Dean's Newsletter

Archive of previous newsletters

Electronic Medical Records at URMC

April 14, 2006

In my June 2, 2005 newsletter on the Department of Imaging Sciences, I asked the following question, meant to capture the revolutionary change that had occurred in that Department: "Remember film?"

It was not so long ago that our clinicians would retrieve a patient’s file from the Radiology "film library." This not-so-nostalgic experience included sorting through a bulky stack of xrays, MRIs and CT scans to obtain the images of interest, and then physically carting them over to a light box for viewing. This experience has now been replaced by one in which the patient’s diagnostic images of interest are brought up on computer screens...wherever they may be. The images can still be viewed on site in consultation with radiologists, but they can also be seen on computer screens in the office or at home.

For a number of primary care offices of the University of Rochester Medical Faculty Group (URMFG), we can now ask an analogous question about patient records: "Remember charts?"

In these offices, we have converted the paper chart into an efficient, organized electronic medical record (EMR). Indeed, this conversion has gone so well, and has attracted so much excitement and interest, that we plan to extend the implementation of EMRs to all URMC ambulatory sites--whether primary care or specialist, hospital-based or faculty practice--by early 2008.

Dave Krusch, MD

No doubt, the traditional medical chart is something of a security blanket for clinicians who have spent their entire careers dependent on the information contained within these paper files. Review of the patient’s medical record, page-by-page, has a long tradition in clinical practice. Using the paper chart, the clinician can obtain important information about previous visits; medications and allergies; diagnoses and treatments; referral and consultant letters; and pathology, OR and lab reports. But think of the inefficiency of this system, and of the potential for medical errors. Every time a laboratory report (or any other piece of paper related to that patient) arrives in the office, it must be sorted, and physically filed in the chart. Cumulatively, across all lab reports, this involves many hours daily of tedious and error-prone work. Assuming that all relevant material from our own hospital or referring office has been filed in the right place in the right chart, there may still be missing information. For example, what about a diagnostic study and/or physician visit that was performed at a hospital or office in a different health system? Such information must then be requested, by fax or phone, but might not be available until the next visit. Having assimilated as much information as is available, and having completed a history and physical exam, the physician must then document this information in an office note, along with a summary of differential diagnoses, and recommended diagnostic steps and/or treatments. This is often dictated or, even in 2006, written by hand into the chart.

Stephen Cohen, MD

It is easy to acknowledge that there may be errors in reading the handwriting of such notes, or in interpreting medical slang and abbreviations. It can also readily be understood that the requirement for writing out the entire summary of the visit by hand might lead to a level of conciseness which leaves out important details. Dictation addresses the issues of handwriting and an overly abbreviated summary, but there are costs associated with dictation—not only the financial costs of the transcriptionist to type the note and the clerk to file it, but the time cost of the delay in getting this information into the chart, and the medical implications of such delay.

Just as digital images have replaced film in our Department of Imaging Sciences, should not electronic medical records replace paper charts in our faculty practices? In 2003, we explored this possibility by piloting the use of Allscripts Touchworks, a system for creating an ambulatory EMR. Under the leadership of Dave Krusch, MD, Jerry Powell, and Martin Haibach, a committee that also included Stephen Cohen, MD, Bob Panzer, MD, Ray Mayewski, MD, Betsy Slavinskas, and Halle McNaney chose Allscripts for implementation at URMC after an exhaustive review of alternative products from a variety of vendors.

The vision or our ambulatory EMR was to:

• have a single "patient-centric" paperless ambulatory EMR for all of URMC;
• eliminate fragmentation of patient information;
• improve patient safety;
• improve office efficiency; and
• provide a tangible return on investment.

From the standpoint of implementation, a number of Allscripts features had the potential to allow us to achieve this vision. The EMR could: convert the paper chart to an efficient, organized electronic chart; reduce or eliminate transcriptions costs; improve patient safety related to medications through electronic prescribing; enhance access to important medical data by including laboratory test results, diagnostic images, and pathology and OR reports; improve billing coding, compliance and office efficiency; facilitate the viewing of patient information—securely and confidentially—by appropriate health care providers throughout URMC; integrate financial and clinical systems in ambulatory settings through partnership with IDX; and improve physician office workflow.

Ray Mayewski, MD

In November 2003, Allscripts was piloted at five ambulatory sites involving 28 providers and all support staff. Data on a number of key measures were obtained at baseline (September, 2003) and subsequently in March 2004 and September 2005. These measures were: chart pulls, filing time, support staffing needs, transcriptions costs, total patient visit time, and days in accounts receivable. In addition to these quantitative measures that relate to return on investment, qualitative assessments by staff and patients were clearly important components of the overall assessment.

A report of this pilot study by a Department of Surgery PGY3, Dara Grieger, MD, and by two SMD faculty, David Krusch, MD and Stephen Cohen, MD, has been submitted for publication. This manuscript, entitled "A Pilot Study to Document the Return on Investment for Implementing an Ambulatory Electronic Health Record at an Academic Medical Center," contains some dramatic results. For example, at baseline there were 1,193 chart pulls daily across the five sites. After six months of EMR implementation, there was a 79% reduction in chart pulls, and after two years, a 96% reduction! Considering the savings from reduced chart pulls, reduced transcription costs, and other financial benefits, total annual savings across the five ambulatory sites was estimated at $399,662, or $14,055 per provider. Accounting for the cost of initiating Allscripts, it was estimated that start-up costs were re-captured within 16 months, with subsequent annual savings of $9,983 per provider.

As compelling as these financial results are, the real excitement of the EMR can be found in its impact on day-to-day (or minute-to-minute) patient care. On "AC1," (first floor of the Ambulatory Care Facility), faculty and staff of the General Medical Division of the Department of Medicine have been using Allscripts since November 2003, and the residents went live in the Faculty Resident Practice just over a month ago. There was concern that since AC1 involved over 60 residents, each of whom sees patients only once a week in a continuity clinic, implementation of Allscripts would be fraught with resistance and errors. Just the opposite occurred. "The residents grew up with computers," explained Betsy Slavinskas, Director of the Ambulatory Facility, "unlike many of the faculty." Pat Feola, Nurse Manager for AC1, agrees: "Their attitude was: ‘What took you so long?’ They jumped in and got to work." Steve Judge, MD, is Chief Resident of Internal Medicine, and started a week ago on rotation as the Chief responsible for the AC1 urgent care clinic. "It took me no time to learn the system. It’s great. Here’s the office record of a patient we saw ten minutes ago (showing me the computer screen). It’s done. If this patient were referred to a specialty clinic this afternoon, the physician there could read my note, understand my thought process, and have available complete information on medications, lab reports, past history etc."

One of the amazing things that Betsy and Pat pointed out is that the large file rooms that used to hold massive numbers of charts are now redeployed for staff who are more directly involved in patient care. For example, nursing staff now occupy space previously assigned to files. These nurses answer the huge numbers of questions from AC1 patients by typing into Allscripts a summary of the phone call in real time, and then emailing tasks (prescriptions, visit appointments, lab testing, etc.) to the appropriate individuals. Gone are a series of phone calls or phone mail messages, with the possibility of errors in communication. What happened to the information contained in the old charts? All data and visit notes since January 2004 have been (or soon will be) scanned into Allscripts! Thus, all information since 1/04 on a patient seen in the AC1 clinic is a keystroke or click away.

Catherine Gracey, MD, an Assistant Professor of Medicine, Medical Director of AC1 and Associate Program Director for the Internal Medicine Residency, uses Allscripts in her own faculty practice on AC1, and also in conjunction with her direction of the outpatient resident practice. "Using Allscripts, not only is the information more complete and accurate," she says, "but the quality of the information is much higher, which improves patient care." Dr. Judge concurs. He points out that now, as a resident writing a note, "you know that it will be out there instantly for everyone to read, whether in a referral clinic, on the wards, or in the ED. You want to communicate that you have been complete in your review of the patient’s problem, and that your recommendations show crisp thinking. And no spelling errors!"

There are other benefits of complete implementation of the EMR system across URMC. In terms of professional liability, EMRs reduce the risk posed by multiple medical histories in different locations, often with inconsistent information. A physician in an emergency room can access historical laboratory, pathology and imaging data, and also check a patient's allergies and prescription medications, even if the patient is unable to describe or recall his or her medical history. The EMR improves patient care by ensuring that the correct information, such as the proper medication or dosage, is retrievable and legible.

We must recognize, however, that the very features of an electronic medical record which are advantageous from a patient care standpoint are the same ones that might potentially increase the risk of breaching confidentiality. Across the URMC clinical system--ambulatory and inpatient-- EMRs provide easier access to patients’ confidential medical information by a variety of personnel.

Considerable care has been taken to ensure that facile access to the patient record is protected by many layers of security. All access and changes are kept in an audit history, the servers and databases are behind secure firewalls, and the data are replicated in real time to a duplicate secure database at a second physical facility. In many ways, the EMR is more secure and reliable than the paper record ever was.

In summary, the Allscripts Touchworks pilot was a spectacular success, whether measured by return on investment or by staff enthusiasm. Word-of-mouth about the system has traveled across the entire URMC clinical enterprise, creating demand for a faster roll-out than initially planned. At the last Executive Committee of URMFG, it was decided to allocate the necessary funds to accelerate the implementation schedule. Thus, the Allscripts team is now proceeding with an energetic roll-out schedule: in parallel, we are now implementing EMR capability for hospital-based practices, the primary care network and URMFG specialty practices. By July 2006, Allscripts Touchworks will be in use by over 15 separate sites consisting of 250 faculty and residents, and nearly 700 support staff.

First, the EMR pilot; next, primary care offices; now, all ambulatory care offices--primary care and specialty--by early 2008. On the horizon—electronic documentation of inpatient records to complement the inpatient computerized order entry system and radiology/lab report system, and the potential for a Regional Health Information System for the entire community. Such progress truly reflects our University’s motto,

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry