EMR forms foundation of digital healthcare

Changes in the way medicine, including radiology, is practiced are imminent, and the increasing costs of care are driving those changes. One way to meet the challenge head-on is to move to a fully automated healthcare system, starting with the electronic medical record, according to Dr. Leo F. Black.

Black, retired CEO of the Mayo Clinic in Jacksonville, FL, described the clinic's long and arduous journey to digital automation in a presentation at the Society for Computer Applications in Radiology meeting in May. The clinic determined in 1992 to improve service to patients, increase efficiency, and decrease costs by implementing an electronic medical record.

"We decided then to devote our energy to putting all of our clinical information into an electronic format," he said.

Once that information had been digitized into one large database, various software programs that could extract information for particular needs would be overlaid on the data.

Implementation was far from easy, Black said. The hospital system, with an outpatient center and three primary clinics, is still putting the final touches on its digital automation process.

Automation of the outpatient clinic and primary-care facilities was completed in 1996, but the momentum slowed in 2000 as the hospital redirected its efforts toward handling a major move and the potential Y2K problem.

Momentum is an integral part of moving to healthcare automation, according to Black.

"If you slow down, people start jumping from the canoe," he said.

Another major challenge is the amount of behavioral change automation requires from everyone involved in providing healthcare. Implementing an EMR eliminates much of the support, such as transcriptionists, that physicians have traditionally relied on. Doctors have to become more self-contained, Black said. And as insurers and employers pay less, and patients must pay more out of pocket, doctors should learn the direct cost of healthcare for their patients.

While these behavioral changes may sound painful, they are crucial, he said. Not only will they result in cost reductions (the clinic experienced up to 32% in savings as measured by internal rate of return), they will ultimately improve the quality of healthcare. Innovations such as providing kiosks throughout the hospital to give patients up-to-date scheduling and billing information and visiting with patients electronically in their homes are among the future advances that an EMR and healthcare automation might enable.

"Physicians have to begin to be the change agents in this arena. They have to sell these changes because they will do a lot of good for a lot of people," Black said.

One change the digital patient record has brought to radiology is a shift from traditional morphology-based reports to more radiological consultations, according to researchers at the University of Texas M.D. Anderson Cancer Center.

A current trend is to integrate radiology workstations with clinical information systems, said Dr. Kevin W. McEnery, associate head of informatics at M.D. Anderson. Because information system integration provided radiologists with a bounty of clinical information, it became important to determine what information is most valuable for them.

McEnery and colleagues analyzed August 2003 audit files from the center's homegrown EMR, called ClinicStation, and its integrated RadStation PACS workstation. Both information systems recorded more than 20 million events, which the researchers analyzed to learn how radiologists and nonradiologists were using information such as radiology and pathology reports, laboratory results, and transcribed documents.

"Radiologists were looking at radiology reports almost 50% of the time," McEnery said.

This means they were accessing ancillary clinical information not related to radiology the other 50% of the time. Prior images and incomplete patient histories represent missing pieces of the patient puzzle, and accessing the entire database made available by the EMR allows radiologists to go beyond just providing morphology reports. They can offer expert diagnostic consultations, a necessary transition if radiologists are to stay clinically relevant, McEnery said.

The audit reports indicate that radiologists are already making use of the extra information that is available to them.

"Anecdotally, clinicians are telling me that we radiologists all seem a lot smarter then we used to be," he said.

Some problems with presentation of the ancillary data have arisen. Pathology reports that make perfect sense to pathologists may require more effort for radiologists. This problem could be solved by using more structured documents across the enterprise, according to McEnery.

The audit logs indicate that radiologists are active data users, he said, and radiologists should participate fully in development of future electronic medical records.