayo Clinic in Scottsdale, AZ, and the Straub Clinic & Hospital in Honolulu.
"When I go to the hospital, I usually order lab tests on several patients," says Straub plastic surgeon James H. Penoff. "After that, I see patients in my office and again may order tests. The results of the inpatient and outpatient tests are automatically displayed on my computer terminal for my viewing and action."
Straub uses a clinical messaging system from a company called Axolotl. The system combines hospital data with a digital transcription service and a secure form of e-mail that lets doctors exchange notes. (We'll run a close-up look at electronic clinical messaging in next month's Computer Consult.) Right now, the database includes only a fraction of the patient record, but Straub plans to add more.
"The next thing we're putting online is a summary sheet," says Penoff. "Then we're going to start writing prescriptions online. That will give us lists of all the medications a patient is taking, plus drug interactions and recommended dosages."
Big information technology vendors like Cerner, Eclipsys, and Meditech are also starting to help hospitals deliver clinical data online to physician offices. Cerner, for example, sells a read-only EMR program called Web PowerChart that can organize online hospital data in a variety of helpful ways, alert doctors to clinical events, and allow them to manage and sign off on documents. Some 760 Texas Health Resources doctors use the programunder licenses purchased by the hospital systemto view reports in CareGate on individual patients. (Like other physicians who use CareGate, they can also see clinical reports as they come in.) Fleschler notes that Web PowerChart enables him to view lab results longitudinally, which he couldn't do without the EMR.
Two leading EMR vendors, Misys Healthcare Systems (formerly Medic Computer) and GE Medical Systems Information Technologies, are also trying to provide a seamless inpatient/outpatient record. Misys, which claims that 1,200 hospitals use its lab software, plans to add computer programs for other departments and to connect them with its EMR for office-based physicians. And GE Medical Systems, which has agreed to buy the assets of bankrupt MedicaLogic, envisions integrating its inpatient EMR software with MedicaLogic's outpatient EMR program, known as Logician.
It won't be easy to get hospitals and doctors to agree on a common EMR, let alone implement one. Nevertheless, burgeoning online communications between hospitals and physicians will help promote electronic medical records, predicts Fran Turisco, director of emerging practices for First Consulting Group in Lexington, MA. "Once doctors get used to having that type of information available on their inpatients, it would be a natural progression for them to say, 'I'd like to use this all the time, whether the patient is in my office or in the hospital.' "
Ken Terry. Computer Consult: Hospital records anytime, anywhere. Medical Economics 2002;9:29.