ATLANTA The electronic medical record (EMR) is beginning to look a little bit like the weather. You know, that topic that everybody talks about but can't really do anything about.

Well, let's amend that saying a little bit.

There has been some recent progress in the adoption of EMRs by healthcare; however, those adoptions are coming mostly, and rather slowly, in the big hospitals and big physician practices, while rarely found and when found, often under-used in the broad range of small practices.

Thus, offering a sort of tea leaves-and-crystal ball look at this issue, presenters and panelists at a technology summit, sponsored here last month by the Technology Association of Georgia (TAG; Atlanta), outlined more obstacles than drivers for both EMRs and the development of integrated computer uses across healthcare in general.

Preparatory to a panel discussion on EMR systems, Barbara Archibold, head of global healthcare practice for IBM (Armonk, New York), indicated that healthcare should best use its crystal ball to look less at the future and more intensively at the past "lessons we can take from various other industries to accelerate change" in healthcare's use of computer technology.

Change in the arena of integrated healthcare computer and data systems "has only begun," she said, resulting from what she termed a system "out of alignment" and the incentives for change "not well aligned."

The result, she said, is that the consumer is most often the one "stuck in the middle."

But polishing her own crystal ball approach, Archibold offered her views concerning the trends that she believes need to be pursued to achieve integrated electronic healthcare systems, from three perspectives: the payer, the provider and what she called the healthcare "ecosystem."

Payers, she said, must be much more closely attuned to consumers, given the variety of new choices and offerings, combined with more information about healthcare to create an "empowered consumer."

Archibold defined "consumer-driven healthcare" as meaning greater demands by patients for more services and more efficient services. She predicted, as just one example, that more people will be asking why they can't go online and register in advance for elective surgery or access other health services, thus modeling "many of the things from the retail or commercial perspective they can do."

The result, she said, is that payers "need to respond faster to this competitive situation." And Archibold asked, rhetorically: ""From the healthcare perspective, shouldn't we be pushing some of this [healthcare] information to our consumers?"

That information, she added, ought to be pushed with more precise segmentation: "new moms, senior citizens, 40-year-olds sports-minded, dual-income-no-kids" (known as DINKs), who are all increasingly focused on wellness and improved lifestyle.

On the provider side, Archibold foresees the need for healthcare IT to put greater emphasis on detailing its benefits. "We need to do a better job of helping customers understand the value [of IT] to help them make the argument for expenditures that are necessary on the technology side."

While she noted that it is fairly easy to demonstrate, for instance, the quick return on investment of a new MRI system, it becomes much more difficult to show how IT produces results via reductions in medical errors, time and money savings and better clinical outcomes.

The strategy for doing this requires "a holistic perspective," she said, involving the reengineering of workflow processes. Archibold suggested that this means less emphasis on hoped-for assistance from tomorrow's technology but rather an examination of workflow processes and "taking the technology of today and using it to better advantage."

Here, she emphasized integration, noting that even in many academic medical centers, there is a lack of connection, often in the same building, between research and the treatment of patients. As she put it, research concerning specific diseases is often "on CDs in the back room and not related to clinical information."

Sharing of this information, she noted, would lead to "personalized medicine."

While for clinicians this term is being used to mean the discovery and development of the best matches between the right therapy and the right patient, Archibold used it more specifically to mean employing IT to identify and deliver that most useful therapy to the patient, rather than leaving the information on the shelf.

Healthcare in this, she said, has taken "only baby steps to where we can be."

The third perspective and trend Archibold offered was in looking at the healthcare IT "ecosystem . . . where all healthcare players come together payers, providers, physicians, medical device makers, pharmaceuticals."

Noting recent efforts by the Department of He-alth and Human Services, healthcare IT czar David Brailer and statements by President George Bush to push "a strategic framework for action" on EMRs, she said the key issue here is not "a technological problem." Rather, she termed it "a standards problem building communities and positioning the various organizations and getting them to agree on what's important."

This will require, she said, bringing together "what the health systems want in a central repository" and the looser control that physician might want over this information. Other questions will include "who owns and who pays" for these systems. "These are the kinds of things that we're going to be working with across various healthcare communities across the next several years."

And clinicians should be "at the core" of this effort, Archibold said, with healthcare IT systems and processes not something we "do to, but do with" them.

"With interoperability of existing technology and a community with common goals, we can take the EMR, prove its value within institutions and then extend that value across the community," she said.

Archibold's presentation, followed by breakout panels, was developed by TAG as one of various special programs for its members.

EMR adoption means tough choices

"A tough sell." That is a very succinct characterization of the current environment for marketing of healthcare information technology (IT) and especially the EMR. The characterization was provided by one member of a panel presenting at the healthcare IT summit and appeared to capsulize the view of the entire panel. If true, it casts a rather large shadow over future prospects for IT adoption in U.S. healthcare.

The summit probably raised more questions than answers in attendees' minds concerning how to make the healthcare IT "sell" easier. The panel specifically focused on the uphill prospects in the U.S. for transforming the broad use of a comprehensive EMR from vision to reality. Some surveys have pointed to EMR use by as few as 5% of the nation's physicians, with that percentage heavily skewed by smaller practices where their use is very limited indeed.

A somewhat heftier figure was offered for the state of Georgia by panelist Bob Addleton, PhD, president of the Medical Association of Georgia (Atlan-ta), who reported that a survey by his association found that 15% of respondents said they are using an EMR, but he offered that figure with a variety of qualifications.

The survey population was self-selected, he noted, since done by e-mail and thus representing those physicians who already had at least some minimal computer expertise. Further, he said that interpretation of the survey had to assume truthfulness in reporting and that the systems described were true EMRs both requiring "grain of salt" acceptance, he suggested.

Considering the 85%, or more, of non-EMR users, Addleton put the key question concerning the EMR rather bluntly: "Why ain't more of it in doctors' offices?"

His answer was several-fold. Physicians, he said, don't have the time, capability, expertise or "inclination" to embrace IT; they don't have enough trusted and reliable information concerning the best choices; and vendors haven't taken the time to understand the actual needs of physicians. Physicians "haven't related IT to patient care issues or how it can help them do a better job of what matters to them," he said.

Further barriers are the initial and follow-on costs, Addleman noted, adding, "Physicians, by and large, are not known as canny business people for understanding the deep financial aspects of their practice."

Still another issue he cited was the proliferation of vendors with more than one member of the panel citing a figure of at least 800. And Addleman noted that, when you have too many choices, "more is less."

"How do you even narrow it down?" he asked, comparing the process to shopping for jeans at the GAP, expecting an easy choice of one, but faced with an explosion of styles and types.

Pitching in with still another negative for the sector was Jeffery Daigrepont, principal of The Coker Group (Roswell, Georgia), offering Bill O'Reilly-style, he said a "no-spin" on the subject.

With Diagrepont noting that his company has no affiliation with any vendors and therefore can offer an entirely independent view, he said that many physicians and physician practices had been victimized by EMR and IT vendors. "Part of the reason why the industry is so reluctant to adopt [is] they've been taken advantage of," he said. So they have become understandably wary and find it difficult to make a selection.

In the extreme, he said that for many individual physicians and practices, selection of an EMR or other important computer system looms as "a career-defining decision that many are reluctant to make."

Additionally, Daigrepont said that the software chosen, though it may work properly, often is the wrong kind for the practice and thus represents "a lot of poor planning, poor processes." Under this category, he said there is often little groundwork or training prior to install, citing the case of a neurology practice that, with its initial buy, contracted for 22 tablet PCs but offered no training on how to use them.

"Two docs did go live," he said. "The other 20 physicians gave the tablet PCs to their kids to play with."

Daigrepont offered a Letterman-like list of 10 mistakes "in making IT decisions":

  • Not using a structured process in making the choice of products.
  • Not defining the needs that the system must satisfy.
  • Hiring a consultant who is really a reseller.
  • Paying too much attention to a system's bells and whistles.
  • Not including key users in the selection process "Psychologically, everyone needs to embrace the system" chosen, he said.
  • Buying more than you need.
  • Allowing vendors to drive the process.
  • Allowing the "powers that be" to choose the system, rather than those who will use it.
  • Confusing the salesperson with the product.
  • Not using a request for proposal process.

Diagrepont acknowledged the fairly stiff up-front costs to install EMRs as well as the often unplanned-for downstream costs of support and maintenance. But he qualified this negative with a key comparison. The EMR "is expensive, absolutely, but so is your paper system," he said. "Just watch the process unfold with a missing [paper] chart it can shut an entire business down, bring it to a screeching halt. One person interrupts two to three others who can't really help."

And he offered a short list of tips to guide those seeking to purchase an EMR.

  • Require the selected vendor to put its source code in an escrow account, in case the company goes out of business.
  • Pursue an "EMR lite" strategy, meaning an incremental or phased-in approach to adopting the system and then integrating it with the organization's other systems.
  • Take enough time to make a solid decision.

"Time is on your side," Daigrepont said. "You will have up to 10 years of regret for making a quick decision."

A battle fought 'in the trenches'

Implementation of the EMR is a "life . . . fought in the trenches," said Dedra Cantrell, RN, chief information officer at Emory Healthcare (Atlanta), a member of the panel. Cantrell said that over the past several months she has been "living the life that previous speakers have talked about."

That life has been focused on choosing, implementing and providing training in the use of an EMR system across Emory Healthcare, which is providing a variety of services through a range of facilities and venues, as well as linking to other healthcare services in the Atlanta region.

That effort has been dubbed EeMRI, for Emory e-Medical Record Initiative, and Emory has been "truly in the trenches of this huge strategic initiative," Cantrell said, calling it an initiative mainly focused on "making people healthy."

She told the summit attendees that Emory has invested $15 million in EMR implementation, and she outlined a rather long list of steps the organization has taken as well as ongoing steps which underlines the difficulties of developing EMRs in any system, large or small.

That effort has involved moving a huge legacy depository of data, by "migrating 112 million rows of discrete results into a new repository," linking it with the organization's other IT systems and, ultimately, developing a broad-based EMR that will aid both patients and physicians.

Besides the goals of "improving [patient] care, quality, efficiency, consistency [and] patient satisfaction," she said the new system would advance the organization's research and "push information to physicians at the right time."

Cantrell emphasized using the experience of other programs, but using only what fits. "What works at Clarian [Indianapolis] or Duke [Durham, North Carolina] doesn't mean it's going to work at Emory," she said.

The implementation effort has come in three phases. Phase I, she said, involved creating a "technical infrastructure and a technical layer, on top." This meant dealing with "five medical record numbers for each person" and, importantly, "to connect all of those record numbers to the right person."

Phase II, she said, had been completed in February, with the system "going live" with seven applications and 10 data migrations, which she called "a huge milestone for us."

What "never ends," Cantrell said, is Phase III.

"When you really get the momentum started, everybody wants a piece, everybody wants to participate," she said, adding the caveat to be "careful about managing the scope so that it doesn't take 15 years to implement."

The core of Phase III, she said, is "care transformation." She somewhat downplayed return on investment, indicating that a financial analysis said the payback might not come for seven years. "ROI is going to be there, a nice thing from the financial perspective," she said. "But it's really about patient care and patient quality of care."

Cantrell similarly downplayed the usual emphasis on the EMR as simply a movement from a paper to a non-paper environment. "Let's get rid of paper it's not about that," she said. "It's about automating the workflow with enabling technology that promotes that process.

"Focusing on process is key," she added. "We look at current workflow, the future state of workflow, the gaps where technology can't provide automation . . . You have to understand your workflow and how your workflow is going to change."

An emphasis of her presentation was encouraging the involvement of many players, "stakeholders," in the effort and doing it in an orderly way.

"The team has to be pulled together," Cantrell said. "There's way too much [in the way of] dynamics and dialogue on the fly. If you're not together, you really miss things and slow the process down."

Besides 50 staff people "continuing on the project full-time," she said that the team holds "daily tactical sessions, daily warring sessions" and that anyone on the project team can "call a war session when faced with an obstacle that they couldn't make progress on."

As other healthcare project leaders have frequently said, big projects need "champions," and Cantrell said the EeMRI effort had "very strong executive-level champions."

She credited Cerner [Kansas City, Missouri] with being a valuable "partner" for EeMRI, but she also agreed with another panel member that "you do not let the vendor drive the process. The vendor is a partner along the way, but you have to own and embrace it [yourself] for it to be successful."

Overall, she described the project as highly successful, though not yet "portable" to other systems when a patient moves outside the Emory system. "We're working on that," she said.

Cantrell noted that the largest challenge has not been technological but rather cultural, especially in promoting a culture change "particularly in an academic health system," where many, often conflicting voices demand to be heard.

"You have 28 CEOs, just in the clinical practice, that you have to bring together in a collaborative way to move things forward." And in developing an integrated system, "you have to make decisions together; any decision may impact several departments or areas down the line."

She also emphasized testing as "something that can't be underestimated as you implement an EMR. It's easy to test for the way things are supposed to work, but . . . you need to think about what happens when you put technology in front of people. They're going to try all kinds of things." Not all of them good, she suggested.

And in passing, Cantrell said that the EeMRI project has meant "challenging the past every single day" and particularly that there is "never a dull moment."