The paperless chase
Your medical documents—coming soon to a computer screen near you
By JONATHAN RABINOVITZ
The patient has come to the veterans clinic in San Jose complaining of back pain. Stephen Ezeji-Okoye, MD, has never met this 47-year-old man, but with a few taps on a keyboard he gets the notes and lab results from the patient’s recent visits to an emergency room 30 miles away: one for dizziness and severe migraine headaches, another for the same complaint of back pain.
Ezeji-Okoye, deputy chief of staff at the Veterans Affairs Palo Alto Health Care System, calls up on the computer monitor an X-ray taken weeks before of the patient’s spine, as well as a list of his prescribed medications, a recent liver test and a letter to the man from another physician — it had gone out only hours earlier — suggesting a follow-up liver test.
It has been almost a decade since Ezeji-Okoye and other Veterans Health Administration clinicians nationwide gave up paper charts and adopted electronic medical records. Before that, patients who were going to a medical consultation sometimes had to carry their records in padlocked canvas bags to protect them if they were left accidentally at a bus stop or in a waiting room, Ezeji-Okoye recalls.
And even that didn’t always work.
“Patients would show up at an appointment, and there was no guarantee that they would have the records we needed — 70 percent at best, 30 percent at worst,” he says. “It wasn’t practical.”
Today, VHA physicians can go on at length about the many benefits to the electronic medical record system, but Ezeji-Okoye offers a quick response as to why he prefers a digital patient file. “It’s here!” he says. “I used to spend almost as much time looking for charts as examining patients.”
The United States health-care system still relies heavily on paper records, but the Bush administration is pushing to create a national network of digital patient information. Kaiser Permanente and the national association of Blue Cross and Blue Shield plans are rolling out plans to create electronic health records. Both Lucile Packard Children’s Hospital at Stanford and Stanford Hospital & Clinics are investing tens of millions of dollars to put in place the latest generation of computerized charts.
The VHA is the poster child in this effort. The way it works offers a glimmer of the benefits to medicine, as well as the challenges, that the future could bring.
“The goal is to achieve a national health-care record with universal standards and privacy protection, but we’re in the early stages,” cautions Henry Lowe, MD, director of the Center for Clinical Informatics at Stanford, noting that only one of every five physicians in the United States uses digital records, at best. In health care the average investment per worker in information technology has been less than half the comparable figure for workers in private industry.
Despite all the other advances in medical technology, doctors are being buried in a rapidly growing mountain of information and have trouble finding exactly what they want when they need it. A study in the Feb. 7, 2005, issue of Journal of the American Medical Association found vital clinical information missing in nearly one of seven patient visits. That is one of a host of problems — ranging from giving a fatal mix of medicines to failing to order routine diagnostic tests — that electronic medical records are supposed to fix. Boosters say it could save thousands of lives and billions of dollars, or roughly 15 percent of annual health-care spending as calculated in a recent study from the RAND Corp.
Yet there are serious hurdles. Even proponents of the new systems acknowledge that protecting the privacy of patients will be difficult, and that a national consensus must be reached on how to balance security and improved records. Some experts say that rather than cutting costs electronic health records could do the opposite — a poorly designed system can make more work for doctors while even a good one could lead to more treatments that, while justified, are expensive.
And the technical challenges of building a nationwide system, in which doctors, hospitals and labs all use the same software standards, are formidable. “There are many potential benefits,” says Lowe, “but there are some serious potential pitfalls in implementation.”
There is no question, however, that the VHA, which will treat more than 5.3 million veterans this year at 154 hospitals and 900-plus clinics, has reaped tremendous advantages from its system. Once widely reputed to provide shabby treatment, the VHA now is hailed for excellence, with its patients, according to a 2003 article in the New England Journal of Medicine, receiving significantly better care on 11 measures of quality than Medicare-covered non-veterans.
When VHA doctors open the entry screen for the electronic health record system, they see several windows listing upcoming patient appointments and the reason for their visits, notifications of developments in treatment of other patients and a more detailed list of the primary problems for the patient whose name is highlighted. With a click of the mouse, a patient’s record appears on the monitor, resembling a paper chart file, with tabs at the bottom labeled “Consults,” “Meds” and “Notes” along with seven other subjects.
“I couldn’t imagine life without it,” says Sherry Wren, MD, chief of general surgery at the VA-Palo Alto and an associate professor of surgery at Stanford. “We don’t use paper anymore — we’re paperless.”
All the information Wren needs is on-screen. She can see, for instance, notes from her patient’s cardiologist, X-rays as well as lab reports, discharge summaries and prescriptions. It also eliminates an irksome problem: illegible handwriting. “I can’t tell you the number of times I ordered a consultation and then couldn’t read it,” she says.
The system not only makes information more accessible when Wren is at work, but also when at home. Earlier this year, she was awakened at 1:30 a.m. with a call from a resident about a critically ill patient with a new complaint of gastrointestinal bleeding. As her husband snoozed beside her, she pulled a laptop onto the bed and logged on. She could see the CT scan of the patient’s abdomen taken an hour or so before, as well as review the latest notes and lab results. She told the resident that surgery was unneeded and recommended a new medication.
“It’s like being in the examining room,” she says.
Indeed, the accessibility of VHA records became readily apparent in the wake of Hurricane Katrina. At a March 27 speech at the National Press Club, U.S. Secretary of Veterans Affairs Jim Nicholson discussed the forced relocation from New Orleans to Houston of hundreds of VA hospital patients. “We were able in every case, after we got them resettled into another hospital, to dial up their medical records.”
Easy access to patient files is the first advantage of an electronic record system, says Mary Goldstein, MD, associate director of clinical services at the VA-Palo Alto geriatric center. The next, she adds, is the system’s ability to support doctors’ decisions, whether it be remembering facts that a human could not be expected to memorize or doing time-consuming calculations.
“Computers are better at some things than people are,” says Goldstein, also professor of medicine at Stanford. “We want to identify those tasks in medicine and use computers to help.”
A case in point: As many as 98,000 people die in U.S. hospitals annually — more than from AIDS or car accidents — because of medical errors, according to a 1999 Institute of Medicine study. That’s not counting tens of thousands more injuries and non-hospital fatalities caused by such mistakes. That study and other research tagged improved information systems as key to remedying this problem.
Under the VHA system, if a physician orders a drug that has a potentially harmful interaction with another drug the patient uses, the system issues an alert. The physician then must decide whether to heed the warning or override it. Similarly, the electronic medical record keeps track of patients’ allergies and helps to prevent doctors from prescribing drugs that may have adverse reactions.
But the VHA system does more than just improve drug ordering. It takes into account a patient’s age, gender, the diseases he or she suffers from and other factors and then recommends diagnostic tests. Within the hospital, it can monitor whether certain procedures are being done when needed, such as screening for blood sugar on intake into the ICU.
Back to the exam room
On that July afternoon, Ezeji-Okoye also sees a longtime patient, a 77-year-old former helicopter pilot. The man is there because of a cough, but the doctor has other concerns. The electronic record tells him that since the patient’s visit last fall, he continues to suffer from diabetes and an enlarged prostate; his leukemia chemotherapy continues under the hematology department; he had a stint in the hospital in March for a bacterial infection in his blood, and a new problem with urinary retention emerged during that stay.
The computer notifies Ezeji-Okoye that the man is due for a flu shot, a colon cancer screening and hemoglobin A1c test, which measures glucose levels for the previous few months. After a few seconds of typing, Ezeji-Okoye tells the patient that he has arranged the tests with the lab.
He then queries the veteran on his ailments. He learns that the man’s diabetes is not entirely under control; he checks the prescriptions on the monitor and suggests that he increase tests of his sugar level from once a day to twice. He places an electronic order doubling the number of test strips. At the same time, Ezeji-Okoye notices that his prescriptions for glargine (a form of long-acting insulin) and for short-term insulin have expired, so he renews them with a few mouse clicks.
He asks the man about his urination and finds out he is going 12 times a day.
The March hospital report noted that the patient’s bladder wasn’t contracting as well as normal. An ultrasound scan of his bladder confirms that it’s still not voiding its contents completely. Ezeji-Okoye has already seen that the patient is on doxazosin, a drug to lessen swelling of the bladder, so he clicks on a drug library to see if he can increase the dose. Unfortunately, it shows that the patient is at the maximum. Ezeji-Okoye tells the veteran that he wants to see if the problem improves if the diabetes is more under control. He sends an electronic query to the urologists to see if they have any further suggestions.
If Ezeji-Okoye had not been aware of the urination problem, he would have put the man on Afrin and Actifed to stop the post-nasal drip causing his cough. Those drugs, however, would make it even more difficult to urinate. He opts instead to prescribe a steroid inhaler, which avoids such complications. He electronically orders the drug, and then reviews all the orders he has placed, neatly listed on his screen.
“We’ll see you again in a few weeks,” he says, while typing a note to ensure that the man receives a reminder.
The VHA has developed its computer code over several decades, and the core of the current system, the Veterans Integrated Services and Technology Architecture or VistA, has been in place since the early 1990s. A few years later the VHA rolled out a user-friendly interface, the Computerized Patient Record System.
While easy to use, the VHA system is not simple: VistA comprises more than 100 independent applications, including the separate program for automated ordering of prescriptions, the one for classifying and ordering patients’ medical problems and others that advise whether particular diagnostic tests are required. What makes the system even more complicated is that every VHA regional division has its own local dialect, though there’s also one central office — the VHA Office of Information — issuing updates and new iterations. The result is a complex mix of codes and programs that VHA computer scientists are looking to overhaul.
“The current VistA system has served us well through decades of transformation in health care,” Robert Kolodner, the VHA’s chief health information and informatics officer, testified in a 2005 congressional hearing. “But VHA has outgrown its facility-centric architecture, and the system is simply becoming too expensive to maintain.” A critical problem is that key medical terms are referred to by different codes, not only by providers outside of the VHA but also by those within it. That makes it difficult for data to travel across the system without time-consuming, expensive adjustments.
“What we have is Babel,” says Mike Lincoln, MD, associate professor of medicine and medical informatics at the University of Utah and chief terminologist in the VHA Information Office. Within the VHA, he says, there are 30 ways to say “yes” and “no,” hundreds of terms are used to indicate a 10-mg tablet of the beta blocker propranolol, and the code for Manitoba at one site refers to the Panama Canal Zone at another.
Such misunderstandings are more than an inconvenience. They mean that when patients move from one region to another, doctors can read the notes from their electronic record, but the data is not necessarily computable. A possible result, for instance, is that a VHA electronic record system at one site might not pick up a patient’s allergy to a certain drug that was entered at another site, because the sites use different codes. This lack of consistency also makes it harder for VHA administrators to compile uniform outcome statistics to determine the efficacy of certain treatments.
And the fact that about 40 percent of veterans receive some care from providers outside the VHA network adds another wrinkle to building a full electronic patient record. Today incorporating the outside information is often just not feasible. “We would love nothing more than to see the entire country covered,” said VA secretary Nicholson in a recent story in the Los Angeles Times. “And most especially the Department of Defense — they come to us with paper files, which is sort of an anachronism.”
Such a national standard is beginning to emerge. Not only is the VHA adopting measures to make its data more universal, but the federal government at large is also taking big steps to lay the foundation for a national system. President George W. Bush has said that a national health information infrastructure needs to be in place by 2014, and his administration and Congress are poised to enact uniform standards and licenses for health data, making such information more portable.
Yet not everyone is cheering. Privacy advocates and consumer groups contend that the federal government and federal law lack adequate safeguards to protect an individual’s health information. They cite two instances at the VA this year alone when computers with personal records were lost or stolen. No information appears to have been abused, and the VA leadership has vowed to put in place more stringent security measures. In addition to questions about confidentiality, a September report from the Government Accountability Office notes that despite the president’s goal of having a national digital record in eight years, his administration lacks the detailed strategy needed to achieve it.
Still, even with these hurdles, the clamor for a national electronic health record is growing louder and, with the success of the VHA system and other private ones, it’s becoming less of a far-off dream. With each year, more people become doctors who used laptops in medical school and believe information should be at their fingertips. Many of them have done their residencies at the VHA. Indeed, roughly half of U.S. physicians do some training at a VHA hospital or clinic.
“Ten years ago, all the literature on the electronic medical record was about how you can’t get physicians to use the computer,” says Lincoln. That is no longer the case. “Given the great percentage of medical trainees who rotate through the VHA, virtually all other institutions are now hiring a cadre who have been trained to expect a high level of functionality,” he says. “They are not going to write their notes with a ballpoint pen.”
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