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February 7, 2005

EMR: Sending Info With Images
By Robbi Hess
Radiology Today
Vol. 6 No. 4 Page 14

Switching to an electronic medical record (EMR) reshapes workflow just as PACS significantly alters radiology workflow. The Vioxx recall provided an opportunity to flaunt one of an EMR’s flashier attributes. While patients at paper-oriented facilities may still not know the news, members of EMR-based systems received almost immediate notification.

Beyond Radiology
In many ways, the radiology department can be cut off from the rest of the hospital and healthcare system. Colleagues and patients come and go for imaging procedures, then return to other areas of the hospital. The higher up the management ladder you climb, the more you’ll need to interact with the rest of the system. This feature is part of an occasional series addressing topics that usually happen outside your department but can affect your career. Eventually, radiology PACS and RIS solutions will be linked to hospital and systemwide electronic medical record systems to create a powerful patient care and efficiency tool.

The Vioxx recall showed how electronic medical record (EMR) systems clearly contribute to the quality and efficiency of patient care. Prior to the advent of the EMR, the task of contacting patients in the event of a pharmaceutical recall was insurmountable, according to Jim Morrow, MD, of North Fulton Family Medicine in Georgia. “There is no way in a paper chart-based practice that we could have purged the records for who takes Vioxx and who needs to be notified,” he said. “In the past, patients either read in the newspaper or heard on the television or radio when medicines were recalled, and it was up to them to get in touch with their physician.”

Morrow said the Vioxx recall, while important, wasn’t an urgent matter. “The study that generated the recall targeted those people who had been taking the medication long term, as there is the potential for adverse health risks with [the] medication’s prolonged use,” he said.

Lynn Boecler, director of pharmacy services for Evanston Northwestern Healthcare in Illinois, said there are a couple different levels of drug recall—an immediate stop usage recall or, as in this case, where Vioxx was being withdrawn from the market. “We did notify the patients immediately because we could,” she said.

Boecler explained that the pharmacy became involved in the recall in this instance because it involved in-patients. “Vioxx is a very common drug and it’s used in many pre-op procedures. Because we use the electronic medical system, we were able to quickly identify how many order sets were in place, recommend new meds for those orders, and replace the order sets.”

Chart Search
In a paper world, Boecler said it would be almost impossible to accomplish the task of pulling the meds. “In the past, with paper charts, this recall would have taken several people and several days of overtime to have effected the recall, and I don’t feel confident that we would have identified everyone,” she said.

Tom Ewing, MD, medical director at PeaceHealth, Oregon, explained that Vioxx was recalled because of the increased heart disease risk inpatients who have been taking the drug for a prolonged period. Vioxx is a medication prescribed predominantly for pain and is used by arthritis sufferers. “There wasn’t a chance that the next pill a patient ingested would be fatal, but the recall and our ability to contact our patients gives them the peace of mind needed to make a wise choice on discontinuation of its use,” Ewing said.

EMR systems are not a new technology, Morrow explained. “It’s the acceptance of the EMRs that has been very slow,” he said. “Many physicians are reluctant to spend the amount of money necessary to purchase and implement the program. Doctors, like a lot of people, aren’t in too much of a hurry to change the way things have already been done.”

The switch to an EMR is indeed a significant departure from the way most medical records are kept, just as PACS significantly alters radiology workflow. “What many physicians don’t realize is that in the long run, the change to electronic records will save them a tremendous amount of money and time,” Morrow said. “Prior to EMR, more than an hour was spent every day simply handling the chart—not the data, the chart.”

Speedy Access and Info
An EMR system provides access to a single, unified source of clinical information and images that can be used by doctors, nurses, pharmacists, lab technicians, and other medical professionals. The EMR system integrates computerized physician order entry with EMRs, so all patient charting, ordering of tests, procedures and medications, registration, scheduling, and physician billing are done electronically through one system. In some systems EMR links to RIS and PACS information, tying radiology images and information to the record.

PeaceHealth integrated the use of an EMR in late 1995. Ewing says the system was introduced to hospitals in a limited capacity in the mid-90s and was later implemented into the outpatient environment. “Having the system is about having access to the right information at the right time in the right format to take care of patients,” he said. “If the patient information had been locked up on a chunk of paper that was only accessible during office hours in a limited way, that wouldn’t have satisfied our criteria of patient-centered care and it certainly would have hindered the recall efforts.”

The Vioxx recall demonstrates the power of an EMR. Within hours of receiving the recall announcement, physicians at Evanston were able to build an alert into the patient record system that blocked new prescriptions or renewals for Vioxx, offered other medication options to physicians, and provided a link to the FDA press release with detailed reasons for the recall. Because of the EMR system, Evanston was also able to simultaneously identify any patient who had ever received a Vioxx prescription, which amounted to more than 2,700 in the past 18 months. A message was sent to each patient’s doctor’s office, allowing the physicians to be proactive in contacting their patients.

At PeaceHealth, Steve Mosier, RPh, MS, manager of medical applications, said that when he heard Vioxx had been recalled, he sprung into action. “First, because we have a shared system, we removed Vioxx from the list of prescriptions that physicians can order, put measures in place to prevent future prescriptions from being generated, and created a series of lists identifying those patients that were on or had recently been prescribed Vioxx,” he said.

Ewing said patient lists were forwarded to regional analysts, who in turn disseminated that information to individual practitioners within PeaceHealth’s group. “We delivered the recall message to all operations areas, and in parallel with that we had a pharmacist within the group write a physician paper summarizing the issues and the options available to the physicians,” he noted. “We felt that information was necessary so our doctors would have access to expert guidance and to let them know what their course of action should be.”

Ewing said the Vioxx recall is only a minor illustration of the need for a viable database. “A major example of its benefit to a practice is to have access to a registry for chronic disease management, such as patients with diabetes,” he explained. “We’ve had great success with tracking our diabetic patients and providing reminders and notifications to physicians.”

Morrow agreed that the ability to track a patient’s list of diagnoses allows for a higher level of patient care. “Almost as important as tracking patient diagnosis is the ability to electronically generate prescriptions,” he said. “Everyone can read the prescriptions, and that greatly reduces any chance for error when someone is reading and filling the prescription. The EMR also alerts the physician to possible drug interactions when writing prescriptions.”

Julie Schnell, director of clinic services at Kimball Health Services in Nebraska, agreed that their practice has seen more efficiencies since an EMR system was installed. “We’ve reduced staff time on filing papers and patient information is easily accessible to all physicians,” she explained. “And we haven’t ‘lost’ a chart in more than two years.”

While Schnell says having the electronic system was instrumental in contacting Vioxx users, it is just as crucial in the everyday operations of the practices. “The charts are legible and easy to read, as are the prescriptions generated by the physicians,” she said. Kimball Health is also considering integrating voice-recognition software into the system to make it more user-friendly for the doctors.

Improving Care
With the neverending burden of federal and state regulations and the demand for better outcomes, technology is definitely the way to go, Schnell said. “This technology [EMR] has the possibility of enhancing patient care by allowing patient information to be delivered where it is needed in real time,” she stated. “Currently, rather than wait for paper records, many tests are repeated due to delays in the paper process. When physicians have access to real-time patient information, it eliminates the need for duplicate testing, they have access to other consult reports, and have a better picture of the patient’s health.”

Information technology, Schnell explained, has the potential to upgrade the health of patient populations. “Being able to mine data, automate follow-up and care protocols, and evaluate courses of treatment are just a few of the benefits,” she said. “Having a patient history that can travel with the patient should allow for greater efficiencies in the healthcare industry, [and it] has the potential to reduce costs. And the risk of patient exposure to duplicate testing could be diminished.”

Morrow said that in 2005, physicians can’t continue to practice as they did in 1964. “I’m a better physician and my patients receive a higher level of care since we started using the EMR. I spend more time listening to my patients and less time documenting my conversations.”

Mosier said patient confidentiality is protected by a tiered security level built into the EMR system. “We have a security analyst who oversees what happens within the regional levels to ensure that we are in compliance with Health Insurance Portability and Accountability Act regulations,” he explained. “Also, the log-in preferences built into the system limit access by individuals based on their role within the organization.”

Another element that is built into the system is time-outs for screen access. “If someone walks away from the terminal, it logs the user off,” he said.

Patient privacy (HIPAA) forms are signed by patients and scanned into the records. “Patient confidentiality is a must,” Morrow said. “In our office, there are different levels of security for accessing patient records, and some levels require two passwords.”

Whether a Vioxx patient was contacted via letter, telephone call from the physician’s office, or automated voice technology, the fact that notification could be accomplished in a matter of hours rather than days was because information was only a few keystrokes away in the patients’ EMRs. And had the recall been a more immediate life-threatening situation, time certainly would have been of the essence.

— Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.

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