Integrated patient records: Great idea, but action bogs down in hows, whens

Cooperation is key to building links across systems

The dream of tapping a patient's electronic record from the hospital bedside or the doctor's office seems doable - until you sit face to face with your existing records and your co-workers whose support will make or break the venture. Indeed, clinicians revel in the prospect of having good data, but their enthusiasm cools when they realize attaining the prize entails extra work.

Integrated patient records might well hold the key to the next generation of advances in quality improvement as health care shifts toward ambulatory settings. But some sources who spoke with us doubt the technology is up to it yet.

Harlan Goodrich, vice president and chief information officer of MidMichigan Health in Midland, says his system is like many institutions that had the best available patient record software when they began accumulating it piecemeal and department by department over the last 20 years. Now they face the daunting task of integrating that departmental data. The staff at Midland had to shop for an interface engine they hope can cobble it all together. "The vendor community talks integration," Goodrich says, "but the mentality is proprietary, not truly open systems."

At the Atlanta-based Emory (University) Healthcare and Woodruff Health Sciences Center, records integration must span the university clinics, the hospital, and private physicians' offices. At this stage, however, chief information officer Ron Palmich says the best way to ensure that records reach providers the same time patients do is to "turn the records over to the patients and tell them to carry them to every appointment. Even if they come to the emergency department!"

The questions of who should coordinate and oversee continuumwide patient records and who can handle it stir considerable debate. It's no wonder because of the overwhelming potential for power and abuse. The expenses and responsibility for stewardship of patient confidentiality are another matter. Maintaining the data repositories that could become meccas for health researchers would pose yet another set of administrative demands.

To hear insiders talk, records custodianship may well be the next health policy dilemma to thrash out after we solve the technology issues. In one view, offered with an admitted bias, Goodrich ventures, "It should not be purchaser driven. Managed care organizations should be included, but the coordination should be provider driven." Still, he notes that records integration would be best served with nonphysician providers at the helm. "Medical groups are predominantly interested in 'what data elements are useful to me?' - where we need data sets that cover the whole care delivery system, the business managers, long-term care, and all the providers in between. Ultimately, this model will better serve the needs of the patient."

Janice Schriefer, RN, MSN, MBA, CCRN, research fellow at the University of Michigan in Ann Arbor sees an inherent conflict between who can and who should hold custody. "Unfortunately, the insurance companies are in the best position because they are paying for the care in most of the patient care settings where insurance benefits apply."

The flaw in that scenario, she notes, is that outcome studies based on insurance-derived data would lack the records from out-of-pocket care. "[For example], a group of patients gets 30% of its care from alternative sources not covered by insurance policies, how can you get good outcomes studies when you're missing 30% of the records? Patients don't always tell their physicians when they go to alternative sources. And what incentives do the insurers have to collect data from out-of-pocket encounters?" Schriefer explains.

To further confound the issue, many alternative care providers do not keep records that readily integrate with insurer databases, she says.

When work begins, who shows up?

Remember the little red hen, a character from your childhood stories? She asks her barnyard friends who will help plant and raise the grain to make flour for bread. No takers. But when she asks who will help eat the bread, they all show up at the table. Information management professionals tell us they're too often like that little red hen.

Every department in the institution would love to use comprehensive data if they were already compiled and were maintenance free, Palmich observes. But creating the records heaps extra demands on frazzled people.

"It comes down to a selling job," he confesses, "especially when the work you want doesn't directly benefit them even though it benefits the enterprise as a whole. This is where administrative support helps." The real carrot, however, is when administrators realize how much the data make them more productive.

For some groups, it's easy. Physicians and other providers in emergency departments and drop-in ambulatory centers naturally get excited about integrated patient records because "they're seeing the patient cold," explains Roger Buxton, MS, RN, director of Nursing Information Systems at the Urban Central Region office of Intermountain Healthcare based in Salt Lake City. However, he continues, "the physicians are not excited when they have to enter the data. They would prefer that nurses or clerks enter them, and they could just use [the information]."

To scale that barrier, Buxton and colleagues are devising ways to make a little data input produce larger results. In progress, for example, is a program where doctors enter patient descriptors like gender, date of birth, race, weight, and height. In turn, the computer generates a narrative in the doctor's style such as, this 45-year-old female of medium build. Intermountain is also studying voice recognition technology so providers can dictate their entries. Buxton predicts, "In a few years our systems will be more like Star Trek than we can imagine."

Don't we love that gossip!

Hackers don't pose as big a threat to patient confidentiality as industry insiders, our sources contend. "Most institutions require statements of confidentiality from their staff, but health care workers themselves are still the most susceptible to breaking confidentiality," says Ellen Gaucher, vice president for quality and customer Satisfaction at Wellmark Inc. Blue Cross and Blue Shield of Iowa and South Dakota in Des Moines, Iowa. "It's the human tendency to gossip," she says.

Schriefer expresses an additional and equally unsettling concern. Although she views insurance plans as the most logical records custodians, she still worries. "It's no secret they want healthy people! The more fragmented the record is, the easier it is for people to get insurance, especially when they have pre-existing conditions."

The irony here is that people with pre-existing conditions and multiple encounters with the health care system are the ones who stand to gain the most clinically when providers have complete records of their care. If we ever achieve an integrated record, she says, "parts of it would have to be blinded to insurance companies."

One version of the selective access Schriefer describes is up and running at Baystate Medical Center in Springfield, MA. They created user types - codes and passwords which admit affiliated physicians' offices and one subacute care facility into the hospital records of their patients. At this time, the subacute facility cannot enter notes to the records. The physicians, however, can chart notes to the hospital records of their own patients.

Mary O. Cramer, director of performance improvement services at Baystate, says it's not technology that slows their expansion of hospital data accessibility. "We have to balance the need and desire for information with patient confidentiality."

Four records integration initiatives

Several of our sources agreed to share information with QI/TQM readers. We summarize their stories below and extend their invitations to readers to network with them.

Emory Healthcare and Woodruff Health Science Center.

Late last year, the records integration project began to address the discrepancies in coding patient encounters. They're developing guidelines for consistent coding across inpatient and outpatient sites. On the technological side, they're making their software user-friendly. Where radiology data are typically scattered throughout a record, Palmich envisions an electronic model in which data would be grouped under a tab on a Windows screen.

- Current challenges: Engaging staff for the long haul.

"People underestimate the amount of work that goes into a project like this," Palmich says. "They think they're going to have this new electronic thing, but they don't know it requires a lot of work to maintain it after they get it."

MidMichigan Health.

This institution is leveraging the vendors of its current clinical software packages to do as much interfacing among existing programs as possible. "We're trying to clean up what we have," Goodrich reports. MidMichigan is also evaluating bedside documentation vendors. "We want to have systems that will talk to each other and provide real-time data across the continuum. Some vendors are close, but none are there yet," he observes.

- Current challenges: Keeping an eye on software compatibility.

In evaluating bedside documentation packages, Goodrich says, it's tough to hold a rein on the enthusiasm of clinical departments who want to pilot items with "all the bells and whistles." Goodrich is trying to keep them aware of the compatibility issue, or "I'll end up with 12 systems that can't talk to each other."

Baystate Medical Center.

Baystate spent the last three years designing its present information network of physician offices and subacute care. It started with 44 doctors' offices, setting up terminals that connect to the inpatient records repository. As the shift to ambulatory care progresses, Baystate is attracting interest from additional doctors' practices, long-term care facilities, home care agencies, and even third party payers seeking to join the network, says Lesley Walczak, team leader for the Physician Office Network.

To protect patient confidentiality, the medical center procured an ISDN (integrated service digital network) phone line through the local phone company. The line is owned by and solely accessible to the medical system's network via special passwords and user codes. Their software is TDS 7000 Series by Eclipsys. (See resource information, at right.)

- Current challenges: Balancing technological sophistication and ease of use.

A nurse by training, Walczak constantly juggles clinicians' desires for ultra-friendly data systems, her two technician teammates' excitement over technology for its own sake and her vision of a system with the capacity to grow.

Intermountain Healthcare.

Intermountain has integrated inpatient records since its inception 30 years ago. As it acquired additional hospitals, it hooked them right into the system. Now Intermountain is looking to build a longitudinal data repository (LDR) of lifetime continuumwide patient records. Buxton and colleagues believe they might use a software package such as Health Enterprise Management Systems from 3M in St. Paul, MN, though the decision is not final.

- Current challenges: Creating a master member index as the foundation of the LDR.

Buxton envisions a unique patient identification number derived from a patient's name, social security number, and date of birth. "Providers must have a high confidence level that the record they access will actually pertain to that patient."

As the quest for comprehensive patient data information systems accelerates, Buxton hopes data management and quality improvement professionals alike will bear in mind that "for every piece of data we want out, we have to have somebody to put it in. We have to tally the cost benefits of each measurement in human resources, hardware, and software, as well as bricks and mortar."

[For further information on integrating patient records, contact:

· Ron Palmich, Emory Healthcare and Woodruff Health Science Center, 1784 N. Decatur Road, Suite 400, Atlanta, GA 30322. Telephone: (404) 727-4350. E-mail: ron_palmich@emory.org.

· Janice Schriefer, 1630 Flowers Mill Dr., NE, Grand Rapids, MI 49505. Telephone: (616) 391-2974. Fax: (616) 365-9374.

· Mary O. Cramer, Director of Performance Improvement Services, Baystate Medical Center. Telephone: (413) 784-3297. Fax: (413) 784-8763. E-mail: cramerm@bmcsouth.bhs.org.

· Lesley Walczak, Information Services, Baystate Health System, 3601 Main St., Springfield, MA 01107. Telephone: (413) 784-8629. E-mail: lesley.walczak@bhs.org.

· Roger Buxton, Director, Nursing Information Systems, LDS Hospital. Telephone: (801) 321-1754. E-mail: ldrboxto@ihc.com.

· Harlan Goodrich, Vice President and Chief Information Officer, MidMichigan Health, Midland, MI. E-mail: goodrich@midmichigan.org.

Resources for details on the TDS 7000 software mentioned above:

· Eclipsys, 777 E. Atlantic Ave., Suite 200, Delray Beach, FL 33483. Telephone: (561) 243-1440. World Wide Web: http://www.eclipsys.com.

For training in records integration techniques, contact:

· Healthcare Information and Management Systems Society, 230 E. Ohio, Suite 500, Chicago, IL 60611-3269. Telephone: (312) 664-4467. Or visit their Web site: www.himss.org.]