Group practice intranets: Getting physicians to use them

Most intranets don't offer the clinical data that doctors want. But new methods of tying together old computer systems are starting to change that.

When businesses started flocking to the Internet a few years ago, intranets—private subdivisions of cyberspace protected by computer firewalls—were all the rage. Many health care systems and large physician groups built their own intranets, seeing them as a secure way to lash together all the clunky old information systems used to support the practice of medicine. And the ubiquitous Web browser was expected to be the sleek new "front end" for all of a physician's information needs.

So far, however, that goal has proved to be elusive. Integrating medicine's aging computer systems with the zippy new Web approach has turned out to be difficult, time-consuming, and expensive. It's like trying to teach dinosaurs to dance.

Hospitals, integrated delivery systems, and large IPAs have successfully used intranets to streamline business and administrative functions; a few even disseminate clinical data over these networks (see "Clinical connectivity: The future is already here"). But medical-group intranets usually don't provide physicians with the clinical information they crave. Instead, the intranets mostly serve up the easy stuff, such as e-mail, departmental communications, committee reports, newsletters, and meeting minutes. True, some physician-oriented intranets post practice guidelines, CME materials, performance profiles, formularies, and doctors-only discussion forums. But such marginally clinical postings are hardly physician magnets.

At Lovelace Health Systems in Albuquerque, NM, for example, the intranet offers such mundane features as e-mail, bulletin boards, patient education materials, and board minutes. The clinical data is still on an older, hard-to-access information system, and it will stay there a while longer. Not surprisingly, physicians don't use the intranet very much—and they're not expecting it to offer more valuable features in the near term.

"We've learned that it's expensive and difficult to program the interface between a browser and our existing computer systems," says Cleveland Sharp, a family physician at Lovelace. "It'll be a year or two before we'll get clinical information onto our intranet, but we're moving in that direction."

Physicians and other clinicians at the Group Health Cooperative, a staff-model HMO in Seattle, use their intranet to access practice guidelines and patient education materials, but again, it doesn't provide them with any clinical data. "We may go to a Web-based front end for everything, but it will take us a couple of years if we do," says FP Matthew R. Handley of GHC.

In short, the use of intranets for practical, day-to-day clinical applications "remains more a buzz than a reality," says Rosemarie Nelson, a health-care informatics consultant based in Skaneateles, NY. "There is beauty to the concept of an intranet with a single portal that allows physicians to access all the information they need. But the back-end work of connecting the old computer systems is tough."

Nevertheless, new vendors with new products are emerging to address this need. Known as "portal vendors," these specialized connectivity companies offer software and services to corral the data from multiple information systems and place it on intranets. Partly as a result, clinically oriented intranets for doctors are showing signs of catching on. No physician intranet has yet pulled all the pieces together, but a few groups are building new clinical data infrastructures bit by bit, link by link.

Building an intranet with a clinical purpose

The Carle regional health care network in Urbana, IL, is one of the organizations doing the building. Carle includes the 300-bed Carle Foundation Hospital and the Carle Clinic Association, a group practice of more than 300 physicians covering some 50 specialties and subspecialties. About a year and a half ago, Carle launched DocWeb, an intranet that offers a smattering of physician-oriented information, including departmental notices, reference materials, and practice guidelines. But few physicians use DocWeb. "There's not much going on there," says ob/gyn Roy A. McClintock, one of Carle Clinic's more techno-savvy physicians.

The Carle health care system also has an enterprise-wide intranet called C-Web. Not many physicians visit that, either, partly because it requires multiple logins and passwords that change frequently.

All this will change soon, says Jeff Ford of the group's information technology department. Carle Clinic has decided to hire a portal vendor to help interface its legacy systems with its intranets. "That will give us the tools to maintain applications and push data out to the physician users through Web browsers," Ford explains.

In September, Carle Clinic narrowed the field to three portal vendors—Sequoia Software, Corchange, and Viador—and gave them a list of 18 information priorities developed by Carle physicians. The list includes patient scheduling, lab and radiology results, formularies, clinical reports, practice guidelines, and physician report cards. The physicians' priorities are just the starting point, Ford says. "The long-term goal is to create one Web-based portal for all the physicians' information needs."

Portal vendors charge about $100 to $300 per user to set up interfaces, depending on the size of the organization and how much work is involved. Ford expects Carle Clinic to pay about $125 per user. The clinic's own information technology staff will do much of the programming required to integrate the legacy systems with the intranet, which will keep the expense down. Maintenance and service agreements may be negotiated later at an additional cost.

Since most of the clinic's physicians already have access to a personal computer or terminal, there will be few other costs to develop the new physician-oriented intranet. DocWeb will disappear.

EMR "light": the first step toward computerized records

The portal vendor Carle Clinic chooses will be required to integrate data from existing computer systems and plug in data from new applications as they're added. A key priority for Carle is to introduce a Web-enabled, partial electronic medical record, the EpicWeb Light EMR from Epic Systems of Madison, WI, which the group has been testing since May. This EMR is scheduled for full implementation by the end of the year, which is also when Carle expects to start assembling its intranet portal.

While Carle wouldn't reveal what it paid for the EMR, Epic bases its one-time charge for EpicWeb on the number of patient visits per year to a practice, collecting about $1 per visit. If a group's doctors had close to the national average of 105 visits per week, the practice would pay approximately $5,000 for each physician, plus a yearly maintenance fee.

The EpicWeb system is capable of a full range of online data entry and charting. But for now, Carle's physicians are using it mostly to view information generated outside the exam room. This includes lab, radiology, and pathology results; electrocardiogram interpretations; appointment and scheduling information; immunization data; and dictated reports, including operative notes and discharge summaries. Paper documents won't be scanned in, but Carle aims to make the paper chart go away by having all physicians dictate notes from patient encounters. After they're transcribed, those notes will be accessible through EpicWeb, too.

Carle is taking the "light" approach because a full-scale EMR would be too great a change to be well accepted. "We want to see how the doctors would use EpicWeb before throwing a lot of money into a full EMR," says Ford. "An EMR that requires clinician data entry would be overwhelming for some doctors, especially those who aren't familiar with using a computer."

Even if they don't have to enter data, why would physicians use a medical record that resides on an intranet? "Because the information they need to practice medicine will be at their fingertips rather than in a chart they may not have immediate access to," responds Kimberly Hall, Carle's EpicWeb project coordinator.

One capability that physicians will find attractive is longitudinal graphing of lab and other results. "I can do a flow chart of a patient's lipid panels, PSA, or whatever, even over several years," says internist John F. Stoll, who has been pilot-testing some of EpicWeb's features. "That's a powerful, valuable tool."

A new-results routing function may also help get physicians on board. Currently, Carle Clinic routes a hard copy of all lab reports to physicians for their review and initialing. In August, Carle launched a pilot project through EpicWeb that routes an e-mail copy of lab reports to physicians. Paper lab reports will continue to exist for those physicians who feel more comfortable with traditional routing; but eventually, hard copies could disappear, Hall says.

Further down the road, Carle Clinic may introduce a digital signature system for authenticating operative notes, discharge summaries, and other documents that require a physician's signature. That step depends, in part, on the success of the project to route lab results electronically.

"We're hoping that the new-results routing system will be the wedge in the door to get physicians to try EpicWeb and then to use it regularly," Hall says. "The goal is to get all the doctors to convert to the electronic environment."

So far, the emergency physicians seem to be the ones most taken with EpicWeb, she notes. "They've always had more trouble than physicians in any other department getting a chart on a patient. With EpicWeb, the chart is always there at the click of a mouse."

Also down the road is a comprehensive electronic medical record that will present patient data in a more searchable format. Hall expects that to be Web-based, but isn't convinced it will be from Epic.

Meanwhile, pediatric neurologist William A. Farris of Carle is excited about the prospect of having the vast majority of work-related information—everything from on-call schedules to prescriptions, from favorite Web sites to X-ray images—available to him through the intranet. As he puts it, "Instant access to everything you need through one portal, that's the goal."

Will intranets soon be passé?

Just as intranets are beginning to inspire lofty expectations among practicing physicians, some experts wonder whether they're about to become obsolete.

In the Internet's early days, security concerns led to the development of encryption techniques and firewalls that surrounded private, Internet-like networks. These became known as intranets. But as techniques for ensuring privacy on the public Internet improved, the interest in intranets waned. "In many ways, the whole notion of an intranet is beginning to be passé," says Rosemarie Nelson, a health-care informatics consultant based in Skaneateles, NY. "Health care is getting more and more comfortable with the Internet as security measures become more powerful and effective."

Among these are increasingly robust methods of encryption, digital certificates to authenticate users, smart cards that control access and privileges, and biometric systems that use fingerprints, voice patterns or other unique physical characteristics to identify authorized users.

The big advantage of conveying data across the public Internet is that it increases access. Many intranets allow outside access only from certain locations. Physicians can reach the Internet, in contrast, from just about anywhere: home, office, satellite clinic, or any of the several hospitals at which a physician typically works. A doctor with a laptop or personal digital assistant even has Internet access when he travels.

About one-fourth of the 300 physicians at the Carle Clinic in Urbana, IL, access the group's intranet from their homes, but the dial-up connection leaves much to be desired, physicians say. Jeff Ford of Carle's IT department expects to improve this connectivity by establishing a virtual private network that includes the physicians' home computers and by providing them with high-speed Internet access. The virtual private network is secure and inexpensive, and it will give doctors better access to the Carle intranet, says Ford. But it doesn't confer the mobility of using the public Internet.

"Of course, if we want to put medical records and other sensitive information on the Internet, it's absolutely necessary to continue to improve confidentiality measures," Ford adds. "But as Internet security concerns diminish, health care is moving toward Web-based solutions."

Bradley C. Eichhorst, a family physician and director of clinical informatics for Epic Systems, a Madison, WI-based manufacturer of clinical software, believes this move toward the Internet is just getting started but will become "overwhelmingly strong within the next couple years. Intranets and the Internet will continue to complement each other," Eichhorst says. "But if someone was just starting down this path today, they would do well to skip the intranet and go right to the Internet-based solution."  

Greg Borzo. Group practice intranets: Getting physicians to use them. Medical Economics 2000;22.