Long before President Barack Obama’s economic stimulus package committed billions of dollars to bring medical records into the digital age, officials at Long Beach Memorial Medical Center in Long Beach, California, decided to eliminate the reams of paper their system generated, aiming to improve patient care via reducing medical errors and the duplication of services.
It took six years of intense preparation, but in July 2008, “in the flip of a switch we went from paper to paperless overnight,” says Dr. James Leo, associate chief medical officer. “It was sort of like ripping off a Band-Aid.”
While many hospitals and health care providers might not go for such a drastic approach, the $19 billion in federal stimulus money is designed to help create electronic health records for most Americans by 2014, and as a result, improve health care. Financial incentives for hospitals and physicians who make the transition are intended to ease the process along.
A Rand Corporation study released in 2005 found that despite the high initial costs, a nationwide switchover to electronic medical records would save about $81 billion annually, primarily from a decrease in redundant care, improved safety, and expedited patient care.
Other obstacles remain, ranging from a lack of information technology experts to get the systems up and running to concerns over electronic health records’ privacy and security.
First step is wooing doctors
The first step is getting buy-in from the health care providers involved. According to a recent survey published in the New England Journal of Medicine, only 1.5 percent of hospitals have a comprehensive electronic records system in place and 7.6 percent more have a basic system, while about 17 percent of all doctors in private practice have electronic medical records systems.
Acceptance depends on the culture of an organization, as well as its willingness to change, says Dr. Michael Mirro, a cardiologist in Fort Wayne, Indiana, and head of health care information technology for the American College of Cardiology.
At Long Beach Memorial Medical Center, part of the MemorialCare system in the Los Angeles area, it was the key stakeholders who powered the decision along, driven by the desire to reduce medical errors, cut down on the duplication of services, ensure the consistent application of evidence-based care, and create a reliable method to track information both inside and outside the hospital, Leo says.
“There is a tremendous amount of waste in health care,” Leo says. Tests might be done twice if there is no way to track if they already have been performed. A patient might receive “unnecessary care, duplicative care, or wrong care.”
Finding the right system
But finding the best electronic health records system for a particular practice is no easy process. Todd Johnson, president of Salar, a Baltimore company specializing in electronic documentation systems for hospitals, cautions health care providers should have “no expectations they can just buy a product off a shelf and it will automatically work for them.”
Because each doctor’s office or hospital has unique needs, it takes time to select the right system. Doctors looking for stimulus help need to know that under the stimulus provisions, whatever system is selected has to come from a certified vendor and meet a “meaningful use” provision, which has yet to be defined.
At Long Beach Memorial, a committee studied three different systems in great detail, doing a test run with each and providing feedback on the results. They overwhelmingly voted for the Epic system, which allows a great deal of customization. Leo describes it as “using an Epic chassis, with a specific bus built on top of it.”
Each user had to undergo extensive training before the system was up and running. “This was a commitment all of us made, some willingly, some grumbling,” Leo recalls.
The costs of establishing electronic medical record systems also can give health care providers pause. For the MemorialCare system, which encompasses Long Beach Memorial and four other hospitals, the project cost about $55 million.
Cost is a barrier
Even smaller-scale systems can be pricey. Dr. John Dormois, a cardiologist in private practice in Tampa, Florida, began the switchover to electronic health records in 2001, but was not completely digitalized until 2007. His proprietary system cost $12,000, which was at the low end of systems he’d looked at, with some ranging up to $50,000.
Dormois, like many other health care providers, started out with small changes, like having patients email their questions to him and set appointments online, before investing in a major system.
Today his office is completely digitalized, which makes finding patient records a breeze. One benefit that he can now offer patients is informing them when the Food and Drug Administration recalls certain medications. Prior to installing the system it would have been a struggle to find out who has been prescribed the drug. “Most physicians’ offices can’t possibly find that information,” Dormois says.
At his office, a few keystrokes tell him everyone who uses that medication, and he can immediately have his staff email or call all of them.
Mirro suggests organizations start with electronic prescribing to ease into the digital age. That will give physicians the opportunity to test a system and vendor, without making a major investment.
Though the stimulus money provides $44,000 per doctor who adopts electronic medical records, health care practices run the risk of selecting a vendor, then finding it doesn’t meet their needs, says Mirro, who serves on the Certification Commission for Healthcare Information Technology, which is charged with certifying system vendors.
Another incentive—those who don’t make the switch and serve Medicare and Medicaid patients could lose that funding.
Will Crawford, director of the informatics solutions group at Children’s Hospital in Boston, says of the financial incentives, “It’s a big carrot, but honestly not much of a stick.”
Experts are at a premium
Once a system is selected, there are still hurdles to overcome and concerns to address.
The first is finding experts to get the systems up and running. Crawford says anywhere from 70,000 to 200,000 information technology experts are expected to be needed. “This will continue to be a huge growth area.”
Children’s Hospital, which is part of the Harvard University system, has had been using electronic health records since the 1990s, and Crawford, who used to work for the Department of Health and Human Services in this field, has seen the benefits as well as the challenges.
Among the positives are e-prescribing, which allows health care providers to easily see possible interactions with other medications. “It’s potentially a huge safety benefit,” he says.
In addition, if patients can access their own health records at the push of a button, providers have found they are “more engaged in the management of their own health.” Such systems can also help Medicare patients find the plan that makes the most financial sense for them.
On the downside, Crawford thinks it will be a challenge to get health care organizations to share data. For hospitals, “there’s not much in it for them, other than altruism.”
Making it all work together
Dr. James Pierce, chair of the Bioinformatics and Computer Science Department at University of the Sciences in Philadelphia, is even more vocal with his concerns. Each vendor uses their own proprietary technology, and under the new electronic medical records provisions, health care organizations are supposed to be able to share data. “Which company is going to give up its secrets?” Pierce asks.
Another issue is the limited amount of electronic data storage. But for procedures like CAT scans and MRIs, “the memory requirements are quite significant. It’s not easy to move terabytes” yet the health care records are supposed to be portable, he says. Potentially, “our ability to generate data might overtake our ability to store it and manage it.”
Research is now under way on how to best address the issue, Pierce says. Some health care providers have turned to medical archive solutions provided by companies such as IBM and HP, which sell storage capacity into the terabytes. A complete cardiology workup could require 2 gigabytes of storage space, Pierce says, while just an X-ray or CAT scan can require at least 35 megabytes of space.
Pierce also is concerned about the privacy and security of electronic records. Anything found in there “lives forever. That defines you as a person, as a patient, as you go forward.”
While some have expressed concerns about potential security breaches, Dormois says with the system he uses, everything is encrypted. “It’s just as safe as any bank.”
Leo believes electronic records are even safer than paper charts. Before, anyone could walk up and read a chart left outside a patient’s room. Now anyone who accesses records has to sign into the system, and records of VIPs are flagged with a special warning. Anyone who accesses them needs to have a good reason because the system creates an audit trail. In California, anyone who breaches the system can face hefty fines. “It creates a wonderful disincentive.”
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How hospitals can make the digital transition
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