Paperless Medicine

Doctors’ lousy handwriting is infamous. Every day pharmacists stop customers to ask them what their prescriptions say, and patients pick up orders only to find that they’ve been given the wrong dosage or even the wrong drug. But those pharmacist misreads can mean more than mere hassles.

In a 1999 study, the Institute of Medicine reported that in 1993, almost 7,400 Americans died from medication errors. A decade later, such errors are still a major problem. GlaxoSmithKline, for example, has posted a notice on its Web site warning that patients with prescriptions for its antiseizure drug Lamictal have mistakenly received Lamisil (a medication for fighting nail fungus), Lomotil (an antidiarrheal), Ludiomil (an antidepressant), and other medications-sometimes with dire consequences.

One basic change-using computers to order prescriptions-has reduced   medication errors by as much as 80 percent in some hospitals. Motivated by such life-and-death statistics, a growing though still-small number of doctors and hospitals are weaning themselves from paper, using computers not just to order prescriptions and lab tests but also to track patients’ conditions, medications, allergies, and test results. “We could make tremendous advances in improving health care with the technology that we have in hand,” says Gilad Kuperman, associate director of clinical informatics research and development for Partners Healthcare System in Boston.

Those advances would be a welcome change from the messy, difficult-to-track record keeping that prevails in health care today. Typically, the primary care physician keeps one set of records, hospitals another, and each specialist yet another. And all of these medical histories are logged in old-fashioned paper “charts.” Any information a patient forgets to tell one of his or her doctors-about a severe allergy to a medication, say,-simply doesn’t appear in that doctor’s record.

Indeed, much of the nation’s health-care system is entering the information age kicking and screaming. While Amazon.com and grocery chains compile detailed records of customers’ buying habits, only about 5 percent of U.S. primary care doctors store information about their patients electronically. Resistance to adopting the technology abounds, rooted in doctors’ unwillingness to abandon decades-old ways of doing things and a perception that the benefits to the practitioners are not worth the costs. “McDonald’s has a better record of what they’ve served all their customers than we have of our patients’ medical histories,” says Isaac Kohane, a Harvard University medical informatics specialist and endocrinologist.

Still, the medical world hasn’t been able to entirely ignore the cheap and plentiful computing power and networking technologies developed over the past decade. The U.S. Department of Veterans Affairs now uses electronic records at each of its 163 hospitals, many of which are now essentially paperless. Increasing numbers of private hospitals and medical systems are implementing computerized patient records as well. About 1,500 primary care physicians and 11 hospitals use Partners Healthcare’s medical records system to keep track of several hundred thousand patients. And in February, Kaiser Permanente, the nation’s largest HMO, announced that over the next three years it would implement electronic records for all its 8.4 million members. As more doctors begin to train and work in such hospitals and realize the benefits of their systems, the hurdles to even wider adoption may slowly disappear. And as new genetic information drives medicine toward data dependence, electronic health records will become more than beneficial-they will be absolutely necessary. The medical databases of the 21st century will join the anesthesia of the 19th century and the antibiotics of the 20th as indispensable medical tools.

At the South Texas Veterans Healthcare System, doctors and nurses use a client-server system that links workstations and PCs and provides a graphical interface for reading and entering patients’ data. Each patient record includes such statistics as height, weight, and blood pressure; medical conditions (for example, diabetes); medications the patient is taking; and lab test results. Access to information throughout the VA’s nationwide network of hospitals and clinics is one of the biggest benefits to clinicians, says Vikie Schwartz, assistant chief of the South Texas system’s office of information technology in San Antonio. “We have a clinic in McAllen, which is about five hours away. They can view the same chart that we can view here, at the same time,” she says. If a patient from San Diego had a medical emergency while visiting San Antonio, the records from California would be accessible. Having lists of medications and test results so readily available allows doctors to avoid unnecessarily repeating tests or duplicating prescriptions, saving time and money.

The technology’s benefits go beyond convenience for the medical staff: patients get better care. Take the case of a 70-year-old man who came to the Audie L. Murphy Memorial Veterans Hospital in San Antonio early last December. The triage doctor diagnosed his bad cough as pneumonia and admitted the man to the hospital. Using a PC on the ward to log into the network, the resident on duty was able to check the patient’s medical history, including information from his last visit with a primary care doctor.

After assessing the information, the resident typed in instructions for the man’s care using the computerized order-entry system: prescriptions for intravenous Levaquin (an antibiotic) and an inhaled bronchodilator, orders for a chest x-ray and blood tests and dietary instructions. The system helps decrease errors and holdups in the delivery of medication and fulfillment of tests. “You make sure that the order is complete,” says Schwartz. “And there’s no delay in carting a piece of paper around.” Once the lab results were ready, the doctor could have viewed them from any computer in the hospital. “People who get in and start to use the system begin to realize the power of what they have,” says Gary Christopherson, who was formerly chief information officer of the Veterans Health Administration and is now senior advisor to the undersecretary for health in the VA.

The most compelling immediate advantage of electronic medical records is in their reduction of clerical errors. But once computers enter the picture, other benefits also become possible. Software can, for example, help doctors make better choices. So-called clinical decision-support programs can alert doctors to potentially dangerous problems with a drug or dosage, taking into account a patient’s weight, diagnosis, other medications, allergies, and factors, such as kidney function, that can affect drug metabolism. If the pneumonia patient already had been taking Lamictal to prevent seizures, the software might have flagged the prescription for Levaquin, which can exacerbate seizure disorders.

Clinical decision support can improve patient care in other ways, too, by helping doctors hew to routine treatment guidelines. The software might, for example, suggest that patients who are older than 60 receive flu shots. Although this recommendation might seem obvious, it is easy for a busy doctor to forget. “Doctors are more likely to comply with prevention measures if they have decision support,” says David Bates, a Partners primary care physician who has studied the benefits of electronic medical records. Kaiser Permanente has been experimenting with electronic records since the early 1990s, and so it now has the country’s highest rates of mammography and Pap smear screening, according to Andy Wiesenthal, the lead physician on Kaiser’s national implementation team.

Take a Number

Dramatic increases in computing power and connectivity, combined with studies that prove the benefits of using electronic medical records, have left doctors with little excuse for failing to adopt computerized record keeping, says Daniel Masys, director of biomedical informatics at the University of California, San Diego Medical School. Yet a 2002 study sponsored by the Kaiser Permanente Institute for Health Policy reported that the health-care industry spends only 2 percent of its revenues on information technology, in contrast to the 10 percent spent by other information-intensive businesses. And a 2002 report by the Institute of Medicine called on the U.S. government, health-care organizations, and payers to commit to building a national health-information infrastructure that would “lead to the elimination of most handwritten clinical data by the end of the decade.” What will it take to get from here to there?

“We’re in a very strange cultural warp,” says Masys. “The system as it is now is optimized for the autonomy of individual practitioners.” Electronic  records, with their emphasis on practice guidelines, force doctors to alter their workflow and push them toward standardized care. Some doctors complain that the systems are an “intrusion into the practice of medicine,” says John C. Joe, director of medical informatics at Baylor College of Medicine in Houston. “Most of the physicians here are at the tops of their professions,” he adds. “They feel that their clinical judgment and the skills they have acquired are sufficient” for patient care.

Doctors also worry about time. When systems are first installed, using them slows things down. “Our surveys have shown that using a computer takes 50 to 100 percent more time” than traditional pen and paper, says Peter Waegemann, executive director of the Medical Records Institute, which advocates electronic medical records.

But hospitals that use electronic medical records find that doctors who adapt to the systems don’t want to go back. And increasing implementation is slowly changing attitudes. The VA, for example, is one of the nation’s largest physician-training grounds; its system influences the way thousands of health-care providers work. “We have a whole flood of physicians and nurses and other people coming through training programs, touching the system every day, and then going on to other settings,” says the VA’s Christopherson. These medical practitioners especially like the ability to access data anytime and from anywhere in the hospital, he says. “People are asking, Why can’t we have a system like the VA?’”

Even supporters of electronic records, however, face the issue of expense. The technology offers better care for patients and lower costs for insurers, but individual doctors often bear the financial burden. A computerized order-entry system alone can cost a hospital $5 million, according to Halamka. John Glaser, Partners’ vice president and chief information officer, estimates that simply maintaining its system costs $5,000 to $10,000 per doctor each year. Most smaller hospitals cannot accommodate such expenditures.

The problem is even more acute for a solo or small group practice that could have to pay $60,000 to $70,000 for a commercially available system that might require continual outlays to keep it up-to-date. From a doctor’s standpoint, says Glaser, adopting the technology can seem like all risk and little reward. “It’s expensive, it’s disruptive, and it’s hard to get used to,” he says. And during the three to six months it takes for most doctors to get used to a new system, productivity can fall by as much as 20 percent, Glaser says.

The health-care system itself provides little motivation for adopting the technology. What’s needed, Glaser believes, is a breakthrough in motivation. One possibility would be for insurance companies to offer higher compensation to doctors who use electronic records systems that meet basic standards-in essence, a reward for providing higher-quality care. Some major companies already have started to exert such pressure. The Leapfrog Group is a coalition of such major corporate-insurance purchasers as AT&T, General Motors, and IBM; its members make health-care purchasing decisions on the basis of hospitals’ compliance with specific safety measures, including computerized order entry.

Direct federal grants to help physicians implement computerized records could provide an even bigger boost. The countries with the most extensive use of electronic medical records-England, Australia, and Sweden-have significant government programs that fund doctors. In England, 99 percent of general practices use an electronic records system.

Standard Care

Most medical-informatics systems are proprietary. This lack of standards is “the number one hurdle” in achieving wider adoption of electronic medical records, says Waegemann. Creating uniformly accepted medical and lab vocabularies, as well as protocols for data exchange, would make it possible for far-flung medical-records systems, lab computers, and insurance networks to talk to one another. Doctors and patients could access medical histories, even as patients move from doctor to doctor and state to state.

A number of organizations, including Waegemann’s Medical Records Institute, are pushing hard to establish such standards. The Markle Foundation, a New York Citybased philanthropy that promotes information technology for the public interest, has created Connecting for Health, a public-private collaboration, to advance national clinical-data standards. Government health agencies could also help in the drive to establish such standards; the VA has embarked on a joint venture with the U.S. Department of Defense to do just that. Because the medical records of active military personnel eventually become the histories of veterans, the two departments are collaborating to create fully interoperable systems-possibly with a single user interface. The initiative goes even further, reaching across the federal government and into private health-care organizations such as CareGroup and Kaiser Permanente. Standards arrived at cooperatively by the federal government and the private sector “will become the tipping point to creating at least national standards, if not potentially helping to create international standards,” says VA advisor Christopherson.

Nailing down standards should bring another major gain: helping electronic medical-records systems comply with federal privacy regulations. That benefit alone could be huge. It’s possible, says bioinformatics specialist Masys, “to create a high-assurance, high-security architecture built on the fundamentally unsafe infrastructure of the Internet.” For example, the technology used to encrypt financial information on Web merchants’ servers can be used also to protect confidential medical data. The real challenge lies in making sure these measures are properly implemented. Connecting for Health aims to help physicians and hospitals achieve this goal by identifying and promoting procedures that address privacy and security issues in electronic medical-records systems. With such practices in place, a hospital would be no more likely to run an insecure computer system than to allow surgeons to operate without washing their hands.

As consumers continue to demand a bigger role in-and better quality from-their medical care, physicians will become more inclined to adopt electronic medical records. As they do so, benefits beyond those for individual patients will emerge.

Consider, for example, the national effort to beef up defenses against a terrorist attack involving biological agents. Should victims of a bioweapon begin to show up in hospitals and clinics throughout New York City, it could take days or weeks for physicians to realize that the patients at the various facilities were suffering from a single attack. Software designed to mine data from computerized records could spot the trend quickly, setting off alarms. Recognizing the power of the technology, in January the U.S. government announced a multimillion-dollar effort to use information gleaned from medical databases to monitor for disease outbreaks and bioterror threats in a half-dozen or so cities.

The power of electronic records to connect the dots has implications far beyond the war on terror. As biomedical researchers discover more about the molecular bases of disease and the connection between genetics and health, medicine will become more and more dependent on volumes of data on individual patients. Medical records in the coming decade will incorporate not just demographics and medication histories, but also DNA sequences and gene expression profiles, which describe specific genes that are active in various tissues in the body. IBM Life Sciences, for example, has embarked on collaborative efforts to manage just such medical data in a pilot project with Hadassah Hospital in Jerusalem, Israel. IBM researchers have created an integrated medical record that contains such standard data as test results, physician observations, and lists of prescribed medications, as well as information on the patients’ genomes.

Health care will increasingly be a molecular-medicine view of health and disease,” says Masys. He cites as emblematic one research project that measures the gene expression levels in prostate tumors. Finding correlations between gene expression and the disease’s progression would enable doctors to provide more effective diagnoses and treatments but would require cutting-edge bioinformatics software. “The fusion of both computing technologies and biotechnologies is really the remarkable difference of our time,” Masys says. “If people look back a hundred years from now, they will see this dramatic turning point in human affairs with respect to health.”

Electronic records will enable that transformation, helping doctors make sense of mountains of data and enhancing the quality of health care. And now, with a big push from some of the nation’s biggest health-care providers, the technology’s stay in the waiting room may be nearing an end.

The Record Keepers