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Electronic medical record technology: Something old, something new, something borrowed …

This article appears in the issue April 1998 [Volume 7,Iissue 5]

Electronic medical record technology is doing more for healthcare today than ever before, performing functions that are unique and critical. More deliverable capability is available today than the industry has ever had at its disposal for managing the legal, formatted version of healthcare documentation.

Yet, with all that great opportunity, a wide gap exists between industry needs and deliverable technical capability. "So what's new?" you ask. "Any computer-based technology lags its user needs by a wide margin." It's hard to remember that when press releases seemingly announce capability at the same time that the industry thinks it. It's like being in second grade and learning that a new high school is being built. You're glad to hear it, know you'll need it, but it doesn't make your trip through grade school any shorter.

Currently the ability to purchase software that will perform most health information management (HIM) and patient financial services (PFS) functions is good. For example, in two in-depth selection processes I conducted last winter, half the vendors could deliver full capability with little or no beta (or custom) software involved. That not only simplifies the contract, but also helps reduce implementation risk significantly. Traditionally the electronic medical record (EMR) industry's release of software functionality has not been punctual.

The basics

Of course, storage and retrieval are the most basic capabilities. Most vendors have long since refined their capability in that area. Most offer unit record and longitudinal views, multiple document views simultaneously and all the standard annotation capabilities. Other basics include:

Clinician presentation

Clinicians are casual users of the software relative to PFS or HIM users. The software must present documentation in a straightforward, concise format. While most solutions have refined that, a few are still struggling to produce a presentation that is unique and still functional: no small feat. American Management Systems (www.amsinc.com) and MedPlus (www.medplus.com) have good clinician presentations, as reviewed by clinician staffs.

Automatic form indexing

It's a misnomer that the biggest cost of the system is hardware. Staffing the input team can outrun hardware costs by a large margin. The effect of automatic form recognition is huge, and most vendors have worked hard to refine that aspect of their systems. SunGard/Intelus (http://www.sungard.comwww.sungard.com) has some excellent methods for making patient/visit identification accurately apparent to the indexing software.

Preparing forms for automatic identification is a hospital task. Failure to do so in a timely manner will directly affect staffing requirements for the input team, sometimes by a factor of three or four. Unfortunately, calculating that effort and the resulting staffing requirements is still left out of most purchase processes and left out of the budget.

As an alternative to paper form barcoding, companies such as Prograde (Cincinnati) offer a conversion to all electronic forms in which they are forever-after printed on-demand, with patient identification and form type barcoded on each page. The forms are laser-printed, clear, and automatic indexing is much more probable.

Real multimedia

The EMR has always been the single venue for all chart information to reside and be retrieved. That includes paper documents, text documents (COLD), color photos, medical images, sound clips and full motion video. Thanks to Windows 95, multimedia capability is real, and several vendors can and will demonstrate inclusion of all those different file types. Others, for some reason, can't demonstrate more than text and scanned images, their marketing information belying the truth. It's tricky getting those other file types into the system, though. When evaluating vendors, require that the input of those files (color, medical image and video) be demonstrated. You may find that having the capability and actually using it are two completely different concepts.

Work process automation

Chart completion

Electronic chart completion is a critical capability. The top six or seven vendors have those modules, although to varying degrees of completeness. While the required functionality set will differ by hospital, there is at least one way of handling nearly every function with those modules. The tricky ones are resident-attending rollover (two or more physicians assigned to the same deficiency with the order of priority established) and ad hoc routing (should the chart need to go outside of the predefined workflow). Some vendors do those well; others are still catching up. Look closely only at software that is under general release.

Release of information

For the most part, that function is available from all the solution providers. While the modules may vary in details, there are normally ways to handle most of the release activities.

Cash posting

This one is a kicker. PFS requires remits to be scanned as remits and indexed into cash-day folders by payor, date, etc. Then they post the cash, payment by payment from the images, into the billing system. Concurrently, that page of the remit should be secondarily indexed into the associated patient's folder. Few vendors understand that; even fewer have it deliverable.

While all of them purport to offer PFS software in their suite, few can adequately handle indexing remits into a totally different folder scheme other than patient/visit/document. Even worse, they have no ability to index images into two different folder schemes as described. Without that, PFS finds a major aspect of the workflow impeded. Once again, marketing information doesn't tell the whole story. Look at this functionality carefully when selecting.

New trends and tactics

The industry says two very important things about information access relative to EMR technology:

  • Physicians need access to information from their offices both for chart retrieval and completion.

  • The EMR is no longer a standalone physician information resource, but one that acts in concert with other more primary systems.

    Remote access to charts has always been an important requirement. As long as the remote sites are connected to the main network either via LAN or WAN, the access technically was remote. What's required is access from a physician's office using a standard PC modem. That's a whole new ballgame! Most client-server-based applications are not designed to run across a modem in that way, and using a remote-control program such as PC Anywhere is not effective in that instance, nor is creating a gazillion dial-up lines.

    Enter the Internet. Not only does it allow seemingly faster access but simpler, less proprietary access. A thin-client application and browser can give access to charts while protecting security. However, many vendors will struggle making their complex client applications thin enough for the Web while still functional.

    Consequently, access to documents across the Internet is still a concept to most vendors, even though their brochures say it's real. While they may demonstrate the capability, few have it operating at a site with real physicians doing real chart access.

    Integration

    The EMR's thunder is being stolen. The industry wants software to work together, to be complementary, to reduce redundancy. For EMR technology, that means the limelight is being stolen by another technology, the computer-based patient record (CPR). Those systems are beginning to fulfill their promise of managing detailed statistical information for care events and are becoming the platform of choice for the clinician's first look at patient information.

    So where does the EMR fit? It acts as the historical, legal, formatted, signed version of the care event. And it is sitting there on the right hand of the CPR, waiting to fulfill its vital, yet complementary role in the clinician's quest for knowledge. Most EMR vendors are now asked to make their system integrate with the CPR so that with the press of one button in the CPR system, the EMR system responds with a fully automated retrieval of the relevant patient chart. In some cases, EMR vendors are being asked to upload basic folder/document information into the CPR so the clinician cannot only access the chart but a specific document by picking from a list of available EMR documents displayed within the CPR system.

    David Williams, senior project leader for The Children's Hospital of Philadelphia, explains, "Integration of our EMR system (MedPlus' Chartmaxx) with our clinical or CPR system (Eclipsys 7000) is critical not only for the successful implementation of the EMR, but also for us to realize our vision of an online clinical record. All of our clinicians utilize our Eclipsys clinical system, the operational component of and clinician entry point into the online clinical record. Integration with the EMR system enables clinicians to view a patient's historical record while entering orders or viewing results in the clinical system. The medical record or historical patient information is available when and where a clinician may need it."

    Naturally, non-patient care work processes can continue use of the EMR-specific features and functions. But in reality, that graying together of separate systems makes sense from the clinician's point of view. Computers are tools just like stethoscopes and reflex hammers.

    Meeting great expectations

    All this new technology and hype doesn't change the basic issues. If a hospital is just beginning an EMR project, whether for HIM or PFS, it needs to purchase and implement a solid, functional platform. Comparing one vendor to another is most difficult; comparing vendors to a predetermined set of requirements isn't. Squelch out all the marketing fluff by taking control of the selection process. Make sure the immediate and basic needs are met, such as storage and retrieval, chart completion and cash posting. And require that only software under general release be presented for evaluation.

    Any vendors worth their salt are announcing all kinds of new technology every day. They're learning from the industry and from each other. Most of this new stuff is great on paper, but not worth considering until it's real. For much of it, that means another 12 or 18 months. It'll take the average project at least that much time to get ready for all this leading technology. And guess what? By the time you're ready, it'll be old stuff. In this market, old is good, old is real.


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