Web-based medical record offers immediate access

Virtual electronic medical record is a reality

Health care systems across the country are finding that they can piggyback off the growing popularity of World Wide Web browsing to permit access to electronic patient records and save on technology training costs as well.

"One of the beauties of using the Web is everybody and his mother is on the Internet these days," says Hasan Usmani, president of AXIM Systems Inc. in Medford, MA. AXIM has just rolled out Clinnet, an electronic medical record at the Boston Medical Center that uses Web-browser technology to access patient information. "We are using a way of doing things that people have already gotten used to, so no new training is needed. As much as possible, we tried to use the tools of the Web and the user interface."

Clinnet, which was rolled out in the center’s emergency department, provides on-demand access to patient records for physicians and other medical staff as soon as the information is available in electronic form.

The system debuted in the emergency department of Boston Medical Center, which was formed a year ago by the merger of Boston University Medical Center and Boston City Hospital. The emergency department inherited from the city hospital provided a kind of trial by fire for the new system.

"Because of the high numbers of indigent patients, the medical record comprises what gets developed in the emergency department," Usmani says. "It’s the most critical place where a lot of their patients get seen. This provides critical information for a set of patients for whom a normal medical record was not as frequently available."

The new system provides an elegant solution to the pressing need for instant access and availability. "It puts information easily in everybody’s hands from any station in the hospital that has a Web browser installed and in the future at remote sites that have a Web browser," Usmani says. "It automates the process of reviewing and signing reports that are the daily drudgery of work."

The system, which uses a hospital intranet, allows physicians and residents to dictate their notes directly into an electronic voice file that is transcribed and then added to the electronic record. A "watermark" is seen on the screen if the transcribed notes are still in draft form. An electronic signature shows that a physician has signed off on the notes.

Medical records staff now can search by patient name, a fragment of a patient name, or a medical record number. They also can generate reports based on the name of the physician who entered the report, the name of the attending physician, or a department.

"For medical records staff, they can instantly see what reports need to be signed, how many are outstanding from different physicians. They can keep on top of things that way. If something was signed in error in the medical record, they have the ability to reopen the report. It automates their tasks so they don’t have to spend a lot of time chasing doctors to get them to sign reports," Usmani adds.

Security was an important consideration, says Jim Grace, chief technical officer at AXIM. Physicians must enter a password when declaring a report complete with an electronic signature. Any changes to the medical record require the user to type in a password and every time a change is made, a complete record is kept of who changed it, when it was changed, and what was done. In addition, any time a record is viewed a small log entry is made to show who accessed it and the date and time it was viewed.

Neurosurgeons at the Neurological Institute of Virginia, part of the University of Virginia (UVA) Medical Center in Charlottesville, also can access patient records any time and virtually anywhere their schedules allow, thanks to a new Web-based virtual electronic medical record that recently debuted after two years in development.

Easy access and availability of patient medical records for neurosurgeons were the goals set for implementing an electronic record at the institute. "The lead surgeon wanted portability to his residence. If he were reviewing a patient’s case at home, he would then have this with him," says Garth Wermter, a programmer/analyst who now manages the medical record database.

"UVA was not tightly integrated. There were four or five different information systems," says project manager Jim Kazmer, senior consultant for Hewlett-Packard in Andover, MA. "Much of the record was still highly paper-based," and had to be converted to an electronic record. "Whenever [a neurosurgeon] needed patient information, he would typically ask his staff to get the files. What we were competing against were people."

The system, which is currently limited to the records of patients who have visited the institute within the past 31¼2 years, allows designated clinicians and other health system personnel at the medical center to access patient records using a Web browser such as Netscape, for example. (A demonstration of the Web-based electronic medical record is available at http://vemr.virginia. edu/demo/homepg.html)

Integrating diverse information systems

A challenge for the program’s designers was the need to pull together many different information systems in use throughout the university medical center. They created a single database that mirrors those databases and pulls up the necessary information on demand. Transcriptions of notes are entered electronically, and lab results are updated nightly.

Like Clinnet, the neurosurgery system was designed to mimic the sequences and interactions that any Web user would find familiar. After logging on, a series of screens allow users to select from menus of data. For example, one screen may offer the choice of viewing diagnostic notes, preadmit schedules, transfers, discharges, and outpatient schedules. A click on the hypertext link brings up the next screen.

Users of the Web-based patient record can search for patient information based on patient name or identification number. Once identified, the system displays a description and photo of the patient. "During registration we ask for permission to take a picture," Wermter explains.

Emergency contact information, family, referring physician, and a list of scheduled events for the patient, as well as insurance coverage, lab results, and visit history also are available on the electronic record.

"The potential of the Web is information any time, anywhere," says Kazmer. The Web truly is one of the new technologies that helps deliver that vision. The Web browser has become universal; [almost] everyone has one on their desktop."

Because of its widespread and growing popularity, Web-browser-based technology offers health care systems the opportunity to provide training on new technology to physicians and medical staff working in different locations or cities, Kazmer reasons. "As an outlying physician, I call up a local Internet service provider and get connected, and I’m done. It’s the opportunity to support outlying physicians, affiliated constituents, even patients."

But while using a Web-based browser may seem like a perfect solution to the problems of access and availability, it isn’t for everyone, Kazmer cautions. "Just building a Web-based medical record may not make sense for your organization if your system is already organized, if everybody already knows how to access the information. But if they have a need to access information, and you don’t want to train them and install remote applications that you don’t want to support, the Web might be the right tool."

One of the biggest concerns in designing the Web-based system, Wermter says, is security. The solution was a series of firewalls that assure that only designated users can gain access to the information. Users must log on with an acceptable user name and password. In addition, the database server verifies that the request for access is coming from a known IP address. Computers throughout the medical center are allowed access to the electronic medical record.

A key benefit of the technology is the ability of users to access the information from home, Wermter says. To do so users must have their computers added to the list of acceptable IP addresses. "If a physician were to go to California and try to connect from a [computer] there, he would have to let us know," Wermter says. Users also can call into the dial-in server from their laptops using a user name and password. A further firewall is provided by encryption of all the information.

Hasan Usmani, President, AXIM Systems Inc., Medford, MA. Telephone: (617) 391-1777.

Jim Grace, Chief Technical Officer, AXIM Systems Inc., Medford, MA. Telephone: (617) 391-1777.

Garth Wermter, Programmer/Analyst, Neurological Institute of Virginia, University of Virginia Medical Center, Charlottesville. Telephone: (804) 243-0353.

Jim Kazmer, Senior Consultant, Hewlett-Packard Co., Andover, MA. Telephone: (508) 659-4891.