Electronic Medical Records: An Introductory Tutorial

1
Electronic Medical Records An Introductory
Tutorial

• William Tierney, MD
• Atif Zafar, MD
• AHRQ PBRN Resource Center

2
Outline of Presentation

• Introduction to EMRs (very basic information)
• Barriers to Adoption Some Problems with Data
  Accessibility and Care Processes
• EMRs for Clinical Research
• EMRs and HIPAA Security
• No Nonsense Guide to Selecting an EMR
• Examples of EMRs
• OpenSource
• Commercial
• Lessons Learned

3
Introduction to EMRs
4
Introduction to EMRs

• Why do we need Electronic Medical Records (EMRs)?
• Many problems with the current healthcare system
  (underuse and overuse)
• 30 of children receive excessive antibiotics for
  otitis
• 20-50 of surgical procedures are not necessary
• 50 of back pain x-rays not necessary
• 50 of elderly patients dont get a pneumovax

5
Introduction to EMRs

• Why do we need EMRs?
• Clinical practice is a data intensive operation a
• Inadequate data communication causes medical
  errors
• Human cognition is good at pattern recognition
  but not at remembering lists or evaluating
  multiple business rules.

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Why do we need EMRs?

• Available 24 x 7
• Can be viewed by more than one user at a time
• Is available from remote locations
• To covering MDs
• Others with appropriate needs
• Data can nearly always be found
• Is legible

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Why do we need EMRs?

• Enhances Communication
• Between providers--clinical messaging
• Can tag EMR location with message
• Referrals
• Half of specialists didnt know what main
  question was
• A third of the time no information came back to
  PCP

8
Why do we need EMRs?

• Cost Savings
• Dictation cost savings
• 170/FTE/month
• Chart pull savings
• 217/FTE/month
• Savings accrue to practice, apply to all payers

9
Why do we need EMRs?

• Assist with Decision Support
• Many domainscost and selection of
• Drugs
• 18 reduction found by Overhage
• Lab tests
• 10-15 reduction in cost for charges, last
  result, probability of abnormal
• Radiological studies

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Why do we need EMRs?

• Decision Support
• In inpatients, computerizing ordering decreased
• Serious medication errors by 55
• All medication errors by 81
• EMR can help by
• Structuring medication orders
• 34 error rate with paper vs. 6 with electronic
• Alerting about
• Allergies
• Duplicate medications
• Many other issues

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Introduction to EMRs

• Do EMRs make a difference?
• UNEQUIVOCALLY YES, BUT AT A COST!
• In multiple studies, EMRs have been shown to
• Shorten Length of Stay in a Hospital setting
• Decrease Adverse Drug Events (ADEs)
• Improve Readability, Consistency and Content of
  the medical record
• Improve Continuity of Care
• Reduce practice variation
• Most benefits come from Decision Support.

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EMR Use in the United States

• Even though the US Health Care system is the
  costliest in the world, its performance ranks
  37th in the world according to the WHO!
• Only 5 of US primary care providers use EMRs
  (Bates et. Al., JAMIA 2003), 7 of all physicians
  (Wang, Bates, et. Al., American Journal of
  Medicine, April 2003)

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EMR Use Around the World

• Use PCs Use EMR
• Australia 90 53
• Denmark 95 62
• Netherlands 95 88
• Sweden 95 90
• United Kingdom 95 58
• (c) 2001 Harris Interactive

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Breakdown by Function - 2002

• Australia UK
• Use EMR 90 99
• Of Those
• Prescrip 100 80
• Notes Unknown 45
• Reminders Unknown 70
• Clin Vocab 15 (ICPC) 100 (Read)
• Paperless Unknown 45
• 2B initiative by UK to get all physicians online

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What is an EMR?

• At their heart, EMRs are just a database
• This database hold many kinds of information
  (coded and not coded)
• This database is organized by date, time, pat ID
  and contains
• Patient registration data (name, contact info,
  DOB, SSN, etc.)
• Test results (laboratory, radiology, nuc med
  etc.)
• Medications (active, inactive) and Allergies
• Current list of diagnoses and problems
• Appointment Data
• Clinical Notes
• Billing Information

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What is an EMR?

• So if an EMR is just a database, how is it
  different from other databases, and why is it so
  useful?
• Value Added
• A Clinical Knowledge Heirarchy (term dictionary)
• How do clinical concepts work together
• Ex Digoxin toxicity can occur with hypokalemia
• A List of Current Clinical Recommendations
• A List of Appropriate Medication Indications,
  Doses, Adverse Effects and Interactions and Cost
  Estimates
• Costs, Indications and Utility of Tests

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What is an EMR?

• What are some typical EMR Components
• Lab System Contains all lab tests ordered and
  their results and stored as coded results (LOINC
  etc.) in many systems
• Radiology System Stores test reports
• Pharmacy SystemList of current medications,
  inactive meds and when they were last dispensed
  or ordered
• Billing System A list of diagnostic codes used
  for billing (ICD9, CPT, etc.)
• Registration System Names, Contact Info,
  Personal Info, etc. for patients

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What is an EMR?

• Additionally, many EMRs have
• An Order Entry System (where physicians enter
  orders, prescriptions, notes etc. online)
• A Decision Support System
• Often linked to the order entry system to provide
  guidance at the point of care
• Contains databases for clinical knowledge,
  guidelines, list of medication indications, doses
  etc.

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What is an EMR?

• The spectrum of EMRs
• EMRs target specific user bases, from solo
  office-based practices to large, multispecialty
  tertiary care centers
• Many features are thus directed at managing
  workflows specifically to these user bases
• For example, large commercial EMRs unbundle
  services such as clinical documentation, results
  display etc. while office systems typically
  integrate all of these under the same interface.

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How do Clinicians Interact with EMRs
Order Entry/Results Reporting
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Different Types of EMRs

• EMRs dont necessarily need to be expensive and
  complicated or require that a computer be used to
  enter data
• Can have hybrid computer/paper based approaches
• Ex In the CHICA System, paper is used to
  interact with an electronic data repository
• Standardized paper forms are printed and then
  scanned
• Characters are recognized and the electronic data
  so generated interacts with the data repository

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Different Types of EMRs

• At Indiana University, pediatric clinics use this
  system
• A data repository was developed using Microsoft
  SQL Server
• A clinical guideline system was written in Arden
  Syntax
• An optical character recognition system called
  Cardiff Teleforms is used to process handwritten
  numerical data on preprinted scanned forms
• The data so generated is stored in the database
  and dynamic reminders are generated for the
  physician
• These are printed on the clinic computer
• The entire operation takes lt 2-3 minutes!

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Different Types of EMRs

• The Mosoriot Medical Record System
• Indiana University has an HIV Effort in Kenya
• A Simple MS Access based database holds all
  patient records (3 years worth!)
• Provides forms for data entry, standard term
  dictionary, medication listings, registration
  system, clinical documentation system etc.
• Created by 1 programmer over 2-3 weeks!
• Highly effective, easy to maintain, inexpensive!

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Data Sources

• So how can EMRs populate their databases?
• Data can come from many many sources
• Admission/Discharge/Billing
• Anesthesia Systems
• Cytology Systems
• Diagnostic Imaging Management Systems
• EKG Carts
• Endoscopy Systems
• ER Systems

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Data Sources

• More Data Sources
• Home Care Systems
• ICU Monitoring Systems
• IV Fluid Infusion Control Systems
• Laboratory Systems
• Nurse Triage
• Order Entry Systems
• Pharmacy Systems (Inpatient/Outpatient)
• Pulmonary Function Systems

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Data Sources

• More Data Sources
• Radiology systems
• Risk Management systems
• Registration Systems
• Scheduling and Clinic Charge Systems
• Transcription Systems
• Unit Dose Dispensing machines
• Ventilator Management systems

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Data Sources

• So if there are so many data sources available
  and so many people are interested in using EMRs,
  why are they not more prevalent?

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The Challenges of EMR Implementation
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Problems with Electronic Data

• For the last 30 years the medical informatics
  community has struggled with how to architect the
  vessel that will hold patient data
• Problem is that they have focused on the wrong
  problem!
• We dont just want to create a system that
  permits entry of data electronically, we want to
  create a system that can acquire this data
  automatically from other electronic data
  repositories and make it available at the time of
  service.

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Problems with the Data Sources

• Too many repositories or islands of systems
• Difficult to bridge and combine in useful ways
• Contain different data at different levels of
  granularity
• Each uses a different code to identify the same
  information.
• Many institutions do not capture all of the data
  of interest to clinicians.
• Labs are sent to external reference laboratories
• Patients fill their scripts at community
  pharmacies
• As a result many implementations do not lead to
  satisfactory achievement of the intended quality
  assurance goals

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Problems with Data Sources

• Another problem is that there are many many care
  providing sites in the United States
• Hospitals 5000
• Nursing Homes 19000
• Pharmacies 59722
• Physician offices 200000
• Laboratories 63000
• Emergency Rooms 4856
• Hospice Care 2800
• Home Care agencies 4258
• All of these sites generate data that are not
  necessarily compatible.

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Problems with Electronic Data

• Thus, the problem is not one of creating database
  fields de novo, it is one of merging existing
  fields from many different sources in meaningful
  ways
• When commercial and other EMR vendors create
  proprietary, closed, systems, with custom
  database architectures, they often worsen the
  problem and make it harder to populate the
  database with useful information, inexpensively

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(1) The Role of Standards

• Fortunately, most of the informatics community
  has realized that the solution to the problem of
  merging data lies in the implementation of
  Standards for Data Communication.
• These standards permit data to be easily
  translated from one database system to another

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(1) Standards

• There are many many standards, each for a
  different purpose
• Lab Data Communication
• General Clinical Messaging
• Radiology Image Transmittals
• Diagnostic Coding
• Procedure Coding
• Need to distinguish between coding standards and
  messaging standards.

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(1) Standards

• HL7 (Health Level 7)
• Most widely used standard
• General clinical messaging standard
• Communicates structured data
• Fields for
• Diagnostic Results
• Notes
• Referrals
• Scheduling Information
• Nursing Notes
• Problems
• Clinical Trials data

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(1) Standards

• Health Level 7
• 2000 hospitals, the CDC and most referral labs.
• Also used in Canada, Australia, New Zealand,
  Japan and extensively in Europe
• Bridges many systems, including laboratory,
  dictation, pharmacy, electronic patient records,
  performance databases, data repositories (cancer
  registries) etc.
• Web Site
• http//www.mcis.duke.edu/standards/HL7/h17.htm

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(1) Standards

• LOINC
• Logical Observations and Indicators Names and
  Codes
• A coding standard that is used for LAB data
• Used for representing laboratory observations and
  common clinical measurements
• At least 5 large commercial labs (Corning,
  MetPath, LabCorp, ARUP Labs and Life Chem) have
  adopted LOINC

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(1) Standards

• DICOM
• Another messaging standard
• Standard of choice for transmitting diagnostic
  images
• Closely supported by all of the imaging vendors
  and is working with the HL7 group
• Web site
• http//www.xray.hmc.psu.edu/dicom/dicom_home.html

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(1) Some other coding standards

• ICD9/10 Used to code diagnoses
• CPT Used to code procedure data
• ISO - Used to code units of measure
• UMDNS Device classification standard
• NDC Drug entities classification
• SNOMED organism names, topologies, symptoms and
  pathology
• HOI Outcomes variables
• UMLS Metathesaurus for clinical nomenclature
• Arden Syntax Clinical knowledge

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(2) Patient Identification

• How do we ensure that the information belongs to
  the correct person?
• Patients move and change addresses/tels
• Patients change names or use aliases
• Patients sometimes have multiple SSNs
• There are differences in patient, provider and
  place of service identifiers among data sources

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(2) Patient Identification

• Solutions to this problem do exist but at a local
  institutional level at the moment
• Our institution uses a combination of mothers
  maiden name, SSN and DOB to uniquely identify the
  patient
• The Kassebaum-Kennedy Bill (PL 104-191) will make
  this into a national effort and standardize
  patient and provider identifiers

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(3) Physician Data Capture

• The ultimate EMR promises to capture whatever
  data is needed to perform any EMR task outcomes
  analysis, utilization review, profiling and cost
  estimation.
• This prospect excites many CEOs and CIOs
• However, much of the data needed for such
  functionalities comes from physicians (disease
  severity and clinical findings) and most of this
  data is recorded as un-coded free text.

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(3) Physician Data Capture

• In order for physician generated data to be
  useful it needs to be in coded form so that
  algorithmic assertions can be made
• The problem of coding free text data is of
  paramount importance and information systems
  designers have struggled with this as long as the
  field of medical informatics has been in existence

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(3) Physician Data Capture

• One approach we could take would be to translate
  existing free text dictations into coded,
  computer readable information, but
• Human coding is error prone and expensive and is
  at too high a level of granularity to be useful
• Decades of research into computer based coding
  has still not yielded satisfactory results
• Or the physician could code the data themselves
  by entering structured notes but
• This is costly in terms of time as it requires
  the user to map the terms into computer
  understandable words at a level of granularity
  which is useful

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(3) Physician Data Capture

• Commercial EMR vendors bypass the problem and
  provide every mode of data entry possible
• Direct keyboard entry
• Dictation with human transcription
• Voice Recognition
• Structured Data Entry
• Paper based data collection
• Web/PDA/Mobile devices
• Problem is that we dont know which one is the
  most efficient so users have to think with their
  feet

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(3) Physician Data Capture

• We did a study at Indiana University comparing
  voice recognition with typing and
  dictation/transcription and found that (at least
  for 1 user)
• Voice recognition almost doubled the note size as
  compared with typing
• It took longer to use voice recognition by 1.3
  min as compared with typed notes
• Voice recognition was 30 fold less accurate than
  dictation/transcription
• During proofreading, the user missed 30 of
  errors
• 1.2 of errors changed the intended meaning
• Dictated note turnaround time was from 2-5 days!

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(3) Physician Data Capture

• Managers and quality analysts want data that is
  often never captured
• Formal functional status
• Detailed Guideline criteria
• And we dont even know how much of this kind of
  information is needed?
• For some disorders (angiography and knee surgery)
  data sets have been developed but we do not know
  the operating characteristics or predictive value
  of the data elements?
• How do we define and collect the soft data
  elements?

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(3) Physician Data Capture

• We do have some instruments for some disorders
  (CAGE, Hamilton Scale, SF12/36 etc.)
• But we lack them for many other clinical entities
  and for much of specialty clinical care
• And checklist based symptom questionnaires as
  opposed to validated instruments elicit many more
  symptoms than open ended questions, so which of
  these are really important?

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(3) Physician Data Capture

• Coding of all medical information is unnecessary
• So where do we draw the line?
• (how much should be coded and how much can be
  stored as free text) in order to maximize the
  utility of the information.
• The other issue is with longevity of clinical
  notes.
• How often do you use a note from 2 years ago?
• How long do we need to keep the EMR data?

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(4) Cost

• Cost is perhaps the biggest barrier to
  implementation
• Unfortunately there are few studies that have
  looked at the long term ROI with EMRs
• Most existing studies have been done by the
  system vendors and so the data should be examined
  with a cautious note
• However, the data that is available suggests that
  the ROI is excellent!

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(4) EMR Cost Analysis Studies

• Several studies are worth mentioning
• (1) Renner et. Al. looked at implementing an EMR
  in 1996 in 40 primary care practices
• Its net present value (1996 dollars) was about
  280,000 based on a 5-year model
• They found that reducing the cost of medications
  and preventing ADEs was of the greatest benefit
  in primary care

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(4) EMR Cost Analysis Studies

• (2) Wang, Bates et. Al. looked at the cost of
  implementing a full EMR in primary care as
  compared with paper based chart systems
• Primary outcome was the cost benefit per provider
  over a 5-year period
• Used average statistics from their institution
  (Partners Healthcare, Boston), expert opinion and
  national data to estimate costs
• System Costs (13,100 initial, 3100 each year
  HW)
• Induced Costs (11,200 in year 1)

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(4) EMR Cost Analysis Studies

• (2) Wang, Bates et al.
• Benefits resulted from costs averted (/year)
• Transcription savings (2700)
• Reduction in need for chart pulls (5/chart
  pulled)
• Drug cost savings and prevention of ADEs (2200)
• Laboratory and Radiology cost savings (10,700)
• Charge capture improvement (7700)
• Decrease in Billing Errors (7600)
• All benefits finally being realized in year 4

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(4) EMR Cost Analysis Studies

• (2) Wang, Bates et. Al.
• Resulted in present value of net benefit (2002
  dollars) to be 86,400/provider in year 5
• Breaking down by EMR feature they got
• Light EMR (net loss of 18,200/doc in year 5)
• Online patient charts only
• Medium EMR (net benefit of 44,600/doc in year 5)
• Adds an Electronic Prescribing Module
• Full EMR (net benefit of 86,400/doc in year 5)
• Adds Lab, Radiology and Charge Capture systems

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(4) EMR Cost Analysis Studies

• (2) Wang, Bates et. Al.
• Conclusions An Ambulatory EMR
• Resulted in net benefits across a range of
  assumptions, which increase as more features are
  added and as the time horizon lengthens
• Most benefit was derived from reductions in drug
  expenditures, improved test utilization, improved
  charge capture and reduced billing errors
• The greater the portion of capitated patients the
  greater the return, although benefits also accrue
  for fee-for-service patients (but mostly to
  payers and not health care institutions)
• Limitation Did not consider malpractice
  reduction, increased provider productivity or
  decreased staffing requirements.
• Intangible benefits Improved Quality and
  Decreased Errors

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(5) Other Barriers

• (1) Physician reluctance and fear that their
  productivity may decline (which it does)
• (2) Unreliability of EMR Vendors in a volatile IT
  economy. Lack of adequate IT support from the
  vendors
• (3) Concerns over data security

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Summary Barriers to EMR Use

• Too many data sources, no simple way to
  coordinate and connect them except to use
  standards which are still evolving
• Unique patient identification still a problem
  esp in large tertiary care centers
• Physician data capture inefficient and expensive

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Summary Barriers to EMR Use

• Startup costs can be prohibitive but long term
  benefits are clearly evident form pilot studies
• Physician reluctance a major barrier to use
• Concerns over security still an issue, eg HIPAA
• System vendors are transient and fail to provide
  adequate support

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EMRs for Clinical Research
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EMRs for Research

• So what EMR functions do we need in order to
  effectively do clinical research?
• Answer Depends on what you want to do
• However, to be able to ask questions of your
  practice, you need
• Registration data (Registration system)
• Diagnoses (Billing data)
• Medications (Pharmacy data)
• Labs and other Test Results (Lab/Radiology data)
• AND
• A system to query these databases intelligently

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EMRs for Research

• You dont necessarily need a decision support or
  order entry system but if you want to intervene,
  you may want to include these systems as well

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EMRs for Research

• Note that the registration, billing, pharmacy and
  lab/radiology data usually (but not always)
  exists, outside of the context of any specific
  EMR system
• These are just data repositories which need to be
  tapped into and queried
• So you need a system to access and query these
  databases, independent of any electronic medical
  record system.

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EMRs for Research

• Alternatively, you could build a master
  repository which acquires and stores this
  information and permits intelligent queries to be
  performed
• This is exactly what we did in Kenya in the
  Mosoriot Medical Record System, although data is
  still hand-entered. Eventually it will be
  downloaded using HL7 messages.

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Mosoriot Medical Record System

• An example of an EMR that is inexpensive and
  functional and supports both clinical care and
  research in rural Kenya
• Built in 2-3 weeks by 1 programmer using
  Microsoft Access
• Consists of
• Data dictionary tables which define test names,
  medications, diagnoses etc.
• Forms which are used for data entry
• Has tables for registration data, billing data,
  medication lists, lab and test results
• Currently running on Tablet PC devices in Kenya

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Research Workflow Model
66
EMR Features Conducive to Research

• Reliance on Standards (HL7, LOINC, ICD9, CPT)
• Easy access to data repository, i.e. database
  structure is well documented
• Built-in Practice Profile Management systems
• Built-in decision support and order entry
  functionality
• Able to export data in a standard format (CSV,
  MDB etc.)

67
HIPAA Security
68
Introduction

• HIPAA Heath Information Portability and
  Accountability Act
• Final Security Rule Published in the Federal
  Register on February 20, 2003 (effective 60 days)
• http//www.cms.hhs.gov/hipaa/hipaa2/regulations/se
  curity/default.asp
• Designation 45 CFR 160, 162, 164
• Compliance Dates April 20, 2005
• Covered Entities 24 months after effective
  date
• Small Health Plans 36 months after effective
  date

69
HIPAA Security

• Some excellent links
• http//privacy.med.miami.edu/glossary/gt_security_
  rule.htm
• http//www.hipaadvisory.com/tech/wireless.htm
• http//www.hipaadvisory.com/regs/securityoverview.
  htm

70
HIPAA Security

• Security should not be confused with Privacy or
  Confidentiality
• Privacy The rights of an individual to control
  his/her personal information without risk of
  divulging or misuse by others against his or her
  wishes
• Confidentiality only becomes an issue when the
  individuals personal information has been
  received by another entity. Confidentiality is
  then a means of protecting this information
• Security refers to the spectrum of physical,
  technical and administrative safeguards used for
  this protection

71
HIPAA Security

• Addresses 3 tiers of protection
• Administrative Safeguards
• Physical Safeguards
• Technical Safeguards

72
Administrative Safeguards

• Institutional level
• Develop security management process where
  potential threats to PHI are determined
• Provide training to all employees about HIPAA
• Provides appropriate level of authorization based
  on a protocol for granting access
• Violations should be clearly documented and
  investigated
• A disaster recovery plan should be in place

73
Physical Safeguards

• Applies to 3 elements of the PHI data storage
  infrastruture
• Facility where PHI data is stored
• Workstations on which it is stored
• Media on which it is stored

74
Physical Safeguards

• Require that the facility have access control
• Contingency plans need to be in place in case an
  intruder gains access
• Workstation security measures be in place
• Automatic logoff
• Screen is placed away from potential viewers
• PDAs should be password protected
• Devices and media should be appropriately
  disposed of in case they are no longer needed and
  data should be erased properly

75
Technical Safeguards

• Applies to how information is stored, verified,
  accessed and transmitted/received
• Access and audit controls
• Emergency access to information when needed
• Automatic logoff is enforced
• Data is encrypted and decrypted during
  transmission
• Verify integrity of the storage and transmission
  (digital signatures)

76
Am I HIPAA Compliant?

• Questions to ask yourself and your institution

77
Questions to ask your institution

• 1. Was a security audit done and if so what are
  the results?
• 2. Did I get the appropriate HIPAA training and
  do I have a certificate to prove this?
• 3. Are there procedures in place to grant access
  to PHI to authorized users?
• 4. What are the procedures in place in case of
  disaster, data loss or data theft? Are Backups
  made frequently?

78
Facility, Workstation, Media

• 1. What are the procedures in place to safeguard
  the facility from intruders? Are there
  contingency plans for dealing with intruders,
  data theft or other event?
• 2. How do protect the safety of workstations? Are
  they password protected?
• 3. Can bystanders view the screens on which PHI
  may potentially be displayed?

79
Facility, Workstation, Media

• 4. Is an automatic logoff mechanism enforced?
  What time limits are provided before this occurs?
• 5. What types of data are stored on PDA devices
  and if PHI is stored is it password protected or
  encrypted?
• 6. What procedures are used when disposing of,
  reusing or archiving data on hard disks, CDs,
  floppys and Zip disks? Are PHI data erased
  properly if the disks are to be disposed of or
  reused?

80
Data Level

• 1. Are there audit mechanisms for checking who is
  accessing the PHI data and is this done on a
  regular basis by authorized personnel?
• 2. Are there procedures in place to grant
  emergency access to information if needed?
• 3. Is data integrity checked when the data is
  transmitted or received? (digital signatures,
  digital certificates, checksums etc.)
• 4. Is the data encrypted and decrypted during the
  transmission process?

81
HIPAA Wireless Security
82
Before you Begin

• Do I really need to be wireless of can I get by
  with a wired connection?
• Is space limitation a problem?
• Is mobility absolutely necessary?
• Do I have the permission of my institution to
  install wireless networks?
• Do I have adequate IT support to do this?

83
11 Steps to Wireless Security

• Wireless is inherently unsecure
• Many Many ways of hacking into wireless networks
• Technology base is there to make it secure
• Some simple steps can be taken to maximize the
  security of your wireless network

84
11 Steps to Wireless Security

• 1. Change the default SSID (network name) on the
  router so that your name/location is kept secret
• 2. Disable the SSID broadcast, if your router
  supports it. This will prevent hackers from
  seeing you
• 3. Change the administrators password on your
  router.

85
11 Steps to Wireless Security

• 4. Turn on the highest level of security
  supported by your hardware (i.e. Wireless
  Equivalent Privacy WEP, which is older or WPA
  which is the latest and most secure)
• 5. Make sure you have the latest firmware
  updates. Implement MAC (media access control),
  which specifies exactly which WLAN PC cards can
  access the network and excludes others

86
11 Steps to Wireless Security

• 6. Place the Wireless Access Point (WAP) towards
  the middle of the building, keeping the zone of
  potential access within the building.
• 7. Do your own security audit. Use Network
  Stumbler (www.netstumbler.com) on your Tablet PC,
  laptop of PDA and walk around the perimeter of
  your building to see where and what a would-be
  hacker may see

87
11 Steps to Wireless Security

• 8. If you have a limited number of wireless
  clients (Tablet PCs), provide them with static
  IP addresses, and disable DHCP on your router.
  This ensures that only authorized machines can
  see your network.

88
11 Steps to Wireless Securit

• 9. If we are in an enterprise setting, use VPNs
  (Virtual Private Networks). You can isolate your
  WLAN from the wired network using products such
  as the Netgear FVM318 or the SonicWall SOHO TZW.
  Then you can use the VPN to tunnel directly into
  the wired network securely

89
11 Steps to Wireless Security

• 10. Avoid using public hotspots, areas that are
  insecure and open for general use.
• 11. Turn off file and print sharing on your
  Tablet PCs. Most devices do not prevent
  client-to-client traffic, so people sitting
  across the street from you can be looking at your
  shared directory remotely.

90
Guide to Selecting and Deploying an EMR
91
Selecting an EMR

• Award winning EMRs
• CPRI Davies Award Winners (1995-2000)
• Emphasis on successful implementation, not on
  technology that is behind the design
• Functional Requirements
• Integrate data from multiple sources
• Provide decision support
• Used by caregivers as primary source of
  information
• Must enhance care, not just replace paper
• So who are there award winners and what are their
  strategies for success?

92
Davies Award Winners

• Intermountain Healthcare System, Salt Lake City
• Columbia Presbyterian Medical Center
• Department of Veteran Affairs CPRS (now
  open-source)
• Brigham and Womens Hospital
• Kaiser Permanente, Cleveland OH
• Regenstrief Medical Record System
• North Mississippi Health Services
• Kaiser Permanente, Portland OR
• Northwest Memorial Hospital, Chicago
• Kaiser Permanente, Rocky Mtn. Region
• Harvard Vanguard System

93
Davies Award Winners

• Common Strategies and Attitudes towards
  implementing EMRs

94
Common Strategies

• Vision of healthcare as an information business
• Sustained leadership (5 years )
• Run by project leaders and not CIOs
• Most projects had physician champions
• EMRs subjected not to a cost benefit ROI analysis
  but to an unremitting pressure to show value

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Common Strategies

• Customer Service, Customer Service!
• Frequent, sustained, end-user orientations and
  feedback with demonstrated responsiveness to
  feedback!
• Weekly Regenstrief Pizza Meetings
• Kaiser physician focus groups
• Northwestern weekly feedback with supplements
• System developers were also the salespeople,
  troubleshooters, coaches and colleagues!

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Common Strategies

• Plans in place for system evaluation and change
  management
• All winners had to re-engineer some workflow
  process dont automate a manual process that
  occurs commonly but does not work!
• Incremental deployment dont rush things
• Each increment overcame a specific barrier to
  care
• Systems were viewed as tools to enable care
  process improvement and were not an end to
  themselves

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Common Strategies

• All resulted in a decreased reliance on
  paper-based sources of information
• Decision Support, Decision Support, Decision
  Support -gt provides the largest value added
  compared to a paper system
• Focus on standards based data architecture rather
  than specific applications to do this or that
• FAST RESPONSE TIME!
• Flexible enough to adapt to organizational change

98
So what can I do to implement an EMR in my
practice?
99
Can I implement an EMR?

• Depends on your size and your budget
• Solo practice -gt yes, definitely
• Multispecialty group (2-100) -gt probably (cost is
  around 4-20K per provider)
• Multispecialty, multisite groups maybe
• Tertiary care centers with scattered secondary
  care sites -gt probably need to be brave and
  wealthy!

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What EMR should I choose?

• Do not start in product selection mode
• Begin by identifying the practice processes that
  you wish to improve first
• Then search for the functions you need
• Problem List Medications
• Clinical Encounters Lab/Xray/Pathology
• Telephone Calls Referrals
• Preventive Care Managed care

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Which EMR should I choose?

• Anticipate primary and secondary users
• Primary
• Clinical decision making,
• Documentation
• Support for Billing
• Secondary
• Provider profiling and service utilization
• Quality report cards and outcomes analysis
• Regulatory reporting and justification for studies

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What if I have a limited budget?

• Again, think of using selected modules to enhance
  parts of your practice
• Clinical Note Systems
• Prescription Writer
• Use one or more of the OpenSource EMRs
• Need some level of IT expertise to deploy
• No real support available from the developers

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Examples of OpenSource EMRs

• a. OpenEMR (http//www.synitech.com/openemr/
  lthttp//www.idltechnology.com/products/openemr/ind
  ex.phpgt)
• b. Care2002 (lthttp//sourceforge.net/projects/care
  2002/gt)
• c. Open Infrastructure for Outcomes UCLA
  (lthttp//sourceforge.net/projects/open-outcomes/gt)
  
• d. PatientRunner (lthttp//sourceforge.net/projects
  /patientrunner/gt) mental health record system
• e. OpenSDE (lthttp//sourceforge.net/projects/opens
  de/gt) structured note entry system
• f. MedSurvey (lthttp//sourceforge.net/projects/med
  survey/gt) clinical information system for
  Windows PCs
• g. OpenEMed (lthttp//sourceforge.net/projects/open
  med/gt) Java based EMR
• h. Hardhats (VAs VISTA software) yes this IS
  open source now and available to EVERYONE
  (lthttp//www.hardhats.org/gt), (lthttp//sourceforge
  .net/projects/hardhats/gt)

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EMRs for Primary Care Practice

• Recent survey done by the journal Family Practice
  Management (2001)
• Surveyed 28 vendors
• Price structure highly variable
• Found that the market is highly volatile and some
  vendors went out of business or merged with
  others during the time of the survey

105
EMRs for Primary Care Practice

• Five star systems
• ChartWare
• HealthProbe Patient Information Manager
• EpicCare

106
EMRs for Primary Care Practice

• Four Star Systems
• Logician
• NextGen
• Pearl
• Physician Practice Solutions
• PowerMed EMR
• Practice Partner Patient Records
• QD Clinical

107
EMRs for Primary Care Practice

• Four Star Systems
• SOAPWare
• Welford Chart Notes
• Clinical Works Module (ASP)
• NextGen (ASP)
• Physician Practice Solution (ASP)
• topsChart (ASP)

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EMRs for Primary Care Practice

• 4 physician practices
• ENTITY, Logician, NextGen, ClinicalWorks
• 10 physician practices
• EpicCare, PEARL, Physician Practice Solution
• All others can serve practices of any size

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EMRs for Primary Care Practice

• Most allow ICD9 and CPT codes
• Many allow access from the web
• Most allow multiple modes of data entry
  (keyboard, mouse, touch-screen, light-pen, voice
  recognition etc.)
• Most permit integration of hospital data with a
  primary care database

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Integration with Handhelds

• Some EMRs allow data access from PDAs and other
  handheld or laptop devices
• ChartWare - O-HEAP
• DOCUMENTOR - Partner
• ENTITY - PowerMed
• EpicCare - SOAPWare
• MedicWare - Welford ChartNotes
• NextGen - ClinicalWorks
• topsCHART

111
Other EMR Surveys/Resources

• HealthCare Informatics 2004 Resource Guide
• Comprehensive listing of EMRs, features, costs,
  contact information etc.
• 50 per copy
• Order from
• http//www.healthcare-informatics.com

112
Some Lessons Learned
113
Lessons learned the hard way

• Well-designed renowned vendor products meet about
  80 of your needs -gt where will the other 20
  come from?
• Poorly designed systems will be quickly abandoned
  by time-pressured end-users
• Caveat Emptor Total Solution, Turnkey
  solution, esp if a proprietary black box

114
Lessons learned the hard way

• Clinical/Administrative information is inherently
  structured. Capturing it in unstructured ways
  (images) is a costly mistake
• Data acquisition costs may be more expensive than
  operational expense (I.e. keyboard entry time
  more costly than provider input)

115
Lessons learned the hard way

• Users will accept a tradeoff if there is a clear
  payback in functionality
• Attitudes towards computer use are not age
  dependent
• Be the 10th customer to a vendor, never the
  first!
• Beware of vendors who say we can do that what
  is it?

116
Lessons learned the hard way

• The most important information a vendor will give
  you is the address of 2-3 sites where their
  system is currently in use

117
Acknowledgements

• David Bates, MD
• Daniel Masys, MD

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DISCUSSION AND QUESTIONS