technology to the rescue · 2007-04-12 · technology to the rescue dr.susan andrews’search for...

Technology To The Rescue

Dr. Susan Andrews’ search for an electronic medical records(EMR) system began in April 2000, when the hospital thatowned her family practice in Murfreesboro, Tenn. an-

nounced that it was dissolving the relationship. Faced with theprospect of doing their own billing and scheduling, Dr. Andrewsand three other doctors in the practice decided that instead of pur-chasing a stand-alone system, they would “jump into an EMR,”Dr. Andrews says.

After researching the applications they wanted and the vendorsthat were in the marketplace at thetime, the practice spent about$17,000 per doctor for EMR soft-ware as well as billing and sched-uling programs. Hardware costscame to about the same amount,Dr. Andrews says, noting that inthe four years since the groupmade its initial investment, com-puter equipment prices havedropped dramatically.

By October, the EMR systemwas in place. Dr. Andrews and herpartners started with prescription

and patient notes modules, and in December added billing. TheEMR functions have continued to expand, and the system nowmanages prescriptions; maintains patient notes; automatically en-ters billing, diagnostic and procedure codes and transmits themto the billing department; generates patient education materialsfor conditions such as diabetes, and tracks immunizations andthe status of critical tests, health screenings and exams.

80 w w w. d o c t o r s d i g e s t . n e t

E R R O R P R O O F I N G

Patient safety experts havelong extolled the virtues of in-formation technology in the re-duction of medical errors. Yet,the adoption rate of computer-ized patient records has beenslow; an estimated 14 percent to28 percent of practices have de-ployed EMRs, and it’s unknownhow many of those are compre-hensive systems using stan-dardized protocols.

“We have a template for diabetes that automatically tells us thelast laboratory values, when they were done and protocols forhow often to do certain lab tests and what the results should be,”Dr. Andrews says. All of that information is in front of the doc-tor when a patient comes in, along with a list of all the medica-tions the patient is taking, the date of his or her last eye exam andother health screenings.

Every time a doctor opens a note or sees any patient, a list ofoverdue procedures—Pap smear,mammogram, cholesterol screen-ing or flu shot, for example—ap-pears. Items on the list can be ad-justed according to particular di-agnoses, medications or a patient’sage. The front-office staff mem-bers see the same list when theyschedule patient appointments, “soit’s not just doctors seeing that in-formation,” Dr. Andrews says.

The EMR makes it possible to quickly fax patient summariesto hospitals and other providers. When patients are admitted tothe hospital, for example, the practice can send relevant patientinformation in a minute, Dr. Andrews says.

Currently, the practice is incorporating an “electronic en-counter form,” Dr. Andrews says.

Since implementing an EMR system, the practice has im-proved the quality of care and achieved significant savings, Dr.Andrews says. Doctors practice in two separate sites, and one ofthose offices has cut 1.5 employees by computerizing transcrip-tion and eliminating the use of paper charts. In addition, the prac-tice has taken its billing in-house.

“Staff is working more efficiently,” Dr. Andrews says. Thestaffers are no longer “chasing charts.”

For the past three years, Dr. Andrews and her partners haveparticipated in the Practice Partner Research Group, a researchinitiative that gathers and feeds back quality indicator data to 88practices nationwide. Every three months practices get a book-let that shows how well they are doing in seven categories of pa-tient care, based on data transmitted to the Medical University of



“There is nothing we can dothat would have a bigger impacton improving patient safety thancomputerizing records,” saysDr. Lucian Leape, adjunct pro-fessor of health policy at theHarvard School of Public Health.“We’ve talked about it for 45years and it’s long overdue.”


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0 10 20 30 40 50 60 70 80

They had to wait or come back for another appointment because

the provider did not have all their medical information

They have seen a healthcare professional and noticed that they did not have all

of their medical information

The coordination among different health professionals

that they see is a problem

Percent

Don’t know (1%)

No (67%)

Yes (32%)

Public Perceptions on Role of IT In Reducing Medical Errors

Percent who say:

Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / HarvardSchool of Public Health National Survey on Consumers’ Experiences with Patient Safetyand Quality Information, November 2004 (Conducted July 7 - September 5, 2004).

Have you or a family member ever created your own set of medical records to ensure that you and all of your

healthcare providers have all of your medical information?

South Carolina in Charleston.“We’ve improved how well we are doing with patient care a

tremendous amount,” Dr. Andrews says, particularly in areas suchas control of diabetes and the number of patients receiving crit-ical vaccines such as flu and pneumonia.

“I can’t think of anyone who couldn’t improve their practiceand save money by implementing an EMR,” Dr. Andrews says.

Despite Benefits, EMRs UncommonPatient safety experts have long extolled the virtues of infor-

mation technology in the reduction of medical errors. Yet theadoption rate of computerized patient records has been slow, ob-servers say.

An estimated 14 percent to 28 percent of practices have de-



The California HealthCare Foundation’s EMR buyer’s guide for smallphysician practices, produced by Forrester Research, describes a 12-stepapproach to selecting an EMR:

1. List high-priority needs. For example, “save time and improvequality.” The authors urge purchasers to be specific about their frus-trations and areas in which the practice could gain efficiencies, such astime-consuming chart pulls, telephone tag with the pharmacy to clari-fy prescriptions and coding problems linked to imprecise documenta-tion.

2. List the EMR features most likely to meet those needs.3. Factor in future requirements. These may include collaborations with

local hospitals in electronic record sharing and adding or changing clini-cians, office sites or specialties.

4. Develop a simple request for proposal (RFP). Spell out priorities onfunctionality, usability, support and cost for the practice and ask each ven-dor to describe in writing how their system will address them. “The RFPshould include component-by-component pricing requests for two or threeproduct combinations,” the guide says.

5. Make the commitment that doctors will enter data. An EMR dependson users to enter information daily and build up a data repository that gen-erates information.

6. Choose either a keyboard and mouse or stylus and touch screen.7. Test-drive each system using common scenarios. Rather than

Twelve Steps to Selecting an EMR System

ployed EMRs, and it’s unknown how many of those are compre-hensive systems using standardized protocols, said Dr. JohnLumpkin, chairman of the National Committee on Vital andHealth Statistics (NCVHS), in a memo last fall to TommyThompson, then secretary of Health and Human Services.

A survey conducted last summer by the American Academy ofFamily Physicians (AAFP), however, reflected growing interestin EMRs among family doctors. Among 788 AAFP respondents,nearly 40 percent said they had either converted to EMRs or werein the process of doing so. Nearly three-quarters of the 310 re-spondents that had EMRs indicated that the systems had im-proved the health of their patients, in part by reducing prescrib-ing errors and enhancing patient communication, the AAFP re-ported. Nearly half (49 percent) of survey respondents said they



limiting demonstrations to those prepared by sales staff, “stipulate ascenario, on the spot, as the basis for the demonstration,” the guidesays. For example, create a scenario in which a physician from thepractice examines the patient with a specific medical history, condi-tion and complaints in order to test the EMR’s ability to effectively doc-ument the visit.

8. Get three physician references, with no financial ties to the prod-uct, from each vendor. References should be located in the immediate areaso that potential buyers can visit the sites, observe the system in opera-tion and ask questions about the vendor.

9. Score competing candidates. Review how their offerings stack upagainst each other.

10. Settle on a purchase plan. The basic choice is between purchasinga system outright through a software licensing fee per user or physician,and an application service provider (ASP) plan. Under an ASP arrangement,doctors pay a monthly fee to access an EMR system over the Internet, asopposed to buying and maintaining the software in-house.

11. Get commitments on initial implementation and technical sup-port. The implementation plan should cover conversion of data from pa-per records, interfaces with billing and other existing computer systems,configuration of features such as alerts values and clinical guidelines, andon-site training.

12. Take advantage of a buyer’s market. With dozens of vendors claim-ing to make EMRs for small- to mid-sized practices, take advantage of thecompetition by negotiating for bells and whistles at no charge.

wanted to purchase an EMR, and 15 percent of those plan to doso within a year, 16 percent within two years and 18 percent af-ter two years. Only 7 percent said they had no plans to purchasean EMR.

“There is nothing we can do that would have a bigger impacton improving patient safety than computerizing records,” saysDr. Lucian Leape, adjunct professor of health policy at the Har-vard School of Public Health and a member of the Institute ofMedicine panel that produced the 1999 landmark report, “To ErrIs Human.” “We’ve talked about it for 45 years and it’s long over-due.”

Harnessing the power of information technology is at the coreof a new vision for the practice of family medicine that’s beingadvanced by the AAFP through its Future of Family MedicineProject.

“As we talk about a new model of care, the central nervous sys-tem of the practice will be an electronic health record (EHR) thatmeets a number of criteria, and will help us do a much better jobof taking care of patients,” says Dr. Stephen Spann, professor andchairman of family and community medicine at Baylor Collegeof Medicine in Houston, and chairman of the task force that stud-ied and reported on financing this new model of care. The goal



Barriers to universal adoption of electronic prescribing by physicians: � Cost of buying and installing a system. � Time/workflow impact: Initially, increased time compared with paperprescribing. � Time/RVU to review a warning. � Lack of reimbursement for costs and resources. � Safety improvements not fully publicized. � Not an expected standard of care.

Driving physician acceptance is likely to require: � Proven value in safety/quality improvement. � Systems that are quick to install, easy to learn and fast in use. � Financial or other incentives to overcome cost.

Source: eHealth Initiative, Electronic Prescribing: Toward Maximum Value and Rapid Adop-tion, April 2004.

Identifying and Overcoming Barriers to Electronic Prescribing

of the project is to transform family-medicine practice “to makeit more responsive to patient needs, safer and to deliver higher-quality care in terms of processes and outcomes,” Dr. Spann says.

To achieve that, doctors need information systems that promptthem with reminders about needed screening tests, check for druginteractions and allergies every time a prescription is written, andoffer “embedded decision support” to guide chronic disease andacute-care management, Dr. Spann says.

For example, when a patient with diabetes comes for a check-up and hasn’t had a cholesterol screen in 16 months, a reminderwill pop up saying that the test, which should be done annually,is due. Ideally, information systems also should connect doctorsto up-to-date databases where they can retrieve evidence-basedtreatment guidelines so that “with a click of a mouse doctors canget the latest information” at the point of care, Dr. Spann says.Other technology-related improvements that would impact pa-tient safety include e-mail communication with patients, he adds.

“We believe that the Internet and e-mail are going to enhanceour ability to take care of patients,” Dr. Spann says. Many pa-tients would like to communicate with their physicians “in anasynchronous manner,” with queries about their condition andmanagement of chronic diseases, medical questions and ap-pointment scheduling, Dr. Spann says. In addition, patients couldbenefit from receiving their latest test results, such as blood sug-ar level, electronically, he adds. The problem is that many healthplans don’t reimburse doctors for the time invested in this typeof communication.

“There will have to be a way to reimburse physicians for theirtime to do this,” Dr. Spann says. “Patients are used to doing thingsthrough e-mail and on-line with other industries. This will be animportant part of [healthcare] as well.”

In the new practice model envisioned by AAFP and other pri-mary-care organizations collaborating on the project, IT will beused to reduce errors prospectively, through prevention, and im-prove quality retrospectively through data analysis that feeds in-formation—such as immunization rates and their patient popu-lation—back to practitioners to help them improve care.

While all the elements and technologies are in place to makethese capabilities feasible, the average small group practice faces



the challenge of finding the time, expertise and funding to putthe tools together, experts say.

A 2003 survey conducted by the Commonwealth Fund, for ex-ample, found that “the only information technology used rou-tinely by physicians is electronic billing.” The diffusion of sys-tems considered critical to improving patient safety—such asEMRs, computerized prescribing, order entry and clinical deci-sion support—has been much slower, the study found.

Results of the survey, published in the Dec. 7, 2004, Medscape



0 20 40 60 80 100

50+ Physicians10–49 Physicians

2–9 PhysiciansSolo

Electronic Ordering

Electronic Medical Records

Electronic Access to Test Results

Percent

Current Use of Electronic Access to Patient Test Results, EMRs and

Electronic Ordering by Practice Size

Percent who currently "routinely/occasionally"use the following:

Source: The 2003 Commonwealth Fund National Survey of Physicians and Quality of Care.

General Medicine, an on-line journal, showed that larger prac-tices employing salaried physicians were more likely to useEMRs than solo or small-group practices (see chart on facingpage).

“There remains a technological divide between physicians de-pending on their practice environment and mode of compensa-tion,” said lead study author Dr. Anne Marie Audet, assistant vicepresident for quality improvement at the New York-based Com-monwealth Fund. This discrepan-cy needs to be addressed, Dr. Au-det said, since three-quarters ofU.S. physicians provide care insolo and small-group practices.

Overall, only a quarter of the1,837 survey respondents said thatthey practiced in a “high-tech” of-fice where technology “is usedroutinely to improve operationalefficiency and clinical care,” theCommonwealth Fund reported.

In solo practices, for example, only 13 percent said that theyused EMRs, while 37 percent had electronic access to test results,and 14 percent used electronic ordering. Doctors in groups rang-ing in size from two to nine reported higher rates of technologyutilization, with 23 percent using EMRs, 62 percent accessingtest results electronically, and 25 percent using electronic order-ing. In groups of 10 to 49 doctors, 35 percent said they were us-ing EMRs, 67 percent had electronic access to test results, and37 percent engaged in electronic ordering.

The highest-reported rate of utilization for information tech-nology was among groups of 50 or more physicians, where EMRswere used in 57 percent of practices, 87 percent had electronicaccess to test results, and 46 percent used electronic ordering.

“The findings make clear that while IT is viewed by many asthe future of medicine, there are major stumbling blocks that willneed to be removed to get physicians to routinely use it in theireveryday practice,” said a statement on the study from the Com-monwealth Fund.

The biggest barrier to technology adoption, the survey found,



An eHealth Initiative report re-leased last April found that whileuniversal adoption of electronicprescribing had the potential tosave $27 billion and preventmore than 2 million adversedrug events annually, only 5 per-cent to 18 percent of doctorsand other clinicians used elec-tronic prescribing.

was cost. While the federal government has made IT adoption atop priority and has appointed a national IT coordinator, Dr. Au-



In its assessment of individual EMR products, Forrester researchers con-ducted a four-part analysis and posed questions in each area that couldalso be used as a guide by physician purchasers.

In the first area, EMR functions and features, Forrester asked how quick-ly and effectively the doctor could do the following:� View the patients problem lists, medications, test results and other crit-ical information?� Document the visit and the clinical decision-making process?� Identify clinical issues through alerts and reminders?� Decide clinical issues with the help and support of knowledge referencesand databases?� Order labs, images and other non-medications?� Communicate electronically with colleagues, exchange secure e-mailwith patients, and structure patient communications to facilitate physiciandecision making?� Match ICD and CPT codes to the details of the patient encounter, inte-grate an evaluation and management coding tool, and integrate standard-ized clinical vocabulary?� Comply with rules and regulations on privacy and consent?� Aggregate individual data into records for easy viewing and graphing?� Manage a patient’s chronic diseases and conditions?� Standardize disease management goals for subgroups of chronic dis-ease sufferers?� Query the system’s database to generate individual and group reportson clinical care, quality, outcomes and costs?� Conduct research, registry, and clinical trial-related efforts?

In the areas of usability and support, questions posed by researchersincluded the ease with which doctors and their staff could input informa-tion; access the system remotely; integrate their existing practice man-agement system and claims processing service; get help with the imple-mentation process; access help desk assistance, and arrange reasonablypriced software upgrades.

In the cost arena, purchasers should look for financing flexibility,through the offer of both monthly and long-term license purchase agree-ments, and the option to buy systems under a flexible arrangement, asneeds and budgets allow.

Questions to Ask When Assessing EMR Systems

det and her co-authors called for stronger federal leadership andfunding.

“To spur wider adoption among physicians, policymakers willneed to focus on ways to make IT tools accessible and affordableto all physicians,” the Commonwealth Fund said, citing the ex-amples of the United Kingdom and Sweden, where doctors whoinvest in the EMRs receive government subsidies. As a resultnearly 60 percent of physicians in the U.K. and 90 percent ofthose in Sweden use IT.

In a 2003 report on the use of computerized physician orderentry in ambulatory settings, the Center for Information Tech-nology Leadership (CITL), a research organization chartered byPartners HealthCare in Boston, cited studies that found that only16 percent of primary-care doctors and 11 percent of specialistsused an EMR in their practice. Hospitals and healthcare deliverysystems have also been slow to adopt the technology, CITL re-ported, citing recent surveys that found that only 32 percent ofhospitals had a computerized physician order entry (CPOE) sys-tem in place, and only 13.7 percent required doctors to use thesystem.

There’s been heightened discussion about the role of technol-ogy in preventing errors and improving quality, says Dr. JonathanTeich, chief medical officer for Healthvision and a professor ofmedicine at Harvard Medical School. “What hasn’t been as wide-spread is the adoption and use” of EMRs, CPOE and electronicprescribing, often referred to as e-prescribing, says Dr. Teich,project chair for an eHealth Initiative report on the optimal de-sign and implementation of electronic prescribing systems in am-bulatory settings. The report, released last April, found that whileuniversal adoption of electronic prescribing had the potential tosave $27 billion and prevent more than 2 million adverse drugevents annually, only 5 percent to 18 percent of doctors and oth-er clinicians used electronic prescribing.

“There haven’t been enough hard drivers to compel wide-spread, rapid adoption” of information technology, Dr. Teichsays.

A survey conducted last July by the Medical Group Manage-ment Association (MGMA) asking members to identify the threemost significant barriers to EMR implementation found that



among practices with fewer than 10 physicians, the biggest im-pediments were lack of resources to invest in information tech-nology (48.4 percent), time and effort to prepare the organiza-tion for EMRs (43.8 percent) and the skills and preferences ofsupport staff (29.3 percent). The results, based on the 345 re-sponses, also identified the difficulty of integrating systems (28.7percent), lack of provider support (26.4 percent) and the diffi-culty of establishing a good return on investment (26.1 percent)as important barriers.

In larger practices with 10 to 49 doctors, the top two barrierscited by 128 respondents in this category—cost (47 percent) and

time and effort (42.5 percent)—were the same as in smaller prac-tices. The difficulty of establishinga good return on investment, how-ever, moved into third place, with33 percent of respondents flaggingthat issue, while the difficulty ofintegrating systems ranked fourthat 32.5 percent.

Large practices with 50 or moredoctors continued to identify costas the greatest barrier, with 49.4percent of 68 respondents target-ing cost as one of the three mostsignificant stumbling blocks to

EMR implementation. Lack of provider support ranked secondat 41.4 percent, and the difficulty of establishing a good returnon investment was third, at 37.9 percent.

MGMA is in the midst of a project funded by the federalAgency for Healthcare Research and Quality to determine howmany doctors use EMRs, and how they are being used to per-form a variety of functions in medical management, says Dr.William Jessee, president and chief executive officer of MGMA.The results “should give us a lot more information about wherethe field really is” in adopting and implementing EMRs, Dr.Jessee says.

The study, which will be finalized this spring, has alreadyfound that the term electronic medical record “doesn’t necessar-



EMR capabilities that are linkedto error prevention include im-proved communication tools;easy and quick access to med-ical knowledge; built-in infor-mation, such as appropriatedrug dosage; decision support,and patient monitoring. In onestudy, computerized order entryfor prescription drugs reducedby more than 80 percent thenumber of medication orderswith doses exceeding the maxi-mum.

ily mean the same thing to everyone,” Dr. Jessee says. Whilemany practices have gone paperless and believe that they havean EMR, what they actually have done is transitioned to elec-tronic dictation and transcription, and electronic storage of labresults and other data. “But it is not an EMR in the sense that allthe data is structured and stored in a relational database whereyou could retrieve all patients with diabetes” and find out the lasttime a particular test was conducted on a particular patient, hesays.

“There’s a lot of fuzziness in what terms mean to the field,”Dr. Jessee adds. In addition, doctors may say that their practiceis using an EMR, but what they mean is that two of the 14 doc-tors in the group use the system, says Dr. Jessee.

MGMA is developing tools to help practitioners and evaluateEMRs and make decisions about which system best meets theirneeds.

“We’re encouraging [members] to hurry up before they are runover by the snowball,” Dr. Jessee says. “There’s so much mo-mentum behind IT, particularly e-prescribing, but it’s not a mat-ter of will it happen or will it be required, but how quickly.”

In its detailed report on computerized prescribing, the Wash-ington, D.C.-based eHealth Initiative—a nonprofit group thatpromotes health information technology and whose members in-clude providers, employers, health plans, technology groups, re-search institutions and government agencies—called on stake-holders that stand to benefit from the quality improvements andcost savings associated with information technology to ease thecost burden on doctors and other providers by offering them fi-nancial incentives to implement EMRs and electronic prescrib-ing.

Government and private payers could accelerate the adoptionof technology by reimbursing providers for the utilization of in-formation systems and by paying for improved quality perform-ance related to implementation, the report said. Pharmacies couldalso defray the costs of e-prescribing by paying physicians trans-action fees for its use, while malpractice insurers could reducepremiums for practitioners who adopt information systems.

“Doctors will make use [of technology] if it makes financialsense and it is quick and easy to use,” Dr. Spann says.



The Case for EMRsPatient-safety experts agree that information technology can-

not stand alone as a strategy for reducing medical errors, but theyalso agree that doctors and other health practitioners cannot max-imize safety and quality improvements without the aid of tech-nology.

In other industries, information technology has made possiblewhat has been called “mass customization,” the production ofgoods and services to individual specifications, said a report byDr. David Bates and Dr. Atul Gawande at Boston’s Brigham andWomen’s Hospital and Harvard Medical School. Consumers inthe market for a computer, for example, can build one to theirprecise needs on the Internet.

While medical care is far more complex than a computer pur-chase, “safe care now requires a degree of individualization thatis becoming unimaginable without computerized decision sup-port,” said the report, published in the June 19, 2003, issue of TheNew England Journal of Medicine. Health information systemscan instantly flag interactions among patient medications andperform complex calculations, the study authors said. For exam-ple, more than 600 drugs require an adjustment of dosage forvarying levels of renal dysfunction, Drs. Bates and Gawande re-



Annual per-provider savings for main classes of Ambulatory Computerized Provider

Order Entry (ACPOE) systems.Basic Intermediate Advanced

ACPOE ACPOE ACPOE Brand-to-generic Switching 0 $897 $897 Other Medication Savings $2,083 10,783 16,323 Laboratory Savings 62 1,313 3,027 Radiology Savings 258 2,988 6,580 Avoided Hospitalizations 104 606 1,003 Total $2,507 $16,587 $27,830

Source: “The Value of Computerized Provider Order Entry in Ambulatory Settings,” Cen-ter for Information Technology Leadership, May 2003.

CPOE Systems Deliver Savings

ported. Such a task “is poorly performed by human prescriberswithout assistance but can be done accurately by computers,”they said.

As information technology grows more sophisticated, it canplay a vital role in reducing the risk of harm to patients receiv-ing medical care by “streamlining care, catching and correctingerrors, assisting with decisions and providing feedback on per-formance,” the report said.

EMR capabilities that are linked to error prevention includeimproved communication tools; easy and quick access to med-ical knowledge; built-in information, such as appropriate drugdosage; decision support, and patient monitoring, said the report.In one study cited by the authors, computerized order entry forprescription drugs reduced by more than 80 percent the numberof medication orders with doses exceeding the maximum.

The American College of Physicians’ (ACP) patient-safety ed-ucation program includes an entire module on information tech-nology. The module details the benefits of EMRs and how theyimprove safety through the following features:� Universal chart access. EMRs eliminate the problem of un-available paper records, allow more than one person to work onthe record at a time, and make it possible to access health infor-mation off-site.� Electronic interfaces. Laboratory and x-ray results directlyimported into the record electronically are less likely to containerrors or to have missing data. This saves time that practitionerscan devote to decision making.� Data availability. Paper records are often fragmented, incom-plete and easily misplaced or misfiled. As a result, clinicians“lack the information they need to make decisions,” says ACP’sprepared program on information technology. When data aremore accessible, they can also be used to generate outcomes datathat help the practice improve its quality and safety performance.� Quality assurance. EMRs make it possible to access largenumbers of patient records quickly and easily, and to measurequality indicators and outcomes that would not be possible tocapture through paper records without significant effort. Practi-tioners can use these capabilities to detect the effect of their di-agnosis and treatment and to improve compliance in areas such



as health screenings.� Integration with knowledge resources. Electronic medicaldatabases allow clinicians to enter queries during the patient vis-it to help identify diagnosis and treatment options. � Decision support. Physicians can access systems ranging froma simple drug reference to the most current and relevant evidence-based medical information. � Computerized physician order entry (CPOE). Orderingmedications and tests electronically minimizes errors due to poorhandwriting, improper terminology, ambiguous orders and in-complete information. Prescribers can receive on-screen promptsfor dosage information, drug interactions and reminders that en-sure similar drugs are not confused, or that a drug is not appro-priate for patients with a particular medical condition.

Preventing Drug ErrorsAmong the most widely touted and documented features of

electronic medical record keeping is e-prescribing. The CITL re-port for example, found that more than 8.8 million adverse drugevents (ADEs) occur each year in ambulatory care, and more than3 million of them are preventable. The report, based on a litera-ture review of nearly 2,000 studies and expert input from ven-



� Basic electronic reference. Drug information, dosing calculators andformulary information are available but not automatically shown while pre-scribing.� Stand-alone prescription writer. Search drug by name and create pre-scription; no long-term data about the patient is accessible.� Patient data is included. Demographics, allergy, formulary and payerinformation is available.� Medication management. Prior medications are available for renewal,interaction checks, etc.� Connectivity. System allows communications between doctors’ offices,pharmacies, payers, pharmacy benefit managers and patients.� Integration with EMR.

Source: eHealth Initiative, Electronic Prescribing: Toward Maximum Value and Rapid Adop-tion, April 2004.

Six Levels of E-Prescribing

dors and users of CPOE, projected that an advanced CPOE sys-tem in ambulatory care settings nationwide would eliminate morethan 2 million ADEs annually and avoid nearly 1.3 million doc-tor visits, more than 190,000 hospital admissions and more than130,000 life-threatening ADEs.

CITL defined advanced CPOE as a system that includes elec-tronic ordering, alerts and decision support for medications, lab-oratory and radiology tests. Universal adoption of such a sys-tem could save as much as $44billion a year through more cost-effective medication and testingdecisions and the prevention ofADEs.

“The savings include switchesfrom brand-name to generic med-ications, switches from expensivemedications to less-expensive al-ternatives in the same therapeuticclass, and more appropriate drugutilization,” the report said.

Under most current reimburse-ment methods, those savings would accrue to payers, CITLsaid. However, based on average national capitation data, thereport projected that the typical provider using advanced CPOEin an ambulatory setting could save close to $28,000 a year, in-cluding more than $17,000 in medications, nearly $7,000 in ra-diology, $3,000 in laboratory expenditures, and $1,000 fromADE-related hospitalizations. Savings would also accrue toproviders in the form of a reduction in rejected claims, CITLsaid.

Spurring physician acceptance of CPOE, however, will likelyrequire proven value in safety and quality improvement, systemsthat can be quickly installed and are easy to use, and financial in-centives to overcome cost barriers, said the eHealth Initiative re-port.

“The organizational and cultural challenges required for cli-nicians in practice to make the transition, the fact that the sys-tems are not considered ‘essential,’ and the up-front cost withouta significant financial return focus on clinical practices as the



In addition to cost, one of thebiggest barriers to EMR adop-tion among doctors is “the per-ception that it will slow themdown, and make things moredifficult,” says Dr. JonathanTeich, professor of medicine atHarvard Medical School. “Doc-tors don’t want computers to bean annoyance. In a busy prac-tice, it’s all about how produc-tive you can be.”

largest opportunity to drive universal adoption at this time,” thereport said.

Getting StartedHeightened attention to the needs and concerns of small- and

medium-sized group practices that are interested in adopting anEMR system has generated substantial resources aimed at help-ing them identify their needs and sift through product options inthe marketplace.

Medical societies and patient safety organizations have pub-lished a spate of on-line resources to walk physicians through theEMR selection process, describe key features to look for in EMRsand rate product offerings.

Last summer, 14 medical organizations, including the Ameri-can Academy of Family Physicians and the American College ofPhysicians, announced the creation of the Physicians ElectronicHealth Record Coalition (PEHRC) to help doctors acquire anduse health information technology.



Company Product Website

Allscripts Healthcare TouchWorks www.allscripts.comSolutions

Amicore Clinical www.amicore.comManagement

GE Medical Systems Logician www.medicalogic.comInformation Technologies

iMedica PhysicianSuite www.imedica.com

Medical Manager Health Intergy www.medicalmanager.comSystems (WebMD)

Misys Healthcare Systems Misys EMR www.misyshealthcare.com

NextGen Healthcare NextGen EMR www.nextgen.comInformation Systems

Physician Micro Systems Practice Partner www.pmsi.comPatient Records

Source: Electronic Medical Records: A Buyer’s Guide for Small Physician Practices, Cali-fornia Healthcare Foundation, October 2003.

A Sampling of EMR Vendors for Small Practices

“While physicians are adopting information technology ingrowing numbers, there remain substantial economic and tech-nical barriers to full-scale deployment of electronic healthrecords, especially in small- and medium-size medical practices,”said PEHRC co-chair Dr. David Kibbe, director of the AAFP’sCenter for Health Information Technology. “The PEHRC will al-low physicians to address these barriers with a unified voice andbe powerful advocates for putting health information technolo-gy in the service of quality of care.”

Dr. Peter Basch, medical director for the eHealth Initiative andco-chair of the fledgling PEHRC, said the group was “essentialto advancing the adoption of EHRs in every physician’s office.”

The Agency for Healthcare Research and Quality (AHRQ),meanwhile, has launched a three-year research project to “fur-ther define the value proposition” of health IT, says Dr. ScottYoung, director of health IT at AHRQ. The initiative is aimed ataddressing the funding challenge faced by physician practicesthat want to adopt health IT, but can’t justify the expense.

Most physician practices are “high-volume, low-margin busi-nesses,” Dr. Young says. Capital investments usually come out ofdoctors’ pockets, and in the absence of a “well-defined valueproposition, asking physicians to invest [in health IT] is iffy,” Dr.Scott adds. “It is up to us to further define the value proposition.”

Dr. Young suggests that doctors start the IT journey by asking,“What problem do I want this solution to address?” Practition-ers should assess the capabilities they need, such as e-prescrib-ing, faster documentation and retrieval of laboratory results, andintegrating and sharing files with other providers. Physiciansneed a “clear sense of that from the beginning, because there area host of solutions, all of which answer different questions,” Dr.Young says.

Practices also need to identify their partners in the venture, in-cluding other small offices, health plans and hospitals, to “un-derstand what their drivers are,” Dr. Young advises. Once theyidentify suitable products, doctors need to ask a lot of questionsof vendors and seek out “neutral information” on systems beforemaking a purchase, he adds.

AHRQ is developing a National Health Information Technol-ogy Resource Center to offer expert and technical advice to help



healthcare providers find and implement the best system for theirneeds. The new center is currently open to agency grantees butwill eventually offer expanded access to the provider communi-ty, Dr. Young says.

In addition to cost, one of the biggest barriers to EMR adop-tion among doctors is “the perception that it will slow them down,and make things more difficult,” says Dr. Teich. While practicesthat have adopted EMRs have gained efficiencies, physiciansneed more education about the benefits of EMRs, and models tohelp them maximize those benefits “so that practices can makeuse of EMRs and get up and running quickly,” Dr. Teich says.“Speed drives acceptability,” he adds. “Doctors don’t want com-



Electronic prescribing is not a total shield against medication errors, ac-cording to a recent survey by the United States Pharmacopeia (USP), anonprofit organization that monitors and promotes drug and supplementsafety. Nearly 20 percent of hospital and health system medication errorsreported to USP’s national medication-reporting service MEDMARX in 2003involved computerization or automation.

Errors that result from using a computer can occur in any phase of themedication-use process: prescribing, transcribing/documenting, dispens-ing, administering and monitoring, says USP. Computer entry (CE) errorsoccur when incorrect or incomplete information, such as patient names,drug doses or laboratory test results, is entered into a computer system.According to USP’s data, most CE errors occurred in either the transcrib-ing/documenting phase or dispensing phase of the medication-use process.

In 2003, CE errors were the fourth leading cause of medication errors,according to MEDMARX data. CE errors have steadily increased and rep-resent 11.5 percent of all MEDMARX records from 1999 through 2003. Thedata indicate that nearly three-quarters of all CE errors occur after an or-der is written but before the medication is administered to the patient.

“It would seem logical that applying computer technology to the med-ication use process would have a significant positive impact in preventingmedication errors,” said Diane Cousins, R.Ph., vice president of USP’s Cen-ter for the Advancement of Patient Safety. “Yet, depending on the com-puter’s design or user competence, new points of potential errors canemerge. Healthcare providers need to be focused and vigilant in their useof computers.”

Computerized Prescribing No Panacea: Study

puters to be an annoyance. In a busy practice, it’s all about howproductive you can be.”

One of the risks of an EMR is “alert fatigue” from systems thatproduce so many reminders that doctors stop paying attention toall of them, including those that are critical, Dr. Teich says. EMRs“need to provide shortcuts to the common things” that occur ina practice, he adds. A typical primary-care provider, for exam-ple, uses about 50 drugs, while a specialist commonly uses 30 to40 drugs. Prescribing systems, therefore, should have a favoriteslist that doctors can quickly choose from, Dr. Teich says. “Youneed to look for shortcuts for the most common workflows andstreamline the heck out of it,” he says. An EMR should “do mostcommon things as fast as possible, and everything else some-how,” Dr. Teich adds.

Among the many resources available to doctors seeking thebest EMR for their office is a guide for small physician practicesproduced by Forrester Research for the California HealthcareFoundation. The guide, authored by Michael Barrett, BradfordHolmes and Sara McAulay, was released in October 2003 and isgeared to practices with nine or fewer physicians. Available onthe AAFP’s Center for Health Information Technology Website(www.centerforhit.org), along with a wide array of technology-related resources, the guide provides a detailed evaluation ofeight EMRs appropriate for small offices. Researchers identifiedthe basic features that physicians should look for in any system,and described functions that will become more critical over timeas doctors prepare for future needs.

Most EMRs on the market today include a core set of basicfunctions related to entering, storing and retrieving clinical in-formation, the guide says. At a minimum EMRs should allowdoctors to do the following:� View critical information, including problem lists, medicationlists and test results in an organized way.� Document patient visits.� Customize information displays.

Beyond those basics, “the great potential of EMRs lies inequipping doctors with relevant information at the point of deci-sion on the point of care,” the guide says. Doctors should, there-fore, look for systems that give them the following capabilities:



� Identify clinical issues through alerts and reminders.� Access clinical decision support linked to medical referencesand databases.

EMRs should also integrate computerized physician order en-try (CPOE) for medications, tests, images and other services, andelectronically route those orders to pharmacies and other clini-cians. In addition, the system should facilitate secured commu-nication among practitioners in a way that stores messages as partof the patient record.

The guide further recommendsthat EMRs facilitate electroniccommunication and consultationswith patients, and provide patienteducational materials to help themself-manage their conditions.

Ideally, EMRs should make itpossible to manage the health ofpatient populations in a practice orlarger community by:� Standardizing disease manage-ment across an entire group, sothat clinicians can “identify sub-groups of disease sufferers amongtheir patients and track adherence

to disease-management guidelines and care plans,” the guidesays.� Querying system databases to produce group reports on care,quality, outcomes and costs.� Conducting clinical research. “An EMR should be flexibleenough to accommodate the doctor’s decision to participate inresearch, registry and clinical trial related efforts,” the guide says.

“Our goal is that family physicians will adopt this model soon-er than later in a massive fashion,” says Dr. Spann, referring toAAFP’s new model for care in which EMRs have a critical role.While cost is a primary consideration for most practices, manyvendors are becoming sensitive to pricing and bringing their costsdown, he adds. AAFP has negotiated with several EMR vendorswho have agreed to make discounts available to the organiza-tion’s members.



“While physicians are adopt-ing information technology ingrowing numbers, there remainsubstantial economic and tech-nical barriers to full-scale de-ployment of electronic healthrecords, especially in small- andmedium-size medical prac-tices,” says Dr. David Kibbe, co-chair of the Physicians Elec-tronic Health Record Coalition, agroup created to help doctorsacquire and use health informa-tion technology.

Despite significant challenges in the transition to wide dis-semination of EMRs, experts predict that most practices will beusing them within five to 10 years.

“We have an immensely complex healthcare system,” saysAHRQ’s Dr. Young. “When you look at a system that complexand think about something that’s as powerful and changing ashealth IT, it gives me reason to believe that it will take a littletime to do that,” he adds. “Our mission is to help accelerate theintegration of solutions into everyday practice. I’m optimisticthat it will happen.”



technology to the rescue · 2007-04-12 · technology to the rescue dr.susan andrews’search for...

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