Will doctors use electronic medical records?

Gradual transition overcomes fear of technology

Physicians pride themselves on being on the cutting edge of medical advances. But when it comes to computer technology, they are often reluctant to move away from their age-old paper trail.

Even at Intermountain Health Care (IHC), an integrated delivery system in Salt Lake City that is a pioneer in electronic medical records, gaining physician buy-in is a slow process, says Allan Pryor, PhD, chief medical informatics officer.

In some cases, physicians are simply not computer literate. Others worry that using a computer-based patient record will create more hassles than it will eliminate. "The fear of that technology is a barrier," Pryor says.

The move from paper to electronic records is a gradual one, and the transition must be designed to address physician concerns, says Michael Ralston, MD, director of quality demonstration for the Permanente Medical Group of Northern California. "A lot of physicians are used to looking through a paper chart," he says. "They know where to look for certain information.

"If you have an electronic medical record that is too cumbersome, if it takes too much time to enter information, physicians would see that as burdensome [rather than helpful]," he says.

So here’s the bottom line for physicians: How much will they gain, and at what cost?

IHC has documented immense cost savings and quality improvements from its electronic records. For example, an IHC study found that adverse drug events cost the system about $1 million a year in extra care, as well as increasing the morbidity and mortality of patients. Computer-generated alerts through the hospital-based HELP (Healthcare Evaluation through Logic Processing) system now help prevent those events.

HEMS (Healthcare Enterprise Management System), developed with 3M Health Information Systems in Salt Lake City, provides similar alerts in the outpatient setting and incorporates decision-support software and disease management programs.

HEMS also makes the computer a practical aid. Medication refills can be a "one-click function," says Pryor. The physician quickly learns whether this patient has any contraindication and whether the preferred drug is on the formulary of the patient’s health plan. Physicians at home on call can quickly access a patient’s record if necessary. And records never get stuck between one office and another.

Some of the new efficiencies can be as simple as printing out labels for lab samples and as fundamental as eliminating the hassles of medical record storage, says Melinda Costin, manager of patient care products for 3M Health Information Systems. "You’re doing a much more high-quality job in a shorter amount of time," she says.

Beyond the day-to-day advantages, physicians can learn detailed information about how they practice compared to their peers and how well they are managing chronic illnesses such as asthma and diabetes.

IHC regularly monitors "clinical process failures," or incidents in which something went awry, which are coded from 1 to 4 for severity of complication. Physicians also can log onto an internal network to compare outcomes. (Other physician names are blinded except to the regional medical leader.)

Expect to invest time, money

What is the price of this progress? Initially, an electronic medical record requires a substantial investment of time and money. "To optimize the productivity of the electronic record, you’ve got to make some adjustments in your patient flow," says Pryor. "And change is not the easiest thing for people."

What data are collected by the nurse? What gets entered at the reception desk? Do patients enter information directly, or do they fill out paper forms and staff put the information in?

Physicians need easy access with computer terminals in the exam rooms, laptops, or hand-held computers, says Pryor. Without real-time data collection, the physicians can’t fully benefit from decision support and alerts.

Transferring those old records

Then there’s the issue of transferring old records to the computer version. Pryor suggests paying overtime to nurses to enter the patient information each afternoon for the next day’s patients until the records become current.

"[Implementing an electronic medical record] usually results in several months of additional costs to the clinic," says Pryor. "Then they start reaping the benefits."

The cost of the system, of course, is a major issue. You want your electronic medical record to be compatible with other health care partners, such as the lab, pharmacy, hospitals, and health plans you primarily work with.

The HEMS system costs roughly $300,000 to $500,000. It is priced based on the number of users, so the cost can vary considerably. The cost is offset by savings elsewhere, such as reductions in the need for transcription of notes, says Costin. (For information resources on computer-based patient record software, see box, p. 3.)

Electronic medical record vendors also are alert to the security and confidentiality concerns of physicians and others. The 3M system, for example, allows the physician to block items from access by others. "If there are some things physicians don’t want to share, they can mark those things as private," says Costin.

Meanwhile, advances in technology are making the electronic medical record easier to use. 3M is working on voice recognition software that would allow physicians to bypass the transcriptionist entirely. The physician would speak into a microphone, and the software would convert the voice into written text.

"I think voice recognition will be the final key that throws all the physicians into doing something like that," predicts Costin.

For more information on the Healthcare Enterprise Management System, contact 3M Health Information Systems, 575 West Murray Blvd., Murray, UT 84123. Telephone: (800) 367-2447.