AAMC Reporter: May 2005

Hospitals Expand Use of Electronic Patient Records

By Bob Adams, special to the Reporter

John Tu, M.D., assistant professor, Loyola University Chicago Stritch School of Medicine, logs on to the university health system's digital patient record system - Photo courtesy of Loyola University Health System

Paul C. Tang, M.D., believes that medicine should take a tip from the airline industry — specifically, its reliance on computers.

"Pilots get lots of information," said Tang, who chaired the Institute of Medicine's Committee on Data Standards for Patient Safety. "They have weather, altitude, speed, the location of other planes. But it's in a form they can use to fly the plane. It doesn't come at them as a bunch of numbers. The instruments create a virtual horizon."

The stream of data provided in an airplane can be processed in a more useful fashion than data provided in most patient care settings, according to Tang.

"In the ICU, there are tons of monitors," he said. "We expose physicians to all kinds of raw data. But we don't put it together."

Tang's comments go to the heart of an evolving trend in medicine. Digital recordkeeping of information can help to prescribe medication, monitor patients and catch physicians' errors. Experts say some 10 to 15 percent of hospitals and private practices are making the transition.

President Bush allocated $125 million in seed money over the coming year to enable most practitioners to switch from pen and paper to electronic records in the next 10 years. There is bipartisan support in Congress for the measure.

David J. Brailer, M.D., National Coordinator for Health Information Technology, Department of Health and Human Services

"The ballgame is over," said David J. Brailer, M.D., the National Coordinator for Health Information Technology in the Department of Health and Human Services. "It's not a question of, 'Do they need this?' It's a question of, 'When do they need it?'"

Yet nagging questions remain about using computers in medicine. Ross Koppel, Ph.D., and six colleagues wrote in a recent issue of the Journal of the American Medical Association (JAMA) that they found 22 types of medication error risks that are increased by information technology (IT). Another study found little improvement in patient outcomes.

A recent JAMA editorial, "Still Waiting for Godot," noted that there is "quite a large mismatch" between doctors and computers. Doctors are intuitive, collaborative, and make collective judgments. They often work in chaos. Computer systems are rationalized and linear. The two, the editorial suggested, may be incompatible.

Perhaps the most publicized IT challenge occurred two years ago at Cedars-Sinai Medical Center in Los Angeles. Three months after starting a program that includes major portions of a successfully launched patient registration, order communication and medical records coding system, staff opposition halted the computerized physician order entry (CPOE) component of the system.

Doctors found that instead of scribbling a note, they had to fumble with a computer. Needless "error warnings" flashed on the screens. If a word was misspelled, the computer rejected the order.

"The doctors said, 'We support the idea, but we don't have time for the extra work,'" said Michael Shabot, M.D., medical director for IT at Cedars-Sinai. "The disruption wouldn't go away."

Michael Langberg, M.D., medical director for Cedars-Sinai information services, said that there is "a whole different psychology between the house staff and private physicians. That difference is not trivial. You have to be highly considerate of the physicians' work flow."

Langberg also said that managing CPOE-based orders as patients moved between different levels of care turned out to be highly complex, noting that 40 percent of the patients at Cedars-Sinai move to a different room each day.

Elsewhere, the transition fared better, but not without major adjustments from the staff. Arthur Krumrey, vice president and chief information officer at the 536-bed Loyola University Medical Center in Maywood, Ill., said the center's new electronic system, installed in February, is working well so far, but noted that the change is especially hard on physicians. They need to get accustomed to sitting at a computer and typing instructions instead of writing them on paper.

"Doctors have spent 20 or 30 years of their lives optimizing their use of time," Krumrey said. "And now they have to really make changes."

Electronic records, at least in theory, would reduce the error rate. Patient allergies and drug interactions could all be stored digitally. If a doctor entered the wrong medicine, the machine would flash a warning.

Beyond this, electronic patient records would eliminate doctors' scribbling. They would transmit orders for drugs directly to the pharmacy. They could give a doctor or nurse immediate access to all of a patient's records — even at home. They would allow doctors' orders to be followed right away.

"With paper, it used to take two hours before an order was carried out," said Reid Coleman, M.D., of Lifespan health system in Rhode Island. "Now, by the time we see the next patient, the X-ray techs are coming down the hall."

While some physicians hail the advance of digital technology, some skepticism is entering the debate.

"I have doctors who rave about it," said Bob Irwin, the IT specialist at Robert Wood Johnson University Hospital. "They look at it over coffee at home. They can plan their day. But others think the machines are 'practicing medicine.'"

Other hospital administrators note the ability of electronic records to capture a patient's entire profile in a single view.

"Fetal monitor strips, EKGs — we can see them all at the patient's bedside," said Dawn Reinicke, head of IT at the Avera McKennan Hospital in Sioux Falls, South Dakota. "It's real customer service."

In general, hospital officials give this advice in setting up a system: Start slowly. Consult with physicians and nurses early. Obtain quality equipment. Change one department at a time. Be sensitive to doctors, who have to change a lifetime of work habits. Realize that IT alters the whole culture of medicine.

"I'm glad that computers are building cars," Brailer observed. "But this is the one industry where the outcome is longer or better human life."

As the nature of recordkeeping changes, privacy becomes a major concern of patients. IT professionals say they are building firewalls and audit trails to make the records safer. Some say electronic records will be more secure than paper, since the system will keep track of everyone who accesses the files.

Private industry is playing a role nationally. The Certification Commission for Healthcare Information Technology brings together vendors, hospitals, consumer groups and others with a stake in IT. Regional groups are also being formed to share information about implementing electronic patient records.

Physicians are beginning to discuss creation of a national set of standards for using electronic patient records. The ultimate goal is to enable a doctor in another state to have immediate access to a patient's records for consultation.

Even some proponents of electronic medicine caution against high expectations. And others worry that large institutions' technological savvy will draw patients away from smaller facilities.

"Some people worry about the cynics who say it can't be done," Brailer said. "The people I worry about are the enthusiasts who think it's going to change the world. Electronic medicine won't lead to nirvana. It will lead to better care for patients."

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