The road to viable computerized medical records systems is strewn with empty promises. But after almost two decades of false starts, a number of possibilities have appeared on the horizon. The task now is not to invent a system, manufacturers say, but to address the skepticism of physicians and large provider organizations regarding the value of electronic medical records. Their concerns cover everything from the need for security to the need for standardized terminology.
Because electronic medical records systems have the potential to make an enormous impact on the day-to-day practice of medicine, it is ironic that, although providers accept electronic billing and scheduling as all but routine, they are reluctant to embrace the use of EMRs, users and manufacturers say.
Warner Slack, M.D., co-director of clinical computing at Boston's Beth Israel Deaconess Medical Center, says, "Physicians can log on in their home or office and get information from the CDC (Centers for Disease Control), National Library of Medicine or other sources, but to this day it's hard for them to get (online) information regarding their own patients." Slack is associate professor of medicine and psychiatry at Harvard Medical School and author of Cybermedicine (Jossey-Bass, 1997).
Because access to EMRs is relatively new, market penetration is difficult to gauge. The Chicago-based Healthcare Information and Management Systems Society surveyed healthcare executives and managers this year in its annual HIMSS Leadership Survey.
Eleven percent of the 993 respondents said their organizations have fully operational computer-based patient records systems compared with 2% in 1998.
Another 32% said they have begun to install EMR hardware and software, 25% have developed a plan to implement EMR systems and 29% have no plans as yet for the use of such systems. Three percent did not answer.
The Medical Records Institute of Newton, Mass., surveyed attendees at its conference in May. Sixty percent of the 500 respondents said they either already have implemented EMRs or have plans for implementation.
The Mayo Clinic Scottsdale, which opened in Scottsdale, Ariz., last November, was wired during construction with a combined proprietary-commercial EMR system that physicians use to track lab results, pathology, radiology, admissions history, discharge summary and more.
In a recent survey of the Mayo physicians, about half said the system has increased efficiency, says John Camoriano, M.D., chairman of the information systems steering committee. Fifteen percent reported that the system decreased efficiency, and 35% said they didn't notice any change.
"The differences (appear to be related) to subspecialties," Camoriano says. "Surgeons tend to want information delivered to them by a resident or paramedical staff, while internists are more likely to sit in front of a computer screen and delve into the information themselves."
One clear advantage of the EMR system, Camoriano says, is that it has increased physician compliance with the requirement that they sign charts. Now they can sign charts electronically, which is more convenient than tracking down records on paper, he says.
Carmoriano estimates that Mayo has invested approximately $10 million in its EMR system, including hardware, software, training and design. The hope is that the new system will:
- Improve patient care by providing up-to-the-minute information that allows multiple caregivers to access the same patient data at the same time;
- Enable Mayo to provide patients with a single registration, bill and schedule because both the hospital and the clinic are using the same electronic system;
- Provide electronic "tracking" of patient flow, giving physicians immediate access to patient data;
- And, in the long term, create online reminders and guides for physicians and nurses, customized to meet the needs of individual patients.
Instead, computers in the exam room are used to show patients their X-rays and lab data.
Initially, the EMR system was slow and needed new hardware, Camoriano says. And, he admits, leaving old systems to try something new required some adjustment.
"Our scheduling system is less efficient than it used to be," he says. "We knew upfront that it would be but accepted that decrease in functionality in order to achieve the gains inherent in a system that is integrated across the inpatient and outpatient environments.
"On the other hand, our physicians are able to get at data to return patient phone calls without asking a secretary to get the chart for them, and this has increased productivity in real, but hard to measure, ways." Camoriano says it takes about six to 12 months for most organizations to adapt to an EMR system.
The value of EMRs to individual physicians is fairly clear. They can type notes into them during office visits, scan in loose paperwork, view laboratory results, chart patients' progress, conduct database searches among their patient populations, track HCFA requirements--in other words, they can better organize their overall clinical information.
But the value of such systems to large care providers is somewhat murky, as none delivers everything large providers need.
"Vendors typically create a system with which they can get a business rate of return," says Jeff Blair, vice president of the Medical Records Institute and a member of the National Committee on Vital and Health Statistics. "They've been able to do that more readily with acute-care institutions that have the money (to purchase the EMR system). That is rapidly changing. You see vendors that are growing very rapidly to target group practices.
"My advice (to physicians)," he says, "is that the first time they look at a system, they'll see it doesn't have all the functions they want. (The ability to operate) with other systems is critical because more and more the value of the system will be (based on the strength of) its connectivity with the rest of the healthcare profession. None of the systems out there are perfect, but they're evolving."
Camoriano at Mayo agrees that "there isn't one system that does it all. The key is to find a vendor that has admission, discharge, transfers, registrations and results. (Many) vendors come from billing backgrounds and often have carried that thinking into their clinical systems, so patients may be identified not as much by their diagnoses (but by their) billing codes."
The 12 physicians of the Sentara Medical Group of Hampton Roads, Va., use an EMR system made by Hillsboro, Ore.-based MedicaLogic for tasks such as assessing outcomes and making adjustments, notifying patients of the withdrawal of drugs from the market, new treatments and even for attracting more business, says Daniel Crabtree, M.D., of Sentara.
"We've seen a significant increase in ancillary services rendered, including labs and immunizations, due to mailing of timely reminders, so much so that it has helped to dramatically defray the cost of the system," he says.
"In the first two years (since we implemented the EMR), we have not seen a dramatic drop in overhead. But we anticipate that we will."
Crabtree says the Sentara physicians chose not to force everyone in the group to use the EMR system, so they are running dual systems (paper and EMR), which is costly. But the number of doctors on the system is beginning to increase, he says.
Having a physician working next to you who doesn't stay until 7 p.m. to complete dictations or read through a stack of charts on his desk works as a silent endorsement of the EMR system, he says.
To ensure patient privacy, the MedicaLogic system stores Internet data on a site that has military-grade security and requires biometric identification, including retinal scanning and finger printing, to gain access. The company has gone so far as to hire professional hackers to test its system.
"People have to trust this," says MedicaLogic CEO Mark Leavitt, M.D. "We're betting the company on it."
An additional measure of security may come from proposed federal regulations that will require patients have a way of knowing who has seen their medical records. Unlike paper charts, electronic charts generate audit trails that clearly show who's seen what.
"Doctors have to look at EMRs not as a computer system but as the nucleus of the emerging national healthcare information infrastructure," says Blair, of MRI.
As for the EMR industry, Blair says it needs to develop a common medical vocabulary, communication standards, and formats and privacy standards.
"(Electronic systems are) going to be the way physicians communicate with other physicians, payers and researchers and the way they'll get consults, referrals and continuing education," he says.
Among the largest EMR vendors, according to company figures, are Physician Micro Systems in Seattle, McKesson HBOC Information Technology Business in Alpharetta, Ga., and MedicaLogic.
Physician Micro Systems' Practice Partner software is used worldwide at 200 sites by 5,000 physicians, most in primary-care settings. The company's sales grew 50% last year, largely because of the increased use of its EMR products.
Physician Micro Systems, a private company, did not reveal the amount of money that increase represents.
There are several EMR system options offered by McKesson HBOC, including its stand-alone Smart Medical Records program, which is used nationwide at 12 sites by 250 physicians. As the largest healthcare information technology vendor, with revenues of $23.6 billion per year, the company also manufactures portable EMRs, which are used by thousands of home-healthcare nurses, and has developed other EMR products for use in hospitals.
MedicaLogic's products, which include DOS-based ClinicaLogic and Windows-based Logician, are used nationwide at 424 sites by 7,400 providers. Another product, AboutMyHealth, is expected to be available before the end of the year. The new product will give patients access to their medical records via the Internet.
Also nearing launch is Logician Internet, which will provide individual physicians with on-the-Web tools to create and store medical records online using only a PC and an Internet connection.
To determine whether an EMR system is worthwhile for a particular doctor or organization, Blair suggests physicians attend an EMR conference, where they can see firsthand how the various systems operate and talk with other physicians about what has worked for them. Leavitt emphasizes the chaos that's inherent in the move from paper to computer and the need for all providers to get involved.
Although it takes a while to get used to, once physicians are familiar with the workings of their EMR systems, it's like power steering or air conditioning, he says. "You wonder how you got along without it."
Bruce Kleaveland, senior vice president of sales and marketing for Physician Micro Systems, says, "There's no question that the Internet is going to have a big impact on EMRs." A simple example, he says, is a patient with an upcoming appointment who logs on to his or her physician's Internet site to fill out a medical history form before the appointment.
But the goal for now, industry spokesmen say, is to get more physicians using EMRs, period, something Leavitt is very optimistic about.
"It would really surprise me," he says, "if--in less than five years--EMRs haven't been adopted by half of all ambulatory or office-based physicians."
Robin F. DeMattia is a Warrenton, Va.-based business writer and editor.