Originally Published MX November/December 2005
INFORMATION TECHNOLOGIES
Plugging into the NetworkAdoption of universal EHR systems is great news for device manufacturers in tune with their customers.
Brad Burg
What's a more reachable goal—the moon or universal electronic health records? Apparently, this country is going to find out. America famously hit that first target within the 10-year time frame set by President Kennedy, and in 2004, President Bush announced the same timetable for creating a nationwide health network. Today, there are signs everywhere that the new mission is under way, and medical device manufacturers are wise to make sure their products are onboard.
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| Dolan |
Consider the high-tech heart care that now exists in the Heartland. In Oklahoma and Indiana, healthcare facilities such as Indiana Heart Hospital (Indianapolis) and Saint Francis Heart Hospital (Tulsa) feature fully digital systems—paperless, wireless, and filmless. "All our records—the lab work, the pharmacy records, the radiology—they're not only stored, but fully accessible," says Robert S. Dolan, CEO of Saint Francis. "This isn't just data management, it's image management."
Further west, the California-based healthcare behemoth Kaiser Permanente (Oakland, CA) has begun moving the records of its 8.4 million patients into an electronic health records (EHR) database. "We have an entire data-entry division," says Kaiser spokeswoman Laura Marshall. "And we're giving patients access to their records, too, starting in Hawaii."
The government, also, is seemingly on a faster track, and not only the Bush-created Office of the National Coordinator for Health Information Technology (ONCHIT; Washington, DC), whose well-publicized goal is to meet that 10-year EHR schedule. The defense department's medical service has declared war on paper, too, with its own upgraded EHR system, the Composite Health Care System II (CHCSII). That system is being improved in connection with the U.S. Department of Veterans Affairs, which has led the way with paperless systems at all of its 163 hospitals.
In short, things are moving, and the economic indicators are favorable. In the announcement establishing ONCHIT, the Department of Health and Human Services estimated that a national health information network could save $140 billion annually. Researchers at think tank Rand Health (Santa Monica, CA) figure a much smaller savings of $81 billion. But in any case, it's a significant chunk of change.
Perhaps not surprisingly, Medicare has recently explored an incentives-based approach to savings, paying higher fees at 277 hospitals as a reward for better outcomes in several treatment areas. Early results have indicated improvement at these facilities. And other insurers, including WellPoint Inc. (Indianapolis) and UnitedHealth Group (Minneapolis), are paying bonuses for high-quality care also.
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| Reed |
True, this doesn't necessarily mean that hospitals can loosen their purse strings for high-tech improvements immediately, but it certainly bodes well for a bright future. Yet device manufacturers are wise to pay attention to the big picture. They must consider not only what kind of equipment will be in demand, but also what healthcare providers will be looking for in the overall design and the usability of the systems that will help them do their jobs. Evaluations of the current system are not always positive.
"Sometimes you have to watch over things like a hawk to make sure you'll get the performance that's promised," says Linda Reed, chief information officer of Morristown Memorial Hospital (Morristown, NJ).
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| Ontai |
"I don't find that plug and play is really here at all," says family physician Sidney Ontai, of Plainview, TX.
And C. Peter Waegemann, an international expert in electronic health records, agrees that "interoperability standards still aren't implemented as they should be." This article takes a look from various perspectives at what's good—and not so good—in the great linking between EHRs and medical devices.
Hospitals' Bumpy Road
While it's natural for medtech's biggest IT players to compete over turf, systems can't remain rigidly proprietary or isolationist in a world that is on its way to networking.
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| Auriemma |
Joseph Auriemma, a senior director of integration engineering for Siemens Medical Solutions (Malvern, PA), says that his company works to create specific interfaces with a host of products, "whether it's a Criterion II Urine Analyzer by Roche Diagnostics (Indianapolis) or an ACL 9000 by Beckman Coulter (Fullerton, CA)." Indeed, Auriemma says that Siemens often forms electronic alliances with rivals. "In terms of imaging, for example, we'll work with integrating a picture archiving and communication system (PACS) from Philips or from GE, which are main competitors."
Siemens isn't the only company to facilitate such cross-corporate linkages. "The other majors do this, too," Auriemma says. "After all, we work together in the standards organizations, trying to achieve interoperability." He says Siemens feels a sense of responsibility to the healthcare community to expedite that interoperability. However, interoperability is less a virtue than a pragmatic necessity when a corporate customer—for whatever reasons—chooses one system from vendor A and another from vendor B.
Selecting multiple systems from one vendor can help to make things run much more smoothly. And when a hospital is built from scratch, that choice may be quite feasible. Saint Francis Heart Hospital, in particular, demonstrates that it can be an enviable option. Opened just last year, the 52-bed facility was built as an all-digital operation. It uses a small catalog's worth of systems and equipment manufactured by GE Healthcare (Chalfont St. Giles, UK). These items range from GE's Ormis system for surgery to its systems for ECG, catheterization images, and lab. Connecting all of these is GE's Centricity system. "So the information is not only digital from the start, but it's completely linked together through Centricity," says Dolan of Saint Francis. The Centricity system interfaces with other vendors' systems too, but mostly for administrative functions. For example, Centricity is linked to a platform for revenue management by Stockell Healthcare Systems (Chesterfield, MO). "GE and Stockell had not worked together before," Dolan says. "But they link very smoothly in our hospital's system."
Such a relatively seamless network means that many of the monitoring and measuring functions are not only connected, but also available to doctors and staff. "For example, we can access all radiology images within the system," Dolan says. "So, beyond static images, the entire cath lab study is available at bedside to be shown to the patient."
Most healthcare facilities, however, are still struggling to create a more digital day. One example is Morristown Memorial Hospital, a 637-bed facility serving the northern New Jersey area and a clinical affiliate of the University of Medicine and Dentistry of New Jersey. According to Reed, key parts of the organization's medical IT are excellent. "We have many systems working well—for example, our information system incorporates much of our radiology and lab systems, and operates as a patient chart." In many instances, information flows digitally at every stage. "Within the system, the physician can issue a CT scan order that travels to the radiology facilities. When the test is done, the image is passed into the PACS, the radiologist looks at it online, and then dictates findings into the system," Reed says.
But much of the hospital is not digital yet, including many devices such as IV pumps, cardiology monitors, catheters, pulse oximeters, and ECG machines. "It will cost a fortune to connect electronic IV pumps and ECG devices," Reed says. She also notes that retrofitting hospitals can have many unforeseen complications due to existing infrastructure, and high-tech solutions can be hampered by low-tech hurdles, too. "For example, we don't always have room for workstations," Reed says.
Physicians' Offices
According to a recent study, only 14% of physicians report that they currently utilize electronic health records in their offices.1 Even when they do, it turns out they still may not be able to interface their records with equipment as much as they'd wish.
Family physician Ontai is a sole practitioner who uses an EHR system called Practice Partner, a product of Physician Micro Systems Inc. (Seattle). He says he finds it a great help in recordkeeping, but not a huge aid in connectivity. "I'd particularly like to see interfaces that would allow my EHR system to connect with lab and x-ray results. But such data often come from stand-alone systems that can't be linked to my system." Ontai shares calls with three other physicians, and he has evaluated their EHR systems: Soapware, by Docs Inc. (Springdale, AR); PracticeStudio, by MicroFour Inc. (Amarillo, TX); and Dr. Notes, by Dr. Notes Inc. (Boca Raton, FL). When it comes to linking to equipment, he says he is not particularly pleased by many of the options available to small offices. Moreover, Ontai says he sees little progress in this area.
One issue is design, Ontai says. "There is still not enough use of standards. Plug-and-play Health Level 7 (HL7) 3.0 needs to happen." HL7 is a central protocol for medical data exchange whose 3.0 release promises a significant improvement in compatibility across systems. But then again, that has been on the horizon for years.
Another issue Ontai identifies is money. "At about $5000 an interface, just for installation, much of what's available is a bit out of my range most of the time, especially if my office uses several different radiologists and diagnostic labs. It's a killer, too, when something goes down—and the maintenance and upgrade fees are also very high," he says.
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| Kwartler |
Specialists often have heftier budgets with which to purchase EHR systems—and they may even find systems with built-in interfaces to specialized equipment. This has proved helpful to Jed Kwartler, an otolaryngologist in the two-doctor Ear Specialty Group (Springfield, NJ). "We chose the AllMeds EHR system because it was a package specific to ear, nose, and throat applications. We do a variety of audiological testing, and our EHR system pulls in audiometric data from Grason-Stadler audiometers. Without that, we would be entering data manually, and usually in summary form," he says.
Kwartler says he is generally pleased with his EHR, its efficiency, and its drug-interaction checking. Yet this physician, too, is frustrated because he doesn't have similar links to certain other equipment. "There are other testing devices that we use for both hearing and balance testing—electronystagmography, evoked otoacoustic emissions, auditory-evoked responses—and for these there is no standard interface," Kwartler says. "If there were, it would be extremely useful both to be able to plot trends in results over time and to lessen or eliminate the large amount of paper needed to record results."
AllMeds (Oak Ridge, TN) markets EHR systems in various specialties, including otolaryngology, orthopedics, neurosurgery, and pain management. Keith Oswald, the company's vice president of sales, says that often medical devices simply lack a serial port for interfacing, although he adds that some manufacturers update their newer equipment to include such ports. Oswald also notes that the Noah software standard—developed specifically for hearing devices and supported by the Hearing Instrument Manufacturers' Software Association (HIMSA; Copenhagen, Denmark)—is not always universally implemented or effective.
Progress, within Limits
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| Haas |
Angelina Haas, MD, has looked at operability from both sides. She is a family physician with an office-based practice, and also the chief medical information officer of the 400-bed three-hospital Susquehanna Health System (Williamsport, PA). The healthcare system's digital data, dating from 1995, were partly available to doctors in 2000 (through Siemens's lifetime clinical record repository), and are now greatly accessible through Siemens's clinical access EHR system. "Our system has 10 years' worth of lab data, x-ray data, and pathology results, all online," Haas says. "And I can access all of that right in my own office."
Yet, as in many systems, connections are certainly not complete. The hospital's ECGs have been connected to the central EHR system for years. However, connection of ICU monitors is just beginning, as is testing of integrated fetal and maternal monitoring.
Haas's office solutions are still developing, too. "My office has its own EHR system, Physician Enterprise Manager (now known as Clinical Manager, a Siemens EHR product), but we do interface with the hospital lab and radiology system, as well as with billing, appointments, and demographic info," she says. Still, she notes, there are certain gaps. "I create my own ambulatory patient records, which get entered into the hospital system later. I can access hospital records on my own computer, but in some instances, the data are still in two places," she says.
Nevertheless, Haas is optimistic about what's been achieved and what's coming. "We have almost one-third of our doctors on EHRs now. I know integration of data among hospitals will be a big step forward, and I'm looking forward to what the regional health information organizations (RHIOs) will eventually achieve in that area."
RHIOs, many of which are still in the planning stage, are regional projects being established nationwide to support the adoption of health IT and the exchange of health information. The federal government has awarded millions in grants and contracts to support the start-up of these organizations. More than 100 first-generation RHIOs have been developing across the country, and several of these efforts are statewide.
Standard Issue
Consideration of the varied viewpoints in healthcare can help medical device manufacturers get a handle on the current state of affairs in the industry.
For progress to continue at the rate the healthcare industry would like, interoperability requires an efficient use of standards—a practice that has been developing rapidly but has not yet fully matured. Certainly use of HL7, digital imaging and communications in medicine (DICOM), and standards produced by the Institute of Electrical and Electronics Engineers (New York City) is widespread in healthcare IT, yet there remain limitations to their use and implementation. As physician Ontai notes, HL7's 3.0 release is greatly needed—and long awaited.
Along with that technical goal, it's crucial to heed the simpler aspects of care delivery at the same time. Early in 2005, for instance, GE announced that its Dinamap Pro 100–400 series of vital-signs monitors could communicate with wCareAssist, a wireless application from Care Fusion (McLean, VA) that can expedite transfer to an EHR. Such compatibility eliminates a classic IT bottleneck in which a device outputs a printout to humans, who later reenter it into an EHR. Clearly a fully digital data flow is preferable, which might suggest the connection of bedside monitors to bedside workstations.
However, most hospitals are more like Morristown Memorial than like Tulsa's Saint Francis Heart Hospital. That is, most don't have a computer workstation at each bed. So the wCareAssist program runs on a personal digital assistant (PDA). The physician reviews the data—blood pressure, pulse rate, etc.—on the PDA and transfers them directly to an EHR system.
Focusing on such point-of-care computing capability is very important, says Waegemann, CEO of the Medical Records Institute (Boston) and chair of the Mobile Healthcare Alliance (MoHCA; Washington, DC). Waegemann believes that all those involved in medical IT should focus more on portability. "Using PDAs or tablet computers is often simpler, faster, and better." But Waegemann does not believe either of those two contenders will necessarily become dominant. "Tablets are a little too heavy for some physicians, and others dislike the PDA's small screen," he says. "But I have seen a whole clinic of cardiologists use PDAs to review ECGs. If you know how to use the device, you can zoom and see what you need to see."
Waegemann says that designers and manufacturers should strive to develop systems and equipment that will be ready for caregivers' varying preferences. "You don't build different roads for SUVs and for sports cars," he says.
Physician and administrator Haas would agree. "I love my PDA and its compact size. I use it every day for patient care." Like many physicians, she relies on that pocket device to run the Epocrates program, produced by Epocrates Inc. (San Mateo, CA) for drugs, interactions, and side effects. "In the hospital, we also use PDAs to access a snapshot of patient records, which shows 24 hours' worth of lab results and dictated reports," she says. However, Haas is one doctor who thinks the PDA is too small to be useful for ECGs. For those, she is trying out a tablet, the LS800 by Motion Computing (Austin, TX). The device is just under 9 ¥ 7 in. "It's pocketable, yet a true tablet. So ECGs and PACS images are quite visible."
In listening to what the healthcare world has to say, manufacturers are reminded that not only is full interoperability still a long way off, but so is a broader goal: ease of use. In terms of office practice, Ontai and Kwartler are reminders that generalists and specialists alike have long wish lists of equipment they would like to see interface easily with their EHR. Both are waiting for true plug and play.
At the same time, Morristown Memorial's Reed stresses something very basic: how important it is that staff can easily understand how to use a device. "Sometimes a device has a complicated manual, which the nurses rarely have enough time to refer to properly. It's tremendously helpful when there are simplified instructions on a device itself or on an accessible screen. Unfortunately, that's not always the case," she says.
Conclusion
For medical device manufacturers, this could be the start of a great era. Everyone, from the president on down to local family physicians, wants a networking system. And there is increasing economic pressure to build a useful one.
When discussing networking needs, even Hurricane Katrina has served a constructive purpose. New Orleans's flooded hospitals underscored how the complications, and thus the costs, of healthcare are increased by not having digital records that can be backed up off-site. There is plenty of momentum toward reaching that 10-year EHR goal—or even beating it, as with the moon shot. And for those who succeed along the way at providing what the healthcare system needs, the coming years may prove to be the good old days.
Reference
Brad Burg is a freelance writer based in Morris Plains, NJ.
Copyright ©2005 MX
