If 2002 was the year that medical practices and hospitals finally began to take a serious look at clinical information technology, 2003 could be the start of a watershed convergence of electronic medical records, clinical decision support, automated billing and consumer-focused quality information.
Last month, after years of searching, the Northern California and Southern California Permanente medical groups, the two largest healthcare provider organizations in the United States with 3 million enrollees each, were preparing to select an IT vendor for a new ambulatory clinical information system.
A decision to move away from several home-grown EMR systems would produce one of the most massive-and, from a vendor's standpoint, lucrative-IT installations in medical group history.
It also would mark something of a coming of age for clinical systems vendors, according to veteran medical informaticist Andrew Wiesenthal, M.D.
"No vendor products were scaleable to that size until recently," explains Wiesenthal, associate executive director for the Permanente Federation, the medical group division of Kaiser Permanente, Oakland, Calif. Final vendor selection had not been made at presstime.
"I think there is going to be a lot of movement in healthcare IT this year," says Janet Marchibroda, CEO of the eHealth Initiative, a yearlong project of the Washington-based not-for-profit Connecting for Health that began in June and aims to improve the quality, safety and efficiency of healthcare through IT.
Connecting for Health and the eHealth Initiative, both funded by Markle Foundation grants, are "building awareness and laying the foundation for an interoperable system," Marchibroda says. "We're looking at driving standards for interoperability of information across the health system."
The eHealth Initiative has four goals: identify the data necessary to deliver better healthcare; reach consensus on standards that should be applied to that data; determine the clinical information needs of stakeholders; and demonstrate interconnectivity between large health systems.
Marchibroda says the list of stakeholders in the healthcare system has widened to include researchers, public health officials, accreditors, employers and consumers, in addition to providers and payers.
"Everybody needs the same data," Marchibroda says, "but that data is not collected electronically and not in a standard way."
Standardizing a patchwork
At Kaiser Permanente, all of the nearly 11,400 physicians in the integrated healthcare organization have access to some form of EMR, while about 2,000 doctors and thousands of other clinicians and case managers are completely paperless, according to Wiesenthal.
But, he adds, systems in each of its seven regions still do not work well together because they built their clinical IT infrastructures separately.
Wiesenthal spent 20 years in quality management for the Colorado Permanente Medical Group before joining the national office in 1998. In Colorado, he helped lead the development of an EMR, including outpatient computerized physician order entry-a rarity in ambulatory medicine even today-and e-prescribing.
"Since then, physicians in the ambulatory setting at Kaiser Permanente in Colorado have not used paper," Wiesenthal says.
In 2000, Kaiser Permanente officials decided to scale the homegrown Colorado ambulatory system across the seven-region, 8.1 million-patient enterprise, but they now appear to be backing away from that plan in favor of using a system developed by an outside vendor.
Kaiser Permanente had chosen the Colorado system as its model for clinical information systems largely because it was dissatisfied with the selection of commercial ambulatory EMRs at the time, Wiesenthal says.
But the high degree of autonomy of the seven regions was an obstacle to the Kaiser Permanente Colorado plan to create a uniform EMR. Kaiser Permanente of Hawaii, for example, went with a full-blown EMR based on the Colorado technology, but KP Ohio opted only to scan progress notes from paper charts.
The Group Health Cooperative of Puget Sound, meanwhile, had purchased a clinical information system from Epic Systems Corp. before the Seattle-based group was merged into the Permanente fold to create KP Northwest. Also, the Northern California region spent "an enormous amount of time" building its own clinical data repository, which still is not complete, Wiesenthal says.
Expectations were that the project using the Colorado system would take six or seven years to implement and cost as much as $2 billion, about two-thirds of which related to hardware purchases, staff training and implementation expenses, according to Wiesenthal.
In the end, he says, Kaiser Permanente officials decided they could get the level of clinical decision support and the integration they desired in a shorter period of time and for the same amount of money by turning to the commercial market.
"We realized that the pace of evolution in the function of our product wasn't keeping up with the pace of the vendors' products," he says.
In the Pacific Northwest, PeaceHealth, Bellingham, Wash., has achieved a high level of clinical IT connectivity and is poised to move to the next frontier.
"We're so far advanced with our infrastructure that we're about ready to go to a place that I've always wanted to go: real-time decision support," explains John Haughom, M.D., Eugene, Ore.-based senior vice president of the Health Improvement Division at PeaceHealth.
Since 1994, PeaceHealth has been building electronic health records for all the communities the not-for-profit delivery system serves in Oregon, Washington and Alaska.
"We view this information as a community asset for the benefit of the community," Haughom says.
All six PeaceHealth hospitals and all four multispecialty ambulatory medical groups participate in the organization's Community EHR, accessing records through a private network.
"As it's become more successful, we've been getting increasingly more requests from independent physicians" with privileges at the hospitals, Haughom says.
Independent practices can lease high-speed access to a central database. The IDX Last Word system supports the entire PeaceHealth organization-some 1,200 to 1,400 physicians for inpatient care and about 250 physicians on the outpatient side who can use the system for free to manage patients receiving care in any PeaceHealth facility.
Physicians in PeaceHealth clinics placed more than 550,000 electronic drug orders in 2002 on an outpatient CPOE system, Houghom says. The organization will be completely filmless in two to three years.
"The docs love it because it is efficient," Haughom says. "We love it because we can provide (medication) decision support. Employed docs can send medication orders directly to pharmacies."
Though the EMR has eliminated much of the paper, PeaceHealth still kills its fair share of trees with inpatient order entry and transcribed progress notes.
As for CPOE in acute settings, Haughom says, "It's such a big cultural issue that we want to make sure we get it right before we offer it to everybody."
PeaceHealth also is being deliberate with plans to link patient records to unaffiliated medical organizations in its service areas because it has HIPAA privacy concerns, according to Haughom.
"We have to manage the privacy and security for patient records from all hospitals and all groups across the entire continuum of care," he explains. "This is a much more complex endeavor than most organizations face."
Clinical decisions first
CPOE has grabbed headlines in the medical community largely because it is the first part of the Leapfrog Group's three-pronged approach to patient safety improvement.
A September report by healthcare research firm First Consulting Group suggests that practitioners eventually will apply clinical decision support broadly to assess quality, safety and appropriateness of care, but the initial focus is on medication safety and CPOE.
However, implementing a CPOE system is expensive and complicated, so the Long Beach, Calif., company says clinical decision support, or CDS, should be in place long before order entry.
According to First Consulting Group, this would represent a fundamental cultural shift, making an organization's approach to patient safety proactive rather than reactive.
Just what this might involve depends on the healthcare organization.
"Everyone has a different definition of what CDS is," says Barry Chaiken, M.D., McKesson Corp. vice president for clinical marketing. "Getting up-to-date results is a form of clinical decision support."
San Francisco-based McKesson, a vendor of large-scale healthcare information systems, and its competitors offer many types of decision support, including results reporting, user-friendly physician portals, pharmacy reference tools, disease management databases and CPOE.
Because of the complexity of clinical decision support, Chaiken recommends that healthcare providers build from the ground up.
"We have so much to do on the easy stuff that we should do the easy stuff," he says. As a physician, "if I'm able to have the latest information available when treating a patient, I'm going to do a better job."
March toward automation
The armed services are light-years ahead of most of the civilian healthcare population in terms of standardization and automation of medical records.
Practitioners and pharmacists, for example, can check the medication histories of any enlisted member of the armed forces from virtually any U.S. military installation in the world to prevent drug interactions or double dosing.
For a military doctor like Army Maj. Steve Krause, D.O., an internist at the 67th Combat Support Hospital in Wurzburg, Germany, having clinical decision support-electronic copies of reference manuals on a personal digital assistant- sometimes is the only way to do his job.
"Out here in Europe, it's become a necessity because you can't get new textbooks very easily without the Internet," Krause says.
He began carrying an iPaq PDA during a three-month peacekeeping mission in Kosovo in 2000.
"You just can't be one specific type of physician because you are treating all kinds of people, from children on up," he explains. "We could not take bulky books with us on Air Force planes into Kosovo, so I downloaded five books onto my PDA."
Demand has been so great from military physicians that Skyscape.com, a Hudson, Mass.-based publisher of electronic versions of medical reference material, recently introduced a PDA version of the Special Operations Forces Medical Handbook for Special Forces combat medics in all branches of the service.
Consumer-focused quality info
Civilian medicine eventually will catch up, in part because the public is clamoring for better healthcare and more information.
A September poll by the Pew Research Center in Washington, D.C., found that 67% of Americans expect to find reliable information on the Internet about health or medical conditions.
Significantly, 46% of U.S. Internet users say they will go online the next time they need healthcare information, while 47% say they will turn to a medical professional-a statistical dead heat. (Among all Americans, however, 59% still will contact a healthcare professional.)
The eHealth Initiative's upcoming demonstration of the transmission of clinical data between healthcare organizations aims not only to test the technology but to show what, if any, value each stakeholder derives from interoperability, says Marchibroda.
An eHealth Initiative workgroup on personal health is seeking to identify a set of data that patients need, "articulating a shared vision for attributes of personal health records," Marchibroda says.
"A universal way of getting information to where it needs to be at the right time has enormous potential," says medical informaticist Douglas Perednia, M.D., medical director of the not-for-profit Telemedicine Research Center and founder of the Association of Telehealth Service Providers, both in Portland, Ore.
To this end, Sen. Edward Kennedy (D-Mass.) has proposed legislation to prompt HHS to develop national healthcare IT interoperability standards and require CPOE adoption. And in December, the American Hospital Association, Federation of American Hospitals and Association of American Medical Colleges agreed to work toward the goal of having all U.S. hospitals report data on quality of care.
CMS will help the effort by leading a two-year pilot program for hospitals in Arizona, Maryland and New York to test ways of communicating this data to consumers.
Perednia says the healthcare system will realize more value by zeroing in on the most useful information than by working to perfect the technology.
"Nobody really cares about the technology any more than they care about the tires on their car," he contends.
Perednia, a dermatologist who left practice three years ago, favors what he calls the "universal medical record," available anytime and from anywhere to authorized parties on a secure part of the Internet.
"Everyone is willing to pay a little bit for a part of that," Perednia says.