The Big Switch
With devices called "COWs" and secure email connecting doctors and patients, UTMB's paper medical records are giving way to electronic ones.
By Michele Rainford
A former special education teacher at Rosenberg Elementary School in Galveston, Anderson retired in May 2004, moved to Houston, and started seeing a physician there. But after several visits, he concluded that he had been more comfortable with his long-time UTMB physician, William Harper, an associate professor of medicine with the Harborside Medical Group. Dauntingly, however, in order to see Harper these days, Anderson must drive a hundred and four miles round-trip.
But often seeing the doctor isn’t required to address Anderson’s concerns. Sometimes all that’s needed is a simple and direct exchange between physician and patient to adjust a prescription or allay an anxiety.
While it’s often hard for tightly scheduled doctors and peripatetic patients to link up on the telephone, email offers a way that the two parties can communicate on their own schedules, just as it does in the business world. But there’s a catch—regular email isn’t secure enough to satisfy federal rules: The Health Information Portability and Accountability Act requires strict patient confidentiality at federally-supported health care institutions.
Happily for Anderson and for many others, UTMB clinics are introducing a new, secure e-mail messaging system called MyChart, which is in the pilot stage with a number of doctors and their patients participating in the pilot. Anderson was among the “early adopters” to sign up. MyChart also lets him view and research health information by topic and request new appointments. Once the system is fully in place, patients will be able to view some lab results, seek renewed prescriptions online, review health information updates, and link to other medical information sites to better manage their own health care.
“I really like the secure messaging system,” says Anderson. “It’s painless to register, easy to use, and it worked well from the first time. The doctor usually responds quickly—within at least twenty-four hours.”
The system ultimately will be available to all primary care physicians, specialists and their patients who want to use it.
“MyChart and the EMR project will allow even better efficiency and communication than we already have here at UTMB,” says Harper. “It will improve the documentation process. Messages automatically will stay in the patients’ charts and will be easily accessible by any other colleague who is also treating the same patient.”
MyChart is just one component of the Electronic Medical Record (EMR) project at UTMB, which is in the fourth year of its five-year, phased effort to convert its hospitals’ and clinics’ paper medical records into electronic patient records. All told, the mammoth project currently is expected to cost about $35 million.
In 2002, UTMB’s leadership decided that an electronic medical records system was a necessity. After painstaking research, the electronic medical record approach offered by Epic Systems Corporation was deemed best suited to UTMB.
“MyChart and the EMR project will allow even better efficiency and communication than we already have here at UTMB.”
Rollout began in March 2005 at Island Pediatrics, the UTMB pediatric practice based at the Primary Care Pavilion on Harborside Drive. The four pediatric community-based clinics went live with the system that June. EpicCare Inpatient Order Entry began its pilot test in August 2005 in the cardiology units of John Sealy Hospital and was launched the following month in the remainder of John Sealy Hospital and in the Texas Department of Criminal Justice (TDCJ) Hospital. Children’s Hospital, Waverly Smith Pavilion and Rebecca Sealy Hospital followed in November 2005, and the Emergency Department began using EpicCare Inpatient Order Entry in December 2005.
Experts say that complete conversion to an EMR system requires a clinical data repository, computerized provider order entry, an electronic medication administration record, point-of-care documentation, access to medical journals, reference materials and clinical documentation tools in one system that is integrated with a picture archiving and communications system (PACS), laboratory, radiology and pharmacy information systems. The UTMB system either already includes, or soon will include, each of these components. Computerized provider order entry, ambulatory point-of-care documentation, and the clinical data repository with links to the laboratory and radiology information systems, the pharmacy information system for the EMR and Epic electronic Medication Administration Record (eMAR) are all up and running at UTMB.
UTMB is in the vanguard of institutions now using these integrated electronic technologies. Others that have done so include the Mayo Clinic, Havard Medical School’s teaching hospitals including Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital and Children’s Hospital Boston, University of North Carolina Hospitals, Duke University Medical Center and Indiana University School of Medicine’s Regenstrief Institute, Kaiser Permanente, the Indian Health Service and Veteran’s Health Administration.
A big incentive for change is the conviction that EMR systems will help save lives by preventing fatal mistakes. A 1999 report by the Institute of Medicine cites reports asserting that “at least forty-four thousand people, and perhaps as many as ninety-eight thousand people, die in hospitals each year as a result of medical errors that could have been prevented.” The report concluded that these errors most commonly “are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.” And it advised that such “mistakes can best be prevented by designing the health system at all levels to make it safe—to make it harder for people to do something wrong and easier for them to do it right...”
Today, a child seen in UTMB’s pediatric clinics will have all her records—from immunizations to well-baby visits—available via computer. And if that child is referred to another doctor or admitted to the Children’s Hospital, all doctors and clinicians caring for her instantly can read the electronic medical records online, obviating the need to hand-deliver or securely fax records to the appropriate clinicians.
Laboratory test results for pediatric patients may be viewed online as well. Laboratory Information Systems (LIS), the division within the Pathology Department that stores and manages laboratory test results ordered by doctors, already is fully integrated into the EMR system. Over the past thirty-five years, the department has evolved from using a gargantuan mainframe computer, conducting manual lab tests, and using “runners” to hand-deliver lab results or telephoning doctors with results—a “sneaker net” system, as Beverly Campbell, LIS manager, jokingly calls the old arrangement.
Nowadays, UTMB patients wear bar-coded wrist bands that are a part of the new “point-of-care” technology being introduced to work within the EMR system. Clinicians use hand-held computers that read glucose tests and send the results directly to the patients’ electronic medical records. Less information is being entered manually, reducing the potential for mistakes.
All UTMB treatment areas ultimately will be able to place patient records in the EMR system and electronically order lab and radiology tests and medications—including the two adult community-based clinics and the thirty-eight Regional Maternal Child Health Clinics.
Meanwhile, in John Sealy Hospital, clinicians caring for patients already enter their orders in computers on wheels or COWs—wireless carts with “thin-client” computers, which are network devices without hard disk drives that allow users to access a remote server for applications that reside in, and are processed on, that particular server. A thin-client computer looks like a regular PC, but it’s really just a keyboard, monitor, some memory and the pieces that tie it all together for networking.
“For patient safety, for quality, for efficiency and for a host of other good reasons, we’re making the shift from paper records to electronic patient records using the Epic system.”
These devices allow updates, system management, access, and permissions from a single, centrally managed machine. The nurses now use the COWs to review doctors’ orders for patients and to clarify any unclear instructions associated with them. Also, the COWs let nurses view laboratory results and radiology reports at the bedside. By using the COWs at or near patients’ beds, nurses are able to document, for example, how they plan to prevent bedridden patients’ pressure ulcers and to assess whether patients are at risk of falls. Nurses can now enter records of the medications patients have received, and soon they will be able to enter flow sheets for medications such as insulin and blood thinners.
Timothy Hilt, a nurse clinician and EMR project team member, calls the computers on wheels “an excellent tool” that “allows us to begin moving nursing documentation to the patient’s bedside, which we anticipate will improve patient satisfaction as well as patient safety thanks to timely alerts based on best practice.” COWs are also available in the TDCJ Hospital.
UTMB’s new Epic Rx Pharmacy System and the Epic electronic Medication Administration Record (eMAR) are now fully integrated with the other Epic EMR system components for a complete electronic record of each patient’s care at UTMB.
UTMB now has one complete system for hospital patients: doctors enter their medication orders directly into the system, the pharmacy fills the orders using the same system, and medication is administered by the nursing staff and respiratory therapists.
The EMR system streamlines patient admissions by documenting past patient care, current and past medications, and a medical issues list.
Via an e-mail message to UTMB clinicians a couple of years ago, Karen Sexton, vice president and chief executive officer for UTMB hospitals and clinics, articulated the rationale for the EMR initiative: “For patient safety, for quality, for efficiency and for a host of other good reasons, we’re making the shift from paper records to electronic patient records using the Epic system.”
Sexton continued: “We’re making good progress because we chose a good product, put good people and substantive resources to work on it, and because of you. Change is never easy; it’s confusing and uncomfortable, even when it’s the right thing. But the faculty and staff at UTMB are remarkable; they understand that the EMR is the future, and their support, guidance, feedback, patience and hard work are what’s making the project so successful.”
Electronic boards provide information to families in OR waiting rooms
Since October 2006, families in the Operating Room waiting rooms at UTMB have had a new tool to provide them with information on their loved ones undergoing surgery.
The fully functional electronic “grease boards” provide real-time, basic information on the patients in surgery. The grease boards work with the Electronic Medical Record System application OpTime,which is used to schedule surgeries and maintain the physician preference cards used to document supplies and equipment needed for surgery.
The electronic grease boards are forty-inch, wall-mounted monitors that provide color-coded updates with basic information such as “patient in surgery,”“surgery started,”“surgery completed,” and “patient out of OR.” The color codes are listed at the bottom of each screen.
A unique number is assigned to each surgery patient. Family members get their patient’s unique number from the nurses’ station and can then identify and read all the updates for that patient.
“The new OpTime system and the electronic grease boards ensure that the waiting room environment is family-centered,” said Karen Sexton, vice president and chief executive officer for UTMB hospitals and clinics. “The system helps to keep the families together and in contact as it provides necessary updates. Families are kept in the loop; they are reassured about what’s going on with their loved ones and they gain an understanding of the process, the timeframes involved and the transitions from one area to another. If we can help allay even a little of the anxiety of our family members waiting for news of their loved ones, we want to do it.”