Hospital goes on-line with electronic medical record

Physician order sets to go on-line soon as well

Texas Children's Hospital in Houston is using information technology to encourage physician support for its clinical pathway and other quality improvement efforts. In May, the hospital went live with a pilot project to test the use of electronic medical records on selected units: the endocrine service, the pulmonary service, the eating disorders clinic, the pediatric nursery unit, the progressive care unit, the nutrition and gastrointestinal clinic, and the adolescent/sports medicine clinic. The project allows 500-plus users - including case managers, physicians, therapists, and other caregivers - to get acquainted with the system before it's rolled out hospitalwide.

The plan to move to an electronic medical record (EMR) system began in 1994, when administrators at Texas Children's incorporated the idea in the hospital's strategic plan. After approval from the board, which agreed to set money aside to fund the project, a timetable was set for implementation. Administrators also selected a vendor to supply to the necessary technology: OACIS Healthcare Systems, based in Greenbrae, CA.

"We realized we would be looking at a constellation of multiple systems, interfaced together to create the on-line medical records," says Pat Perry, vice president of information services at Texas Children's. "So we went through a process to define our requirements, review the market, and select a vendor, negotiate a contract, and then begin that implementation."

Perry says the hospital selected OACIS because of its ability to customize screen design. Physician and clinician design teams analyzed and made recommendations about how the system should display information. They also helped make decisions about content, including what sort of demographic and encounter information should be presented.

After contracting with OACIS a year and a half ago, the hospital has used the company to install a clinical database repository, which now contains results from - and generates reports for - the laboratory and radiology systems. "Plus we pull over scheduling information - appointment scheduling systems, patients demographic, and encounter information - from our patient registration system," she says.

The goal, Perry says, is to provide one easy-to-use interface that physicians and other clinicians can use to access data easily no matter where they are. That's important because, over the last few years, Texas Children's has grown into its own integrated delivery network. "We've probably got more than 40 physician offices out in the community, plus specialty care, community health centers, and a separate home care division. We've got a separate managed care entity - and an international division," she says. "So the goal is to use the electronic medical record to make sure that wherever the child is seen within the network, the appropriate person is able to bring up the appropriate medical information about that kid. The paper medical record doesn't work that well when people are flying about from different physical sites."

The problem is, sometimes the electronic medical record doesn't work either, when it has to rely on data being rekeyed into an electronic format. That's why the hospital will initiate soon its plan to implement electronic physician order forms. "Rather than having physicians write their orders on pieces of paper, and hand them to a unit clerk, and then have the clerk transcribe them into the system, we'll have physicians directly entering their orders on-line," Perry says. "That will help grease the skids toward physician use of our guidelines and pathways, because we'll be able to show medical staff who uses these guidelines. Right now, we do it on paper, and it's very intensive to try and monitor compliance. If physicians are actually ordering their tests on-line, we'll be able to see compliance much more readily."

Even so, paper medical records still predominate at Texas Children's, and realistically, that situation's not likely to change soon. For the time being, only results are on-line, except in one department. A separate pilot in the hospital's cancer center already has physicians and nurse practitioners writing all clinical notes electronically. "So rather than having clinicians, for instance, handwriting a progress note after they see a patient, we've developed a clinical workstation in-house to learn how clinicians would actually use an on-line medical record," she says.

The pilot project already has demonstrated to administration that getting staff and physicians to accept an electronic system requires buy-in on the part of physician leaders. In the cancer center, for example, the chief of pediatric oncology essentially mandated that everyone was going to document on-line. "They had a physician leader who was very active in the design and the development of the product," she says. "And he was enthusiastic in getting all of his colleagues to use it. As a result of that, they all use it, and there's not one of their patient who's not on line."

The system is based on client-server technology. A remote access tool allows clinicians to dial into the system, where they're asked to supply their unique password and identification code. Security software monitors the system to detect whether a user is trying to hack the system by attempting numerous log-ons.

The key security issue in developing the system, however, was how to protect confidential data without annoying clinicians by making them jump through hoops to gain access. For example, an attending physician wants a consult on a patient. If only the attending physician can access the patient's record on-line, how does the consulting physician gain access? "These are the kinds of things we're going through with our medical staff," Perry says.

Whether physician support for the EMR project continues remains an open question, she says. She acknowledges that in making results available on-line, the hospital so far has done the easy part. "Right now, we're giving them a very graphical, intuitive interface. Three clicks and they're at the lowest level of detail of data, so we're giving them something that's much nicer and easier to use," she says. It remains to be seen, though, what the reaction will be when electronic physician notes and order sets become standard.

In any case, she maintains that sooner or later, EMR systems will replace paper systems simply because of the demand. "And our goal is to get there sooner. We consider it very much a strategic advantage to make the investment in technology."

For more information, contact: Pat Perry, vice president of information services, Texas Children's Hospital, Houston. Telephone: (713) 770-3534.