Monday, October 09, 2006

Electronic Medical Records

Partners Healthcare System had an ad in the Globe yesterday talking about the development of their Electronic Medical Records (EMR) System. They deserve credit for their progress on this important project. We have a similar effort underway in our hospital. As of this week, we have the same adoption of EMRs as Partners - 85% of our faculty are using electronic records in their practices. In addition, all of these doctors will be using ePrescribing (electronic delivery of accurate prescriptions to pharmacies) by the end of the year. Several dozen of our physicians have this available to them now.

But along with this good news comes a problem:

Twenty-seven percent (27%) of the patients who are seen at either BIDMC and Brigham and Women's Hospital are also seen at the other hospital. But if you have a blood test at BWH, and doctors at BIDMC want to view the results at your next visit at our place, the information is not available on their computers. Why is that? It is because our EMR system and the one run by Partners Health Care are not interoperable. Likewise, if you need to go to an emergency room in Worcester, but your primary care doctor is part of Partners primary care network or is one of our primary care affiliates, the ER there cannot get instantaneous electronic access to your medical history.

As we each make progress with our own systems, it would be great if we could also learn how to share data across systems. Interoperability is at an early state in the country because of the need for standards, privacy concerns, and lack of a consistent architecture. We look forward to working with our colleagues across the state to solve these problems.


Tom said...


I expect there will be some federal guidance on this shortly. This is the same sort of problem the HIPAA legislation was designed to address.

HIPAA created a standard electronic language for insurers and healthcare providers to exchange information. The theory (we’re not quite there yet) was that there should be one way to electronically send a claim, check the eligibility of a patient, check the status of a claim, etc. The hope was that any provider could send any insurer an electronic transaction, eliminating the mountains of bureaucracy that currently exist.

Think of it in terms of ATM’s. When ATM’s first came out, people were limited to using only their banks ATM’s. Today, you can use any ATM, you might have a fee, but all the ATM’s now speak the same electronic language. This is a similar project (incidentally, developed by the same standard-making bodies).

Standardization efforts are also gearing up for the National Provider Identifier. Essentially every healthcare provider will have a standard number that can be used in claims across all payers. These projects have wide support politically because they will result in saving federal dollars as well as improving the quality of healthcare.

HL7 is already working on the structure of these health record standards.

Jonathan Vafai said...

As a resident, I can add that it is extremely frustrating when we get a patient who has gotten cared for at a neighboring hospital for their entire life and then land in our emergency department for one reason or another. I always wonder why a partners computer could not be wired into our ED, and vice versa. This wouldn't solve the problem of patients from other outside hospitals, but ~30% is a pretty good start.

Maxine said...

As I patient, I love the Patient Site and the ability to look up my records and test results. I am also impressed when my doctors read my records before I get there or while I'm there and question me about various things they see.
However, I am leery about those records getting out of the BICMC community. how secure would they be. could they be hacked?

Anonymous said...

A very good point, Maxine. The confidentiality requirements under federal law, HIPAA, are very strict. All providers know this, and so there would be strong standards in place. Even now, within our hospital, if a patient record is accessed by anybody, there is an electronic audit trail and to who looked at it and what happened during that session. At a minimum, a similar standrad would have to be in place if records were shared with other providers.

Tom said...


HIPAA provides for an "accounting of disclosures." This is the audit trail mentioned. It means that at any given point you can ask your health plan or healthcare provider to inform you to whom they've shared your information. Usually information is shared only statistically to auditing bodies (Department of Health, Division of Medical Assistance) and all the identifying data is stripped away. However, it is now a right of your to know all of that.

Once electronic health records go nationwide this will still have to be an option. I wouldn't worry about the security too much, HIPAA provided for a separate "Security Rule" (separate and more stringent and specific than the privacy rule) that will presumably cover these transactions.

Grindstone Healthcare Consulting said...

have you considered using the CCHIT standards as a starting point for discussions on inter-operability. they (CCHIT) are even proposing standards for internally developed EHR's.

David Harlow said...

EMR adoption at 85% is pretty impressive. Per a recent Health Affairs article, the figure nationally last year was only about 25%.

With the cost for implementing an EHR system pegged at about $35K per doc, small practices are hard-pressed to get with the program. Even the recent safe harbors relating to funding EHR and e-prescribing systems are not the panacea they were intended to be . . . . At least some tax-exempt hospitals and hospital systems are not going to fund physicians' EHR systems without some guarantees that the IRS wont come after them for in appropriatley granting benefits to for-profit physician entities.

So it's nice to know that the only problem for some providers is interoperability; for most providers, the hurdles are at a much more basic level.

Even as the interoperability certifications are being passed out for new products, early adopters like BIDMC and Partners will have to spend some serious bucks to allow their existing systems to talk to each other. That's just one of the costs of being out in front.

In the scheme of things, interoperability is a relatively minor technical problem, and it will be worked out, just as an earlier commenter noted that inter-bank ATM network issues have been worked out.

The larger issues revolve around how to tease the full value out of the EHR system: by gleaning best practices information from the tremendous volume of data at places like BIDMC and Partners, and by using the data to build meaningful pay-for-performance systems. P4P is not yet ready for prime time, but it's coming down the pike in a big way, and institutions and practices with the data systems in place will be well-positioned for the future -- for negotiating payor contracts, and also for managing their patients' care.

Anonymous said...

Dear Grindstone,

CCHIT??? Sorry, but you have to use English for us newscomers . . . .


Anonymous said...

David raises some good points. Ultimately, you would want to use the aggregated data from EMRs for decision support for doctors. In essence, these records provide huge amounts of data about certain population groups, disease types, and efficacy of treatment options. The goal is to to enable doctors to use the trends and factors in that information base in real time when visiting with a new patient.

dave said...

CCHIT is the Certification Commission for Health Information Technology. Its a private body that has recently started certifying EMR software. It is working closely with the Dept. of Health and Human Services, especially the Office of the National Coordinator for Health Information Tech. You can rely on the fact that Dr. Halamka is 100% up to speed on CCHIT, HL7 and all other standards and standard setting activities. Standards are a necessary, but not sufficient, condition, to the kind of data exchange that Paul wants to see happen.

Anonymous said...

Thanks, Dave, for the translation. Our chief information officer, Dr. John Halamka, is chairing the national group that is trying to coordinate standard setting in this arena. Luckily, he understands these acronyms, so I don't have to worry about them!

Star said...

Very interesting website. Thanks for putting it up. (Mine is health humor--, pardon the plug). We are constantly annoyed by the stupid clipboard--the doctor never looks at it, much less flips through the jumbled chart. And with a 10-min encounter, tops, unless you have a list of concerns, things get left unsaid. My mother's doctor taps into a laptop and his nurse records the vitals on a computer. This is the only one of our many doctors to do this. The rest is dead trees and, as I said, seldom consulted. I fault patients for not spitting it out, though--say what you want to, get answers. I have had to follow the doctor into the hall, but I get a response. Usually. And we call for our test results. And we have procedure reports mailed to us.

Alwin Hawkins, RN said...

You might want to think about a Regional Health Information Organization, or RHIO. Indianapolis and several other communities already have them in place, and they ease the problem of cross-system access in regards to HIPAA problems.

fred trotter said...

I wondered if you would could discuss in a post the impact of the relaxation of Stark laws, and your relationship with your clinics.

I sell support for an Free and Open Source (FOSS) EHR called MirrorMed. There are several different FOSS EHRs around but each of them, if deployed correctly, within the new Stark guidelines would mean that a hospital could provide an EHR for 100% of your satellite practices, for substantially less than 35k per-provider that proprietary systems cost.

Also, there is interest in providing Free and Open Source interoperability libraries. IBM has released some excellent code, and there are others who are doing even more. We are very close to being able to run a RHIO without any proprietary (costly) software.

Fred Trotter

Richard Dale said...

There is a local Boston RHIO, and the BIDMC (& Care Group) CIO, Dr Halamka, is intimately involved as CIO in this as well. Furthermore, the Indivo project started at Children's Hospital in Boston is also being extended to other local healthcare providers (including BIDMC according to on top of the RHIO infrastructure (at least that is what I think is happening).
One commenter noted the progress in Indianapolis, and in fact there was recently a demonstration of inter-RHIO records access between Boston and Indi (again, the ubiquitous, Dr Halamka was involved).
These projects all seem to be pushing the state of the art forward, but also seem sadly limiting. If there is a good RHIO, then by definition it is easy to share data inside the region (the R in RHIO) but harder outside the region. For the highly mobile US population, a national approach is clearly preferable. We know the North Adams area has a great shared EMR system, and Rhode Island is pushing on its own RHIO, but I bet it will be miserably difficult to share data from those fairly close locations to the Boston RHIO... and how about all those snowbirds who split their lives between Boston and Florida (or Arizona, or ... well you get the picture).

gary said...

I am a doctor in private practice at BIDMC. The hospital restricts access to its On Line Medical Record to physicians employed by the hospital. Patients going to various doctors at the hospital who see employed physicians can see all the outpatient and inpatient records greatly facilitating care. However, for non-employed doctors the option of placing outpatient records on a site available to other doctors participating in that patient’s care is unavailable. It is my understanding that both St. Elizabeth’s and Mount Auburn Hospital will have such a shared medical record available to all members of the hospital staff. A system of shared inpatient and outpatient records is essential to patient care and we need to implement this.

Anonymous said...

Every hospital system is working on approaches to give non-employed, but affiliated, doctors a way to enter the hospital's EMR system. There are cost and privacy issues involved in this.

Even if non-owned clinicians paid hospitals to use hospital-based electronic record systems, state and federal laws prevent the comingling of hospital records and private practice records, since the hospital is not the steward of the private practice records.

I doubt that the hospitals you mention have solved this and made this capability broadly available. We have ideas in mind, which we will share with our affiliated doctors over the coming months.