Deploying an EMR: The battle for record access

Imagine this: A patient you've never met comes into your office after having last seen a doctor more than 6,000 miles away. But even before you speak to him, you know his complete medical history, from his allergies to the diagnosis from his last x-ray.

An automated reminder e-mail informs you the patient is due for a vaccination booster and a follow-up to some lab work that his previous doctor ordered months ago. When the patient's checkup is complete, all of the necessary evaluation and management codes for the visit are automatically compiled and ready to be sent electronically to the appropriate payer. Now the next physician to treat this patient will know everything that you've done without ever having to give you a call.

You might think this scenario is a long way off, but the U.S. military health system is already putting these concepts into practice. Advances that are occurring behind the scenes -- as well as lessons that are being learned -- could be invaluable to doctors who don't have a military rank in front of their names.

Physicians from Langley Air Force Base in Virginia to the Naval Medical Center San Diego are already cutting their teeth on the Defense Dept. system. Officials who are following its progress say the results are very encouraging. The effort has attracted the attention of several large health care systems, such as Mayo Clinic, Partners HealthCare System and Kaiser Permanente, which have initiated discussions with military health leaders in the hopes of possibly adapting parts of the system for their patients.

"There's a lot that we can share with the private sector ... that would be useful for their consideration in implementing their electronic health records systems," said William Winkenwerder Jr., MD, assistant secretary of defense for health affairs.

Following the military's lead

Most practices aren't dealing with a highly mobile pool of more than 9 million potential patients. Doctors contemplating the purchase of an EMR system for a much smaller population do not need to consider an industrial-strength program like CHCS II.

"It's a lot different to practice in a private practice than it is in the military, or even within a big hospital system," said AMA Trustee Joseph M. Heyman, MD, an obstetrician-gynecologist in Amesbury, Mass. "Different-sized practices need different types of systems."

However, physicians who are in small or medium-sized practices can look at an aspect of the Defense Dept. system to see how their EMR might work in the future. When fully implemented, the Theater Medical Information Program will allow doctors in combat areas to maintain self-contained medical records on laptop computers that eventually can be uploaded to the central data repository.

Such a model would work well for smaller practices that would do just fine with self-contained medical records, said Larry Albert, senior vice president of the health care practice at Integic in Chantilly, Va., the prime government contractor for CHCS II implementation.

"This portable version could quite possibly have a high level of applicability to a smaller private practice that really doesn't need a clinical data repository but just a database where they keep the records for their patients," Albert said.

Another element of CHCS II that could be encouraging to physicians is that it operates on commercially available software and hardware. Such vendors as Oracle, Hewlett Packard and 3M have helped the military health system log medical records for more than 5 million beneficiaries so far and are allowing facilities using the new system to document more than 14,000 patient encounters per day. The computer program doctors use to record patient visits, test results and diagnoses to the permanent EMR is based on the Windows operating system, which is already familiar to many doctors.

Moreover, military physicians at different facilities have been able to share patient data despite the fact that some sites utilize widely differing software and hardware configurations, said Capt. Robert Wah, MD, a reproductive endocrinologist and director of information management for the military health system.

The lesson for non-military physicians is to choose the system that best fits their particular practice without falling into the trap of thinking that only the most advanced systems will be interoperable someday, he said.

"Before you start building or acquiring or buying any technology, sit down and understand what your needs are first, and then go out and shop," Dr. Wah said. "If you go shopping first without a shopping list, you're just going to buy the brightest, shiniest object out there, and that doesn't help you."

The Defense Dept. is also working on interoperability with another EMR system. Information officers are currently transferring select patient information from CHCS II to VistA, the electronic medical record system for the Dept. of Veterans Affairs. Officials from both departments report they are well on their way to implementing two-way exchange of all health information between Defense and the VA.

The very process of entering patient information into the new Defense Dept. system is also an exercise in crafting compatibility. Much of the information is coming directly from CHCS I, the department's decade-old, facility-centric system that relies on a completely different data model than the new initiative.

Learning the hard way

The military effort hasn't been without its landmines. In the spring of 2004, problems in the system that manages the central patient record database caused massive slowdowns, sparking widespread complaints from military doctors who suddenly found they could not easily access and amend records. Although the Defense Dept. got the system back on line within a matter of days, the CHCS II initiative was set back several months.

Practices who either own an EMR or are planning to purchase one must realize that such glitches can and do occur with health information technology, Dr. Winkenwerder said. The central lesson that Defense officials learned from the outage was that responses to such crises must be quick and transparent in nature.

"What you have to be careful about is losing the trust of the physician users and the credibility of the technical people," Dr. Winkenwerder said. "The way around that is to engage in conversation and to be really clear in communicating with people."

Such system failures occur in the private sector as well, and the results can be similarly frustrating to the physicians involved, according to Dr. Heyman. When the EMR supporting his solo practice crashed several years ago, he initially thought that he had permanently lost the information for all of his roughly 1,000 patients.

"I was ready to kill myself, or at least lose my license and retire," Dr. Heyman said. "It's not just the idea that you lose it, it's the idea that you've made this incredible investment and now it's all gone."

Defense officials and CHCS II contractors say that last spring's problem cemented their belief that the physician is the most important element of any electronic medical record effort.

"We have really heavily involved physicians ... in the design of these systems because they have to work for physicians," Dr. Winkenwerder said. "Physician acceptance is probably the biggest barrier to implementation of electronic health records."

The Defense Dept. initiative has demonstrated that the technological challenges of mastering a new EMR system are secondary to the need for physicians to acquire a completely new mindset, Dr. Wah said. Doctors are used to dealing with a medical record that goes with them rather than with the patient, and they are unaccustomed to a setup by which multiple personnel can access the information at the same time.

"It's a radical change in the way we can start taking care of patients in terms of workflow and patient flow," Dr. Wah said.

A model for change

The aggressive rollout schedule for CHCS II is indicative of the Defense Dept.'s desire to take the lead in the governmentwide campaign to implement EMRs and encourage the private sector to do the same. President Bush last year established a goal for all Americans to have a personal electronic medical record within the decade.

The office of David Brailer, MD, the national coordinator for health information technology, is in regular contact with defense officials in the hopes that the private sector can build on the Defense Dept.'s progress. Dr. Brailer has shown particular interest in the data standards that allow differently equipped military facilities to access shared patient information.

A government focus on ensuring that a national EMR would similarly allow private practices to share information despite the use of varying products would play to the advantage of physicians who are already set up.

"Dr. Brailer will end up with a system of standards rather than a standard system," said Integic's Albert. "There are just so many people so entrenched in different directions that it could be financially punishing to organizations if we did not come up with standard ways to enable them to maintain the investment they've made. We need to ask them to leverage that investment rather than throw it away."

Meanwhile, the investments that the military has made in CHCS II are already paying off.

Dr. Winkenwerder reported that maintaining a central record of patients' medical information has helped avoid more than 100,000 potentially harmful drug interactions. When all 9.1 million beneficiaries and 139 military treatment facilities are plugged into the system, the ability to track disease outbreaks and determine physician best practices also will be greatly enhanced.

But some military physicians who were expecting a minor miracle with the advent of the new system have been disappointed -- yet another lesson that private practice physicians should take to heart, said Dr. Wah.

"There's an expectation with information technology that you just bring the big black box in and click it on and the world just gets better," he said. "It is a tool just like any other tool. Computers can help physicians take better care of their patients, but they don't actually take care of their patients."