Electronic Medical Records:

An Introductory Tutorial
William Tierney, MD
Atif Zafar, MD
AHRQ PBRN Resource Center
Outline of Presentation
Introduction to EMRs (very basic information)
Barriers to Adoption: Some Problems with Data
Accessibility and Care Processes
EMRs for Clinical Research
EMRs and HIPAA Security
No Nonsense Guide to Selecting an EMR
Examples of EMRs
OpenSource
Commercial
Lessons Learned


Introduction to EMRs
Introduction to EMRs
Why do we need Electronic Medical Records
(EMRs)?
Many problems with the current healthcare system
(underuse and overuse)
30% of children receive excessive antibiotics for otitis
20-50% of surgical procedures are not necessary
50% of back pain x-rays not necessary
50% of elderly patients dont get a pneumovax
Introduction to EMRs
Why do we need EMRs?
Clinical practice is a data intensive operation a
Inadequate data communication causes
medical errors
Human cognition is good at pattern recognition
but not at remembering lists or evaluating
multiple business rules.
Why do we need EMRs?
Available 24 x 7
Can be viewed by more than one user at a
time
Is available from remote locations
To covering MDs
Others with appropriate needs
Data can nearly always be found
Is legible

Why do we need EMRs?
Enhances Communication:
Between providers--clinical messaging
Can tag EMR location with message
Referrals
Half of specialists didnt know what main question
was
A third of the time no information came back to
PCP

Why do we need EMRs?
Cost Savings:
Dictation cost savings
$170/FTE/month
Chart pull savings
$217/FTE/month
Savings accrue to practice, apply to all payers

Why do we need EMRs?
Assist with Decision Support:
Many domainscost and selection of:
Drugs
18% reduction found by Overhage
Lab tests
10-15% reduction in cost for charges, last result,
probability of abnormal
Radiological studies


Why do we need EMRs?
Decision Support:
In inpatients, computerizing ordering decreased
Serious medication errors by 55%
All medication errors by 81%
EMR can help by
Structuring medication orders
34% error rate with paper vs. 6% with electronic
Alerting about
Allergies
Duplicate medications
Many other issues

Introduction to EMRs
Do EMRs make a difference?
UNEQUIVOCALLY YES, BUT AT A COST!
In multiple studies, EMRs have been shown to:
Shorten Length of Stay in a Hospital setting
Decrease Adverse Drug Events (ADEs)
Improve Readability, Consistency and Content of
the medical record
Improve Continuity of Care
Reduce practice variation
Most benefits come from Decision Support.
EMR Use in the United States
Even though the US Health Care system is
the costliest in the world, its performance
ranks 37
th
in the world according to the
WHO!
Only 5% of US primary care providers use
EMRs (Bates et. Al., JAMIA 2003), 7% of
all physicians (Wang, Bates, et. Al.,
American Journal of Medicine, April 2003)
EMR Use Around the World
Use PCs Use EMR
Australia 90% 53%
Denmark 95% 62%
Netherlands 95% 88%
Sweden 95% 90%
United Kingdom 95% 58%
(c) 2001 Harris Interactive
Breakdown by Function - 2002
Australia UK
Use EMR 90% 99%
Of Those:
Prescrip 100% 80%
Notes Unknown 45%
Reminders Unknown 70%
Clin Vocab 15% (ICPC) 100% (Read)
Paperless Unknown 45%

$2B initiative by UK to get all physicians online
What is an EMR?
At their heart, EMRs are just a database
This database hold many kinds of information (coded
and not coded)
This database is organized by date, time, pat ID and
contains:
Patient registration data (name, contact info, DOB, SSN, etc.)
Test results (laboratory, radiology, nuc med etc.)
Medications (active, inactive) and Allergies
Current list of diagnoses and problems
Appointment Data
Clinical Notes
Billing Information

What is an EMR?
So if an EMR is just a database, how is it different
from other databases, and why is it so useful?
Value Added:
A Clinical Knowledge Heirarchy (term dictionary)
How do clinical concepts work together
Ex: Digoxin toxicity can occur with hypokalemia
A List of Current Clinical Recommendations
A List of Appropriate Medication Indications, Doses,
Adverse Effects and Interactions and Cost Estimates
Costs, Indications and Utility of Tests
What is an EMR?
What are some typical EMR Components:
Lab System: Contains all lab tests ordered and their
results and stored as coded results (LOINC etc.) in
many systems
Radiology System: Stores test reports
Pharmacy System:List of current medications, inactive
meds and when they were last dispensed or ordered
Billing System : A list of diagnostic codes used for
billing (ICD9, CPT, etc.)
Registration System: Names, Contact Info, Personal
Info, etc. for patients

What is an EMR?
Additionally, many EMRs have:
An Order Entry System (where physicians enter
orders, prescriptions, notes etc. online)
A Decision Support System
Often linked to the order entry system to
provide guidance at the point of care
Contains databases for clinical knowledge,
guidelines, list of medication indications,
doses etc.

What is an EMR?
The spectrum of EMRs
EMRs target specific user bases, from solo
office-based practices to large, multispecialty
tertiary care centers
Many features are thus directed at managing
workflows specifically to these user bases
For example, large commercial EMRs unbundle
services such as clinical documentation, results
display etc. while office systems typically integrate
all of these under the same interface.
How do Clinicians Interact with EMRs


LAB SYSTEM
PHARMACY SYSTEM
RADIOLOGY SYSTEM
REGISTRATION SYSTEM
BILLING SYSTEM
Physicians
Clerks
Nursing Staff
Coding Staff
Patients
Insurance Co.
Order Entry/Results Reporting
Different Types of EMRs
EMRs dont necessarily need to be expensive and
complicated or require that a computer be used to
enter data
Can have hybrid computer/paper based
approaches
Ex: In the CHICA System, paper is used to interact
with an electronic data repository
Standardized paper forms are printed and then
scanned
Characters are recognized and the electronic data so
generated interacts with the data repository
Different Types of EMRs
At Indiana University, pediatric clinics use this
system:
A data repository was developed using Microsoft SQL Server
A clinical guideline system was written in Arden Syntax
An optical character recognition system called Cardiff Teleforms is
used to process handwritten numerical data on preprinted scanned
forms
The data so generated is stored in the database and dynamic
reminders are generated for the physician
These are printed on the clinic computer
The entire operation takes < 2-3 minutes!

Different Types of EMRs
The Mosoriot Medical Record System
Indiana University has an HIV Effort in Kenya
A Simple MS Access based database holds all
patient records (3 years worth!)
Provides forms for data entry, standard term
dictionary, medication listings, registration
system, clinical documentation system etc.
Created by 1 programmer over 2-3 weeks!
Highly effective, easy to maintain, inexpensive!
Data Sources
So how can EMRs populate their databases?
Data can come from many many sources:
Admission/Discharge/Billing
Anesthesia Systems
Cytology Systems
Diagnostic Imaging Management Systems
EKG Carts
Endoscopy Systems
ER Systems
Data Sources
More Data Sources:
Home Care Systems
ICU Monitoring Systems
IV Fluid Infusion Control Systems
Laboratory Systems
Nurse Triage
Order Entry Systems
Pharmacy Systems (Inpatient/Outpatient)
Pulmonary Function Systems

Data Sources
More Data Sources
Radiology systems
Risk Management systems
Registration Systems
Scheduling and Clinic Charge Systems
Transcription Systems
Unit Dose Dispensing machines
Ventilator Management systems
Data Sources
So if there are so many data sources
available and so many people are interested
in using EMRs, why are they not more
prevalent?
The Challenges of EMR
Implementation

Problems with Electronic Data
For the last 30 years the medical informatics
community has struggled with how to architect the
vessel that will hold patient data
Problem is that they have focused on the wrong
problem!
We dont just want to create a system that permits
entry of data electronically, we want to create a
system that can acquire this data automatically
from other electronic data repositories and make
it available at the time of service.
Problems with the Data Sources
Too many repositories or islands of systems
Difficult to bridge and combine in useful ways
Contain different data at different levels of granularity
Each uses a different code to identify the same
information.
Many institutions do not capture all of the data of interest
to clinicians.
Labs are sent to external reference laboratories
Patients fill their scripts at community pharmacies
As a result many implementations do not lead to
satisfactory achievement of the intended quality assurance
goals
Problems with Data Sources
Another problem is that there are many many care
providing sites in the United States:
Hospitals 5000+
Nursing Homes 19000+
Pharmacies 59722+
Physician offices 200000+
Laboratories 63000
Emergency Rooms 4856
Hospice Care 2800
Home Care agencies 4258
All of these sites generate data that are not necessarily
compatible.

Problems with Electronic Data
Thus, the problem is not one of creating database
fields de novo, it is one of merging existing fields
from many different sources in meaningful ways

When commercial and other EMR vendors create
proprietary, closed, systems, with custom database
architectures, they often worsen the problem and
make it harder to populate the database with useful
information, inexpensively
(1) The Role of Standards
Fortunately, most of the informatics community
has realized that the solution to the problem of
merging data lies in the implementation of
Standards for Data Communication.

These standards permit data to be easily translated
from one database system to another
(1) Standards
There are many many standards, each for a
different purpose
Lab Data Communication
General Clinical Messaging
Radiology Image Transmittals
Diagnostic Coding
Procedure Coding
Need to distinguish between coding standards and
messaging standards.
(1) Standards
HL7 (Health Level 7)
Most widely used standard
General clinical messaging standard
Communicates structured data
Fields for:
Diagnostic Results
Notes
Referrals
Scheduling Information
Nursing Notes
Problems
Clinical Trials data
(1) Standards
Health Level 7
2000 hospitals, the CDC and most referral labs.
Also used in Canada, Australia, New Zealand, Japan
and extensively in Europe
Bridges many systems, including laboratory, dictation,
pharmacy, electronic patient records, performance
databases, data repositories (cancer registries) etc.
Web Site:
http://www.mcis.duke.edu/standards/HL7/h17.htm
(1) Standards
LOINC
Logical Observations and Indicators Names and
Codes
A coding standard that is used for LAB data
Used for representing laboratory observations
and common clinical measurements
At least 5 large commercial labs (Corning,
MetPath, LabCorp, ARUP Labs and Life
Chem) have adopted LOINC
(1) Standards
DICOM
Another messaging standard
Standard of choice for transmitting diagnostic
images
Closely supported by all of the imaging vendors
and is working with the HL7 group
Web site:
http://www.xray.hmc.psu.edu/dicom/dicom_
home.html

(1) Some other coding standards
ICD9/10 Used to code diagnoses
CPT Used to code procedure data
ISO+ - Used to code units of measure
UMDNS Device classification standard
NDC Drug entities classification
SNOMED organism names, topologies,
symptoms and pathology
HOI Outcomes variables
UMLS Metathesaurus for clinical nomenclature
Arden Syntax Clinical knowledge
(2) Patient Identification
How do we ensure that the information
belongs to the correct person?
Patients move and change addresses/tel#s
Patients change names or use aliases
Patients sometimes have multiple SSNs
There are differences in patient, provider and
place of service identifiers among data sources
(2) Patient Identification
Solutions to this problem do exist but at a local
institutional level at the moment
Our institution uses a combination of mothers
maiden name, SSN and DOB to uniquely identify
the patient

The Kassebaum-Kennedy Bill (PL 104-191) will
make this into a national effort and standardize
patient and provider identifiers
(3) Physician Data Capture
The ultimate EMR promises to capture whatever
data is needed to perform any EMR task
outcomes analysis, utilization review, profiling
and cost estimation.

This prospect excites many CEOs and CIOs

However, much of the data needed for such
functionalities comes from physicians (disease
severity and clinical findings) and most of this
data is recorded as un-coded free text.
(3) Physician Data Capture
In order for physician generated data to be useful
it needs to be in coded form so that algorithmic
assertions can be made

The problem of coding free text data is of
paramount importance and information systems
designers have struggled with this as long as the
field of medical informatics has been in existence
(3) Physician Data Capture
One approach we could take would be to translate
existing free text dictations into coded, computer
readable information, but:
Human coding is error prone and expensive and is at
too high a level of granularity to be useful
Decades of research into computer based coding has
still not yielded satisfactory results
Or the physician could code the data themselves
by entering structured notes but:
This is costly in terms of time as it requires the user to
map the terms into computer understandable words at a
level of granularity which is useful
(3) Physician Data Capture
Commercial EMR vendors bypass the problem
and provide every mode of data entry possible:
Direct keyboard entry
Dictation with human transcription
Voice Recognition
Structured Data Entry
Paper based data collection
Web/PDA/Mobile devices
Problem is that we dont know which one is the
most efficient so users have to think with their feet
(3) Physician Data Capture
We did a study at Indiana University comparing voice
recognition with typing and dictation/transcription and
found that (at least for 1 user):
Voice recognition almost doubled the note size as
compared with typing
It took longer to use voice recognition by 1.3 min as
compared with typed notes
Voice recognition was 30 fold less accurate than
dictation/transcription
During proofreading, the user missed 30% of errors
1.2% of errors changed the intended meaning
Dictated note turnaround time was from 2-5 days!
(3) Physician Data Capture
Managers and quality analysts want data that is
often never captured
Formal functional status
Detailed Guideline criteria
And we dont even know how much of this kind
of information is needed?
For some disorders (angiography and knee surgery)
data sets have been developed but we do not know the
operating characteristics or predictive value of the data
elements?
How do we define and collect the soft data elements?
(3) Physician Data Capture
We do have some instruments for some disorders
(CAGE, Hamilton Scale, SF12/36 etc.)

But we lack them for many other clinical entities
and for much of specialty clinical care

And checklist based symptom questionnaires as
opposed to validated instruments elicit many more
symptoms than open ended questions, so which of
these are really important?
(3) Physician Data Capture
Coding of all medical information is unnecessary

So where do we draw the line?
(how much should be coded and how much can be
stored as free text) in order to maximize the utility of
the information.

The other issue is with longevity of clinical notes.
How often do you use a note from 2 years ago?
How long do we need to keep the EMR data?
(4) Cost
Cost is perhaps the biggest barrier to
implementation
Unfortunately there are few studies that have
looked at the long term ROI with EMRs
Most existing studies have been done by the
system vendors and so the data should be
examined with a cautious note
However, the data that is available suggests that
the ROI is excellent!
(4) EMR Cost Analysis Studies
Several studies are worth mentioning

(1) Renner et. Al. looked at implementing an EMR
in 1996 in 40 primary care practices
Its net present value (1996 dollars) was about $280,000
based on a 5-year model
They found that reducing the cost of medications and
preventing ADEs was of the greatest benefit in primary
care
(4) EMR Cost Analysis Studies
(2) Wang, Bates et. Al. looked at the cost of
implementing a full EMR in primary care as
compared with paper based chart systems
Primary outcome was the cost benefit per provider
over a 5-year period
Used average statistics from their institution
(Partners Healthcare, Boston), expert opinion and
national data to estimate costs
System Costs ($13,100 initial, $3100 each year + HW)
Induced Costs ($11,200 in year 1)

(4) EMR Cost Analysis Studies
(2) Wang, Bates et al.
Benefits resulted from costs averted ($/year)
Transcription savings ($2700)
Reduction in need for chart pulls ($5/chart pulled)
Drug cost savings and prevention of ADEs ($2200)
Laboratory and Radiology cost savings ($10,700)
Charge capture improvement ($7700)
Decrease in Billing Errors ($7600)
All benefits finally being realized in year 4

(4) EMR Cost Analysis Studies
(2) Wang, Bates et. Al.
Resulted in present value of net benefit (2002
dollars) to be $86,400/provider in year 5
Breaking down by EMR feature they got:
Light EMR (net loss of $18,200/doc in year 5)
Online patient charts only
Medium EMR (net benefit of $44,600/doc in year 5)
Adds an Electronic Prescribing Module
Full EMR (net benefit of $86,400/doc in year 5)
Adds Lab, Radiology and Charge Capture systems

(4) EMR Cost Analysis Studies
(2) Wang, Bates et. Al.
Conclusions: An Ambulatory EMR
Resulted in net benefits across a range of assumptions, which
increase as more features are added and as the time horizon
lengthens
Most benefit was derived from reductions in drug
expenditures, improved test utilization, improved charge
capture and reduced billing errors
The greater the portion of capitated patients the greater the
return, although benefits also accrue for fee-for-service patients
(but mostly to payers and not health care institutions)
Limitation: Did not consider malpractice reduction, increased
provider productivity or decreased staffing requirements.
Intangible benefits: Improved Quality and Decreased Errors
(5) Other Barriers
(1) Physician reluctance and fear that their
productivity may decline (which it does)
(2) Unreliability of EMR Vendors in a
volatile IT economy. Lack of adequate IT
support from the vendors
(3) Concerns over data security
Summary: Barriers to EMR Use
Too many data sources, no simple way to
coordinate and connect them except to use
standards which are still evolving
Unique patient identification still a problem esp
in large tertiary care centers
Physician data capture inefficient and expensive
Summary: Barriers to EMR Use
Startup costs can be prohibitive but long term
benefits are clearly evident form pilot studies
Physician reluctance a major barrier to use
Concerns over security still an issue, eg: HIPAA
System vendors are transient and fail to provide
adequate support
EMRs for Clinical Research
EMRs for Research
So what EMR functions do we need in order to
effectively do clinical research?
Answer: Depends on what you want to do
However, to be able to ask questions of your
practice, you need:
Registration data (Registration system)
Diagnoses (Billing data)
Medications (Pharmacy data)
Labs and other Test Results (Lab/Radiology data)
AND
A system to query these databases intelligently
EMRs for Research
You dont necessarily need a decision
support or order entry system but if you
want to intervene, you may want to include
these systems as well

EMRs for Research
Note that the registration, billing, pharmacy and
lab/radiology data usually (but not always) exists,
outside of the context of any specific EMR system

These are just data repositories which need to be
tapped into and queried

So you need a system to access and query these
databases, independent of any electronic medical
record system.
EMRs for Research
Alternatively, you could build a master repository
which acquires and stores this information and
permits intelligent queries to be performed

This is exactly what we did in Kenya in the
Mosoriot Medical Record System, although data is
still hand-entered. Eventually it will be
downloaded using HL7 messages.
Mosoriot Medical Record System
An example of an EMR that is inexpensive and functional
and supports both clinical care and research in rural Kenya
Built in 2-3 weeks by 1 programmer using Microsoft
Access
Consists of:
Data dictionary tables which define test names,
medications, diagnoses etc.
Forms which are used for data entry
Has tables for registration data, billing data, medication
lists, lab and test results
Currently running on Tablet PC devices in Kenya

Research Workflow Model
LAB SYSTEM
PHARMACY SYSTEM
RADIOLOGY SYSTEM
REGISTRATION SYSTEM
BILLING SYSTEM
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EMR Features Conducive to
Research
Reliance on Standards (HL7, LOINC, ICD9, CPT)
Easy access to data repository, i.e. database
structure is well documented
Built-in Practice Profile Management systems
Built-in decision support and order entry
functionality
Able to export data in a standard format (CSV,
MDB etc.)

HIPAA Security
Introduction
HIPAA = Heath Information Portability and
Accountability Act
Final Security Rule Published in the Federal
Register on February 20, 2003 (effective 60 days)
http://www.cms.hhs.gov/hipaa/hipaa2/regulations/secur
ity/default.asp
Designation: 45 CFR 160, 162, 164
Compliance Dates: April 20, 2005
Covered Entities: 24 months after effective date
Small Health Plans: 36 months after effective date
HIPAA Security
Some excellent links:
http://privacy.med.miami.edu/glossary/gt_security_rule.htm
http://www.hipaadvisory.com/tech/wireless.htm
http://www.hipaadvisory.com/regs/securityoverview.htm
HIPAA Security
Security should not be confused with Privacy or
Confidentiality
Privacy: The rights of an individual to control his/her
personal information without risk of divulging or
misuse by others against his or her wishes
Confidentiality only becomes an issue when the
individuals personal information has been received by
another entity. Confidentiality is then a means of
protecting this information
Security refers to the spectrum of physical, technical
and administrative safeguards used for this protection
HIPAA Security
Addresses 3 tiers of protection:
Administrative Safeguards
Physical Safeguards
Technical Safeguards
Administrative Safeguards
Institutional level
Develop security management process where
potential threats to PHI are determined
Provide training to all employees about HIPAA
Provides appropriate level of authorization
based on a protocol for granting access
Violations should be clearly documented and
investigated
A disaster recovery plan should be in place
Physical Safeguards
Applies to 3 elements of the PHI data
storage infrastruture:
Facility where PHI data is stored
Workstations on which it is stored
Media on which it is stored
Physical Safeguards
Require that the facility have access control
Contingency plans need to be in place in case an
intruder gains access
Workstation security measures be in place
Automatic logoff
Screen is placed away from potential viewers
PDAs should be password protected
Devices and media should be appropriately
disposed of in case they are no longer needed and
data should be erased properly
Technical Safeguards
Applies to how information is stored, verified,
accessed and transmitted/received
Access and audit controls
Emergency access to information when needed
Automatic logoff is enforced
Data is encrypted and decrypted during
transmission
Verify integrity of the storage and transmission
(digital signatures)
Am I HIPAA Compliant?
Questions to ask yourself and your
institution
Questions to ask your institution
1. Was a security audit done and if so what are the
results?
2. Did I get the appropriate HIPAA training and
do I have a certificate to prove this?
3. Are there procedures in place to grant access to
PHI to authorized users?
4. What are the procedures in place in case of
disaster, data loss or data theft? Are Backups
made frequently?

Facility, Workstation, Media
1. What are the procedures in place to safeguard
the facility from intruders? Are there contingency
plans for dealing with intruders, data theft or other
event?

2. How do protect the safety of workstations? Are
they password protected?

3. Can bystanders view the screens on which PHI
may potentially be displayed?

Facility, Workstation, Media
4. Is an automatic logoff mechanism enforced?
What time limits are provided before this occurs?
5. What types of data are stored on PDA devices
and if PHI is stored is it password protected or
encrypted?
6. What procedures are used when disposing of,
reusing or archiving data on hard disks, CDs,
floppys and Zip disks? Are PHI data erased
properly if the disks are to be disposed of or
reused?

Data Level
1. Are there audit mechanisms for checking who is
accessing the PHI data and is this done on a
regular basis by authorized personnel?
2. Are there procedures in place to grant
emergency access to information if needed?
3. Is data integrity checked when the data is
transmitted or received? (digital signatures, digital
certificates, checksums etc.)
4. Is the data encrypted and decrypted during the
transmission process?
HIPAA Wireless Security
Before you Begin
Do I really need to be wireless of can I get
by with a wired connection?
Is space limitation a problem?
Is mobility absolutely necessary?
Do I have the permission of my institution
to install wireless networks?
Do I have adequate IT support to do this?
11 Steps to Wireless Security
Wireless is inherently unsecure
Many Many ways of hacking into wireless
networks
Technology base is there to make it secure
Some simple steps can be taken to
maximize the security of your wireless
network
11 Steps to Wireless Security
1. Change the default SSID (network
name) on the router so that your
name/location is kept secret
2. Disable the SSID broadcast, if your
router supports it. This will prevent
hackers from seeing you
3. Change the administrators password
on your router.

11 Steps to Wireless Security
4. Turn on the highest level of security
supported by your hardware (i.e. Wireless
Equivalent Privacy WEP, which is older or
WPA which is the latest and most secure)
5. Make sure you have the latest firmware
updates. Implement MAC (media access
control), which specifies exactly which WLAN
PC cards can access the network and
excludes others

11 Steps to Wireless Security
6. Place the Wireless Access Point (WAP)
towards the middle of the building, keeping
the zone of potential access within the
building.
7. Do your own security audit. Use Network
Stumbler (www.netstumbler.com) on your
Tablet PC, laptop of PDA and walk around
the perimeter of your building to see where
and what a would-be hacker may see
11 Steps to Wireless Security
8. If you have a limited number of wireless
clients (Tablet PCs), provide them with static
IP addresses, and disable DHCP on your
router. This ensures that only authorized
machines can see your network.

11 Steps to Wireless Securit
9. If we are in an enterprise setting, use
VPNs (Virtual Private Networks). You can
isolate your WLAN from the wired network
using products such as the Netgear FVM318
or the SonicWall SOHO TZW. Then you can
use the VPN to tunnel directly into the wired
network securely
11 Steps to Wireless Security
10. Avoid using public hotspots, areas that
are insecure and open for general use.

11. Turn off file and print sharing on your
Tablet PCs. Most devices do not prevent
client-to-client traffic, so people sitting across
the street from you can be looking at your
shared directory remotely.

Guide to Selecting and
Deploying an EMR
Selecting an EMR
Award winning EMRs
CPRI Davies Award Winners (1995-2000)
Emphasis on successful implementation, not on
technology that is behind the design
Functional Requirements:
Integrate data from multiple sources
Provide decision support
Used by caregivers as primary source of information
Must enhance care, not just replace paper
So who are there award winners and what are their
strategies for success?
Davies Award Winners
1995 Intermountain Healthcare System, Salt Lake City
Columbia Presbyterian Medical Center
Department of Veteran Affairs CPRS (now open-source)
1996 Brigham and Womens Hospital
1997 Kaiser Permanente, Cleveland OH
Regenstrief Medical Record System
North Mississippi Health Services
1998 Kaiser Permanente, Portland OR
Northwest Memorial Hospital, Chicago
1999 Kaiser Permanente, Rocky Mtn. Region
2000 Harvard Vanguard System
Davies Award Winners
Common Strategies and Attitudes
towards implementing EMRs
Common Strategies
Vision of healthcare as an information
business
Sustained leadership (5 years +)
Run by project leaders and not CIOs
Most projects had physician champions
EMRs subjected not to a cost benefit ROI
analysis but to an unremitting pressure to
show value
Common Strategies
Customer Service, Customer Service!
Frequent, sustained, end-user orientations and
feedback with demonstrated responsiveness to
feedback!
Weekly Regenstrief Pizza Meetings
Kaiser physician focus groups
Northwestern weekly feedback with supplements
System developers were also the salespeople,
troubleshooters, coaches and colleagues!
Common Strategies
Plans in place for system evaluation and change
management
All winners had to re-engineer some workflow
process dont automate a manual process that
occurs commonly but does not work!
Incremental deployment dont rush things
Each increment overcame a specific barrier to
care
Systems were viewed as tools to enable care
process improvement and were not an end to
themselves
Common Strategies
All resulted in a decreased reliance on paper-based
sources of information
Decision Support, Decision Support, Decision
Support -> provides the largest value added
compared to a paper system
Focus on standards based data architecture rather
than specific applications to do this or that
FAST RESPONSE TIME!
Flexible enough to adapt to organizational change
So what can I do to implement an
EMR in my practice?
Can I implement an EMR?
Depends on your size and your budget
Solo practice -> yes, definitely
Multispecialty group (2-100) -> probably
(cost is around $4-20K per provider)
Multispecialty, multisite groups maybe
Tertiary care centers with scattered
secondary care sites -> probably need to be
brave and wealthy!
What EMR should I choose?
Do not start in product selection mode
Begin by identifying the practice processes
that you wish to improve first
Then search for the functions you need:
Problem List Medications
Clinical Encounters Lab/Xray/Pathology
Telephone Calls Referrals
Preventive Care Managed care
Which EMR should I choose?
Anticipate primary and secondary users
Primary
Clinical decision making,
Documentation
Support for Billing
Secondary
Provider profiling and service utilization
Quality report cards and outcomes analysis
Regulatory reporting and justification for studies
What if I have a limited budget?
Again, think of using selected modules to
enhance parts of your practice
Clinical Note Systems
Prescription Writer
Use one or more of the OpenSource EMRs
Need some level of IT expertise to deploy
No real support available from the developers
Examples of OpenSource EMRs
a. OpenEMR (http://www.synitech.com/openemr/
<http://www.idltechnology.com/products/openemr/index.php>)
b. Care2002 (<http://sourceforge.net/projects/care2002/>)
c. Open Infrastructure for Outcomes UCLA
(<http://sourceforge.net/projects/open-outcomes/>)
d. PatientRunner (<http://sourceforge.net/projects/patientrunner/>)
mental health record system
e. OpenSDE (<http://sourceforge.net/projects/opensde/>) structured
note entry system
f. MedSurvey (<http://sourceforge.net/projects/medsurvey/>) clinical
information system for Windows PCs
g. OpenEMed (<http://sourceforge.net/projects/openmed/>) Java
based EMR
h. Hardhats (VAs VISTA software) yes this IS open source now and
available to EVERYONE (<http://www.hardhats.org/>),
(<http://sourceforge.net/projects/hardhats/>)

EMRs for Primary Care Practice
Recent survey done by the journal Family
Practice Management (2001)
Surveyed 28 vendors
Price structure highly variable
Found that the market is highly volatile and
some vendors went out of business or
merged with others during the time of the
survey

EMRs for Primary Care Practice
Five star systems:
ChartWare
HealthProbe Patient Information Manager
EpicCare

EMRs for Primary Care Practice
Four Star Systems
Logician
NextGen
Pearl
Physician Practice Solutions
PowerMed EMR
Practice Partner Patient Records
QD Clinical
EMRs for Primary Care Practice
Four Star Systems
SOAPWare
Welford Chart Notes
Clinical Works Module (ASP)
NextGen (ASP)
Physician Practice Solution (ASP)
topsChart (ASP)

EMRs for Primary Care Practice
4+ physician practices:
ENTITY, Logician, NextGen, ClinicalWorks
10+ physician practices:
EpicCare, PEARL, Physician Practice Solution

All others can serve practices of any size
EMRs for Primary Care Practice
Most allow ICD9 and CPT codes
Many allow access from the web
Most allow multiple modes of data entry
(keyboard, mouse, touch-screen, light-pen,
voice recognition etc.)
Most permit integration of hospital data
with a primary care database
Integration with Handhelds
Some EMRs allow data access from PDAs
and other handheld or laptop devices:
ChartWare - O-HEAP
DOCU*MENTOR - Partner
ENTITY - PowerMed
EpicCare - SOAPWare
MedicWare - Welford ChartNotes
NextGen - ClinicalWorks
topsCHART

Other EMR Surveys/Resources
HealthCare Informatics 2004 Resource Guide
Comprehensive listing of EMRs, features,
costs, contact information etc.
$50 per copy
Order from:
http://www.healthcare-informatics.com
Some Lessons Learned
Lessons learned the hard way
Well-designed renowned vendor products
meet about 80% of your needs -> where
will the other 20% come from?
Poorly designed systems will be quickly
abandoned by time-pressured end-users
Caveat Emptor: Total Solution, Turnkey
solution, esp if a proprietary black box
Lessons learned the hard way
Clinical/Administrative information is
inherently structured. Capturing it in
unstructured ways (images) is a costly
mistake
Data acquisition costs may be more
expensive than operational expense (I.e.
keyboard entry time more costly than
provider input)
Lessons learned the hard way
Users will accept a tradeoff if there is a
clear payback in functionality
Attitudes towards computer use are not age
dependent
Be the 10
th
customer to a vendor, never the
first!
Beware of vendors who say we can do that
what is it?
Lessons learned the hard way
The most important information a vendor
will give you is the address of 2-3 sites
where their system is currently in use

Acknowledgements
David Bates, MD
Daniel Masys, MD

DISCUSSION AND
QUESTIONS