Electronic Medical Records
Posted on April 18, 2007
Considering the big news at work, I decided to do a teeny bit of research on Electronic Medical Records (EMRs). I still haven’t heard anything about specific plans regarding the new building and such, but I thought if it is going to have clinics, it would seem appropriate if a new state-of-the-art facility had an EMR system. It makes sense to me, though I can see the pros and cons, so I don’t know what the plan is.
Currently we use paper charts, which have their own pros and cons, but there is a movement within the medical field to move to EMRs. Some physicians rave about them, while others are dubious. The two big hurdles are cost and interoperability. Costs at the outset include buying computers to put in each room, buying servers that actually hold the files, setting up a backup (redundant) system to mitigate against a crashed server, software licenses, training the users, salaries of technical staff, and scanning each paper medical record into the system. That’s just the beginning and the costs can be incredible (FWIW, I haven’t gotten actual prices yet). After that the costs should stabilize mostly.
Interoperability is a concern because there are many, many purveyors of EMR’s and they each have their own file formats and ways of doing things. Also, while some EMR systems might be good at some things, they might be weak in other areas. Ophthalmologists look for certain things when they do an exam and note things in the chart, which is okay. However, they are also fond of drawing things and making diagrams of what they see on the exam. I don’t know of many systems that would allow that, though my investigation hasn’t gone that far yet. They are also fairly fond of having pictures taken. This is often a clinical necessity since they might want to know if a spot has grown in the past six months. They can take a look at the picture taken at the previous exam and compare it to the current exam to see if there’s been any change. To make a long story short, I think that costs aside, no EMR system is likely to be 100% of what the doctors want, so then we start weighing the various pros and cons.
All or most of our faculty work at the VA to some extent. Ophthalmologists are sometimes sub-specialized, in that they have done extra studies in certain aspects of eyes and eye disease. If a VA patient needs to see a certain sub-specialist, the sub-specialist will often see them in the VA clinic. Throughout the 80s and 90s the VA system developed its own EMR system. The VA is the largest medical system in the US with over 180,000 personnel, 100+ hospitals, 800+ clinics, and 100+ nursing homes. The VA’s EMR system connects all of those hospitals, clinics, etc so a veteran can go to any VA clinic in the US and their complete medical record will be there. A VA doctor in Indianapolis will be able to see what care the vet recieved when he went to Florida for the winter. The VA system used to be called the Decentralized Hospital Computer System (DHCP), but the latest version is called the Veterans Health Information Systems and Technology Architecture, a/k/a VistA (not to be confused with Microsoft’s latest operating system). I recalled some of the doctors mentioning that once they got used to using VistA, they were pleased with it. All of the doctors who go to the VA get trained on how to use it. Earlier this week, I found out something amazing about it.
It’s free.
Since VistA was developed at government expense and the government can’t profit from that work, it has been released into the public domain. I don’t know all of the legalities, but I know public domain is about as free as free can get. It’s free as in beer, and free as in freedom. Free is a big plus. The fact that the doctors are already trained on it is also a big plus. Of course there is a downside. The database backend for the Windows version isn’t free and I have no idea what it costs. The Linux version called Worldvista isn’t affiliated with the VA, though it is free, and it’s supposed to have the same functionality.
Another possible problem is that it is written in a language called M (a/k/a MUMPS). From what I understand, M was developed before C, so it’s a legacy language. That isn’t really good or bad, but there aren’t many applications written in M and few programmers have dealt with it. I saw a comment that said it was developed in M so M programmers could be sure they would remain employed. I looked on Amazon to see if they had any books on M or MUMPS and there were only a few, and some of those were written in the 80s and 90s. Talk about job security ;-) All that aside, VistA sounds like it is stable and mature, and it does what it’s supposed to do, so I guess I can’t complain too much.
I’m thinking of trying it out, but can’t decide between VistA and Worldvista. I have a Linux box at work running on an old apple G4, so I could try Worldvista on that, though I have a feeling there is a steep learning curve. Possibly on the upside, last year one of the faculty suggested I look into electronic medical records, apparently impressed by the VA’s system.
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Having been an EMR end-user for more than 10 years (Epic systems) I believe that it is the long-time Epic clients that slow down the progress of the EMR applications, especially those apps that have been around the longest (ambulatory). Physicians and other medical professionals are VERY resistant to change, especially when it relates to something that was difficult to adjust to in the first place. Epic has a fine line to walk, they need to keep current clients happy, try to keep up to date with technology and meet the expectations of new or prospective clients. Making a change to satisfy a new or future client could potentially damage relationships with existing clients who are happy with the system the way it is (was). This in combination with the lack of vendor technical support on technically challenging features available in the applications can have a significant impact on the number of upgrades that clients are willing to install.
We need to remember that an EMR is not a website. Users don’t log in to the system because they want to, rather they are forced to. Changes are not always appreciated, welcomed or understood.
I believe that EMRs have the potential to significantly improve the delivery of healthcare, however, the use of EMRs need to become more intuitive as well as adding new funtions to support the quality service goals.
From talking with the doctors about the system the VA uses, they compared it like this. Before the sytem, they would be able to see a certain number of patients in a day. When they had to start using the EMR system, theses numbers went down at first, because it was new and they had to get used to it, However, after a few weeks/months of using it they are back to seeing the same number of patients. The impression they have is that it makes them a little more efficient, but not a lot. The system took getting used to, but since many of the tasks are the same from patient to patient (i.e. entering notes) it didn’t take too long to get accustomed. The general assumption is that it’s not a panacea, though I think it may that they take things for granted.
However the VA system is slightly different that what may or may not happen at the Eye Institute. From what I understand, at the eye institute will only see private patients vs. staffed patients. (For private patients, the physicians get paid per patient, based on diagnosis, procedure, etc. For staffed patients, such as at the VA, the doctors get paid a set amount, regardless of how many patients they see, from what I understand.) Also, it will not be part of a hospital, so we might not have ready access to labs and reports from the patient’s other doctors. Of course, that, like all of this is up in the air.
Personally, I haven’t dealt with any full EMR systems. Since I deal with private patients at IU and Springmill, there are a few different systems in place. Most IUSM practices use IDX for scheduling. Clarian (owns IU and Riley) uses Cerner for orderings labs and tests, registration, some reports, and noting meds and allergies. It also has Careweb (which is a custom app I think) to retrieve labs and reports, though Cerner does the same thing a bit differently. It’s a lot of different systems that don’t talk to each other, so some users have to have two or three applications open. I think VistA might be able to unify a lot of those tasks.