Can your hospital help you get an EHR?

The patient presented with bleeding early in her pregnancy, and Arnold L. "Ned" Wagner Jr., an ob/gyn in Evanston, IL, suspected placenta previa. He called a colleague in the maternal/fetal high-risk unit at nearby Evanston Hospital. While Wagner was on the phone, the perinatologist pulled up the same electronic health record that Wagner was looking at. A few minutes later, Wagner sent the patient over to the hospital to be seen. After doing an ultrasound, the perinatologist confirmed Wagner's diagnosis, had a discussion with the patient, and called the ob/gyn to devise a treatment plan. Wagner then phoned the patient and advised bed rest and other lifestyle changes.

"This all occurred in the space of about five hours," recalls Wagner. "In the paper world, all of that might have taken a week or two."

The favorable outcome of this case stemmed from two unusual factors: First, Evanston Northwestern Healthcare (ENH), the parent of Evanston Hospital and two other acute care facilities, is one of the few healthcare systems in the country that has a single electronic health record for both inpatient care and physician offices. And second, Ned Wagner and his four partners were the first doctors not employed by the healthcare system to accept its offer to let them use its EHR.

Acting as an application service provider, ENH is renting the software to private-practice doctors for a monthly fee that covers implementation, training, maintenance, and data storage. ENH stores the software and data on its own servers, which are connected with the office networks. For about $10,000 per doctor per year, including hardware costs, the physicians have access to a top-of-the-line EHR and practice management system, and they have the same technical support as any of the employed doctors in ENH's 72 outpatient clinics.

Targeting community doctors on the staff Evanston Northwestern's hospitals and clinics began to implement their EHR about two years ago. Today, the system is up and running in all but four of the sites belonging to the medical group. According to the healthcare system's CIO, Thomas W. Smith, doctors have access to all clinical data entered on their patients anywhere in the system, except for psychiatric notes. That includes every problem, every medication, every allergy, and every result from an ENH lab or a Quest Diagnostics lab. It also means that physicians can see all of their colleagues' notes and reports as soon as they're entered.

The limitation of this system: While community doctors have access to the Epic EHR, both in the hospital and in their offices, most of them are not contributing ambulatory data to it. Internist David J. Lerner, who belongs to the ENH medical group, says it would help him a lot if more community physicians had the EHR in their offices.

"Right now, when I refer patients to a [community] specialist, I get a piece of paper back, and I have to scan it in. If any medications were changed, I have to go in and edit the medication list. If the community doctors used our EHR, this would all be taken care of, just as it is in our medical group. Their notes and medication changes would be in the record, and they'd communicate with me through the EHR."

ENH has about 1,200 active doctors on its professional staff. Nearly 500 of them belong to the medical group, and the corporation would like the other 700 to accept its EHR. But over the past year, only 10 private-practice doctors, including some internists and Wagner's ob/gyn group, have done so (a few other practices are said to be interested).

Why has the uptake been so slow? Wagner says it's mainly a political problem. "Nobody trusts the hospital. What they're being asked to do is take their life's blood-their accounts receivable and other financial information-and put it on the hospital server."