It cost Presbyterian Healthcare Services $190 million to build its 68-bed Rust Medical Center in Rio Rancho, which opened in late 2011.
Presbyterian will spend more than that – around $200 million between 2008 and 2015 – to install an electronic health-records system to improve care, productivity and costs among its 600 medical providers at its eight hospitals and 100 clinics around New Mexico.
Experts say electronic health records change in revolutionary ways how a health-care system does business, the way medical providers do their jobs, the way colleagues interact, and the way patients receive treatment.
Health-care providers usually begin migrating to an EHR with the thought that they are simply substituting a computer screen and keyboard for a pen and paper, said Kristine Martin Anderson, a senior vice president with consulting firm Booz Allen Hamilton and an expert in health-information technology.
“It’s an electronic communication tool,” she said.
As such, the system puts more information than ever was available before in front of people who never had access to that information before. That changes work flow, power relationships, accountability and the practice of medicine itself.
Organizations often find an EHR to be a “painful step” in a series of steps that “will change the entire way they approach the business,” she said.
Booz Allen Hamilton has not been part of Presbyterian’s EHR push.
Every scrap of info
In simplest terms, the EHR is supposed to contain every scrap of information relevant to a patient’s care and make it available to anyone who will ever be involved in the patient’s treatment.
If the patient saw a primary-care doctor two years ago with a sinus infection, the visit should be in the record. The doctor’s prescription for an antibiotic is in the record. If the patient didn’t fill the prescription, the electronic system will alert the doctor. If the EHR is doing its job properly, that alert automatically will prompt a staff member to contact the patient to ask why the prescription hasn’t been filled. The record of that alert and call is saved electronically.
If the patient’s sinus problems require surgery two years later, the complete work-up will be in the record. X-rays, CT scans, MRIs, lab records, and notes from any examinations will be in the record.
The surgeon will know what the primary-care doctor saw two years ago. He or she will be able to see the primary-care physician’s thought process and how the medical team working with the patient decided surgery was the correct option. The surgeon can ask the primary, using the electronic system, any questions, offer opinions, kick around treatment options, and all of that interaction can be saved as part of the record.
Tons of detail
The surgeon’s notes and orders go into the record. The nurse’s observations while the patient is recovering from surgery, including everything from temperature and blood pressure to the patient’s complaints about discomfort, are in the record. The patient’s follow-up visit is in the record.
Any time the surgeon, the radiologist, the pharmacist, the nurse practitioner or any other practitioner sees the patient, the primary-care physician is alerted by the EHR. The record shows which practitioners have looked at the patient’s test results.
Ten years from now, when the patient needs cataract surgery, the medical team will know that during sinus surgery she responded poorly to a painkiller and had to be cajoled once she left the hospital into complying with orders for follow-up care.
Kevin E. Hudenko, a general surgeon with Presbyterian Medical Group, has been using the EHR for two years and is a fan.
“If anything, it’s easier,” he said in an interview before performing a gall bladder surgery at Rust.
There are times someone will call from the hospital or from another office asking about a CT scan, say. In the old days, Hudenko said, at best you might have a radiologist’s report, written on paper, that you could read, or you could send someone to try to find the original scan in the office archive.
Today, you click a mouse button, the CT scan appears on your computer, along with the radiology report. And you can do it from home.
Finding mistakes, too
“Most mistakes are made because of a lack of communication,” Hudenko said. “The more communication the better.”
A surgeon who would meet with a patient at a clinic before surgery might know the patient’s name, date of birth and that someone referred him for hernia surgery. Now you can open the EHR, see what the primary-care doctor found, understand what the doctor was thinking and get a sense of why the referral was made.
“It’s a huge benefit to know what you’re facing before you walk in the door,” Hudenko said.
Even better, the patient doesn’t have to repeat his story over and over again for every provider he sees, he said.
Patients usually experience health problems as episodes, so that’s how the system treats them, said Jason Mitchell, a family-practice physician and Presbyterian’s chief medical information officer.
The information available to a medical-care provider is, therefore, episodic and fragmented. A patient might get hospital treatment in one place, then go into a skilled nursing facility, then a rehabilitation hospital, then home where he will be visited by a physical therapist.
It’s quite possible that the only person involved in that course of treatment who knows everything that was done is the patient himself, absent an EHR, Mitchell said.
Teams and information
“The goal needs to be, how do you get the patient back to health,” he said, which requires teams of people and every team member to have access to the same information as every other team member.
That information collection and sharing has multiple benefits, Mitchell said.
“It forces standardization of processes,” he said.
Mitchell said there can be good evidence that a specific course of treatment produces the best results. The EHR assures that everyone involved in the treatment is using the same process or has a good reason to do something else. That improves safety and efficiency.
That standardization extends to scheduling, billing, ordering of supplies, indeed everything that a complicated business needs to do, Mitchell said.
“Without standardization, you can’t even tell what is working,” he said. “You can’t measure anything.”
The practices of individuals and the practice of the entire system is now open to scrutiny, evaluation and improvement, Mitchell said.
“Under the status quo, nothing is dramatic enough to make you look at your practice and improve it, short of being fired or going bankrupt,” he said.
With EHRs, nothing dramatic has to happen. The scrutiny and resulting improvement becomes part of the routine, Mitchell said.
EHRs expose defects in the processes providers use.
“Any process that is broken, inefficient or redundant seems extra broken in an electronic record,” Mitchell said.
The health system also gains the tools to care for populations, not just individuals with a problem. EHRs will let Presbyterian identify anyone in its system with diabetes, for example, just by screening records for certain clinical indicators.
“You can identify patients you didn’t even know existed,” Mitchell said. Presbyterian was able to exceed in one year its three-year goal for treating its diabetic population, he said.
Ironically, said Anderson, people who use EHRs dislike them because of their strengths.
“There will be less important information available that never got seen” before the advent of EHRs, she said. “Now it will be seen.”
Errors or poor practices that could have been forgiven because the information to overcome them wasn’t available will no longer be forgiven because the information is available.
Some medical providers don’t like the standardization that EHRs make possible, Anderson said. Medicine has been “an apprenticeship culture,” she said. Physicians were taught by mentors. A Duke-trained physician had a Duke way of doing things. A University of New Mexico-trained physician had a UNM way of doing things.
Same info for all
“Adherence to guidelines (for optimum patient care) has been very poor, better for some conditions than others,” Anderson said. “Now you have EHRs that capture the same information for all patients,” something the old pen-and-paper approach can’t do. Quality of care improves, “but now it’s this computer system that’s driving the doctor’s work flow.”
Hudenko said EHRs make the work done in a health-care system more transparent, which makes medical providers more accountable.
“You can’t just say to the nurse, ‘I want a CT scan,'” he said.
The order has to be written and entered in the system or nothing happens. If that order isn’t correct – if the physician orders a medication that will interact badly with another medication prescribed by another physician – the computer could reject the order.
“The information doctors have to provide has to be much more precise,” Anderson said. “That lowers communication errors, but it’s more painful for them because now they have to be aware of exactly what the test that they want is called. Often, there is a code that goes with it” that they might have to know.
Before EHRs, these were the nagging details that nurses and clerks handled. Now the staff can’t accept an order that isn’t properly entered in the EHR.
In addition to changing the way the physician works, Hudenko said, the physician can become a choke point in the work flow because nothing can happen until he or she sits down at the computer.
Some human interactions change as well, he said. A little conversation among the medical team can help resolve a complex case, but EHRs make sending brief text messages to team members so easy that there is less time spent on the phone kicking around ideas.
Some members of the team pay a higher price than others, too, Hudenko said. As a surgeon, he gets alerts when something happens to one of his surgical patients. A primary-care physician gets alerts when anything involving one of his or her patients occurs.
Primary-care practices are big, so the physician is constantly being alerted. Since the EHR allows you to connect from anywhere you can get Web access, the primary-care provider is never left alone, Hudenko said.
With so much data available, it is possible providers will have a lot more noise than signal coming at them.
“Having data is helpful, but you have to have good data,” Mitchell said.
Kaiser Permanente, the big California health-care system, “does a beautiful job with data,” he said, but is still learning which data are really useful and who on the team really needs to have the information.
Overcoming the limitations of data and of too much data requires a human being in the system, he said.
Ultimately, Anderson said, most providers come to terms with electronic records.
“As many complaints as you hear about EHRs,” she said, “the vast majority of physicians say they would never go back to paper.”