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It's all in the details Electronic medical records help doctors remember things that add up Tuesday, July 31, 2001 By Christopher Snowbeck, Post-Gazette Staff Writer
After Robert Renk turned 50 in 1992, the former South Park resident visited his primary care doctor several times but never was told to get a screening test for colon cancer.
By the time he was 53, Renk was diagnosed with a terminal case of colorectal cancer that had spread to his liver and lymph nodes. Renk and his wife sued his doctor and last year won a $5 million judgment from an Allegheny County jury.
Contrast that with the story told by Dr. Grant Shevchik, a primary care doctor in Murrysville.
A man came in last year complaining of a cold. After treating the man, Shevchik passed along the conventional wisdom about colon cancer screening that doctors are supposed to provide men in their 50s. The man complied and screenings ultimately uncovered an early case of cancer that is now being properly managed.
Was Shevchik just a better doctor than the physician who treated Renk?
Not necessarily.
Shevchik credits his success in catching the cancer early to a computerized record system in his office.
"The electronic record turned on and said, this guy should have his Hemoccult done. It was an automatic reminder, totally unrelated to what he came in complaining about," Shevchik said.
"An electronic medical record doesn't think for you, it doesn't make diagnoses, but it enables you to practice better medicine by reminding you to do things."
Helping doctors provide proper health maintenance isn't the only benefit of electronic record systems. In hospitals, they can keep doctors from prescribing drugs that hurt patients because they mix badly with other medicines. Similarly, they can warn doctors about patient allergies.
Could the health care system work better for you? Your Health's "Doing No Harm" is an ongoing series about local programs to improve health-care quality -- be they hospital pharmacy systems that prevent medical errors or scheduling changes that reduce waiting time.
Putting health information in an electronic format does raise security concerns. There are also concerns that the competitive interests of individual health systems will prevent the sort of broad sharing among providers that could best serve patients.
But doctors say those problems shouldn't stall the promise of electronic medical records, which help ensure that doctors and nurses have at hand the information they need to best care for patients.
"There are a lot of reasons to try to move from something potentially lose-able and disposable to an electronic chart that is always available," said Dr. G. Daniel Martich, the executive director of a UPMC Health System initiative that is spending more than $300 million to create an electronic health record. "There's a tremendous care risk in just not having the data."
Using information technology to improve the system by which patients get care is one of the recommendations made earlier this year by the federal Institute of Medicine. Doctors and hospitals in Pittsburgh are beginning to respond to the call.
Care at the VA
More than perhaps any other system in the area, the Veterans Affairs Pittsburgh Healthcare System is using an electronic medical record to improve care. Look in any outpatient exam room at the VA's medical center on University Drive in Oakland, for example, and you'll find a doctor sitting before a desktop computer.
Dr. Chester Good began a routine check-up last week for a 76-year-old patient by typing his password and a security code into the system. Good then called up the patient's record, which lists active health problems, allergies, medications, vital signs and lab results. There's also a box where such reminders about preventive screenings pop up.
While talking with the patient, Good called up a file of notes from the patient's last office visit and copied the notes into a file on the current visit. Good uses the computer record from the past visit as a sort of template to guide each exam, so he'll be sure to touch on previous problems.
After talking about the past, Good got to the present by asking the patient about his recent trip to the emergency room. Without the electronic record, Good might not even have known to ask about the ER trip, let alone have access to the emergency physician's notes.
One of the selling points of the electronic system popped up when Good used the computer to write a prescription for the pain killer Motrin: The system immediately showed the patient's creatinine levels and gave the doctor the chance to cancel the prescription.
"His levels are OK, but if he had bad kidneys, I wouldn't want to give him Motrin," Good said. Creatinine, a breakdown product of creatine, an important constituent of muscle, is excreted by the kidneys. Abnormal readings would have indicated kidney problems.
Similarly, if Good had prescribed Motrin and the patient had already been taking the blood-thinning drug Warfarin, the system would have alerted Good to an adverse interaction between the medicines.
"There's definitely been drug interactions that the system has caught," Good says.
Some doctors are uncomfortable with the computer system because it lets administrators generate report cards about how well they are caring for their patients, Good said. But Good appreciates the feedback because "physicians over-estimate how good a job they're doing," he said.
Ultimately, these report cards will help doctors eliminate variations in care that patients receive, said Martich, the director of the electronic health record project at UPMC.
One example of variation: The percentage of women at different hospitals in the UPMC Health System who have a vaginal birth after a Caesarean. A state report earlier this year found that at Magee-Womens Hospital in Oakland, the VBAC was 48.6 percent, well above the statewide average. But the VBAC rate at UPMC Lee Regional in Cambria County was 7.1 percent, one of the lowest rates in the state. Electronic medical records will allow health systems to identify these variations and take steps to identify best practices in caring for patients.
UPMC has signed an agreement with Cerner Corp. of Kansas City to develop an electronic health record that will unite the entire system, including hospitals and doctor offices. For now, it's operating in pieces.
Beginning in May 2000, doctors could turn to 650 computers at UPMC Presbyterian and UPMC Montefiore to see copies of lab results, radiology scans and pathology reports. Since then, the system has grown to include notes from the catheterization lab and microbiology department. Last November, the emergency department began recording patient information on computers. The hospital system does not yet have the decision-support features of the VA's record, but a prescription program could be operating by the end of the summer.
Cerner's electronic medical record was developed for hospitals, so the collaboration with UPMC will involve creating a system that also works in doctor offices.
The pace of progress
That won't happen quickly.
One morning last week, for example, Dr. Anthony Fiorillo, UPMC medical director of the outpatient project, provided a demonstration of the system. After entering his name and password and opening the health record program, Fiorillo clicked on a patient's record to open it.
Then, he waited.
And waited some more.
About two minutes later, the chart finally opened to a screen that let him chose from a number of categories, including the patient's allergy profile, immunization history and medicine list. Fiorillo selected "problem list" to show the patient's active health problems.
But once again, he waited.
"My hardware people are going to hear about this," Fiorillo said.
Fiorillo and five other UPMC primary care doctors in their Oakland practice are working out the bugs in the system, but they hope to roll out the program to 450 UPMC practices in the next 28 months.
"That's mind-boggling to even think about," he said.
One of the great promises of UPMC's system is that it could link a vast hospital network with a huge network of doctor offices. But the task is complicated. Fiorillo said there are 47 different computer systems in the hospitals alone that provide information that doctors would want shipped electronically to the medical record.
"What they're trying to do here at UPMC is huge," said Dr. Richard Ambrosino, a primary care doctor who worked at the VA Pittsburgh Healthcare System before coming to UPMC to work on the electronic health record project.
UPMC is being very cautious about security. Currently, the system does not include full information about patients' AIDS or mental health problems.
The greatest potential of the system, some doctors believe, will come when hospital systems agree to share their electronic information with competing facilities. For example, if a UPMC patient lands in the emergency room of Allegheny General Hospital, that ER physician would also have access to the patient's electronic records.
Dr. John Lloyd, medical director of the Pittsburgh Regional Healthcare Initiative, is among those who see the VISA credit card system as a model, in which competing banks agree to share information to make the global financial system work.
However, hospitals such as UPMC are developing electronic medical records in part to attract physicians to their health systems, said John Quinn, who leads the health care technology division of Cap Gemini Ernst & Young.
"If it's used as a competitive instrument it can be costly and actually make things less efficient and more confusing for everybody," Lloyd said. If health systems don't share information, the potential will be lost.
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