The new goal of these trailblazers: James Holly, M.D., sums it up as electronic patient management.
"Electronic patient records are not the goal," says Holly, CEO at Southeast Texas Medical Associates, a 28-physician practice in Beaumont. Rather, the goal is to use clinical data to improve communication with patients while achieving better treatment results.
For example, Holly, who has been using an electronic records system from NextGen Healthcare Information Systems Inc., Horsham, Pa., for almost a decade in his clinic, now is using the technology to create daily progress notes at one hospital where he treats patients. These notes, organized in a disease management format, provide an "at a glance" look at all the key factors in the patient's treatment, enabling others on the medical team to more easily identify appropriate next steps.
"Very often in medicine the real benefit is paying attention to the simple things," Holly observes.
Rather than wait for the hospital to take the initiative, the 63-year-old internist designed the progress note with the help of his technological staff, creating a summary of hospital activity in what had been just an outpatient record. Because the hospital is not yet ready to incorporate the automated information, Holly and two other physicians are creating electronic progress notes and then printing them out, placing them in paper hospital records, providing a guide for others.
21st century innovation
Across the country, EHR pioneers are working on a broad range of 21st century clinical automation projects. Among the most common are:
* Embedding decision support capabilities, including appropriate alerts, into EHRs.
* Using clinical data to support research aimed at improving the quality of care and preparing for pay-for-performance.
* Looking for ways to increase connectivity so that hospitals and clinics can readily share life-saving clinical information.
* Supporting the growth of EHRs at clinics by coordinating these projects through hospitals.
* Phasing in personal health records that include data entered by patients.
* Adding new components to EHRs designed to make the data more complete. These include a broad range of test results, from diagnostic images to electrocardiogram strips. The military is even taking the step of adding dental records to its EHR (see related story, page 28).
* Providing easier access to EHRs at the point of care through wireless networks.
But all of these efforts are destined to fail unless physicians and nurses -those who actually use the data-are leading the way, executives at pioneering organizations stress. "My role is to evangelize about this," says James Morrow, M.D., vice president and CIO at North Fulton Family Medicine in suburban Atlanta. "My job on this earth is to help people to see that this is not the impossible task they hear it is." (See related story, page 30.)
Many EHR pioneers now are adding medication management or computerized physician order entry systems that include decision support mechanisms. Some are also building alerts into their EHRs to remind physicians, for example, that a patient is due for a test.
At Johns Hopkins Medicine in Baltimore, which started down the path toward EHRs back in the 1980s, CPOE is still being phased in as part of an effort to reduce medical errors. In addition, the organization, which is adding CPOE technology from Boca Raton, Fla.-based Eclipsys Corp. to complement its homegrown EHR, is creating alerts that tell a physician when new lab test results have been posted to the electronic chart, says Stephanie Reel, vice president for information services.
"CPOE is about helping doctors make better decisions at the point where they place the order," she says. This goes one step beyond automating clinical data to actually using the data to influence behavior, she explains.
The key to making CPOE and clinical alerts work, Reel adds, is ensuring that doctors design the systems. "We could never have done this in a million years without physician leadership," she stresses. "Our doctors are committed to patient safety, so they are willing to work an amazing amount of extra hours creating decision support rules to make sure they generate an appropriate number of alerts."
Similarly, the hospital widely acknowledged as the first to implement an electronic records system back in the 1970s is focusing its efforts on building alerts for medication management.
El Camino Hospital in Mountainview, Calif., formed a committee of physicians, nurses, pharmacists and I.T. staff to create alerts in its Eclipsys system, says Diana Russell, R.N., vice president of patient care services and interim CIO.
The group is identifying high-risk patients and then taking steps to create a minimum number of key alerts to influence treatment decisions. "If there are too many alerts, it becomes disruptive, and the tendency is to blow by them," she says.
Morrow, from North Fulton, also warns against creating too many "pop up windows" that ultimately get ignored. In most cases, his practice relies instead on a "patient manager" function that the doctor can use to seek out advice. The practice, which uses software from Allscripts Inc., Chicago, also can flag charts to send out a reminder to the appropriate clinician when a patient is due for a blood test.
"Even with an EHR, you still have to be a physician," Morrow says. "That's the bottom line here."
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