Clinical connectivity: The future is already here

An intranet at the University of Michigan Health System is pulling patient information together into a useful electronic medical record

While on call one weekend earlier this year, internist Steven E. Gradwohl of Ann Arbor, MI, heard from one of his partners' patients, who wanted a refill for Zantac. Even though the patient and his spouse thought he was just having a spot of indigestion, Gradwohl sent the patient to the emergency room, where he was diagnosed with unstable angina.

"If all I'd had to go on was what I was told over the phone, I might not have made the same decision," Gradwohl says. But because he had instant access via his home computer to the patient's online medical records in the University of Michigan Health System, the doctor discovered that the man had been admitted to the hospital a year earlier with a heart problem that the patient had initially believed was acid reflux.

Gradwohl obtained the records through CareWeb, an intranet within UMHS that allows clinicians to obtain key patient information. Many health systems have intranets that use Web browsers to link computers within firewalls separating them from the Internet. The one at UMHS assembles various pieces of clinical data, including lab results, radiology reports, hospital discharge summaries, and dictated visit notes. This information is gathered from 70-odd databases that reside on computer systems throughout UMHS' three hospitals, 30 satellite health centers, and 120 outpatient clinics in Ann Arbor and surrounding towns.

For users, CareWeb combines the ease of Web browsing with the security of a closed information system. Guarded by passwords and logins, it consists of a home page that lists patients' names and a menu of medical information about them. Getting lab results, consultant reports, and even ECG tracings is as simple as clicking on underlined text. The system also offers instant access to MD Consult, a doctors-only Web site that answers clinical questions, and other sites like Grateful Med and MEDLINE that let users search the medical literature.

Doctors, nurses, medical students, and many administrative staffers can access CareWeb through any of the 8,000 dedicated terminals throughout the health care system. Many physicians also use dial-up connections on their home computers, which have been outfitted with special security software.

Launched in 1998 as a tool to bring together patient scheduling and demographic data from two office information systems, CareWeb immediately began expanding into clinical areas. "Somebody asked, 'Why don't we put in the labs?' Then it was dictation," recalls pulmonologist William F. Bria II.

"Every month or two, another 'why don't we' came around," says Bria, who's medical director of clinical information systems at UMHS. "By the end of 1998, it had taken off like a herd of birds. It really captivated the imagination of the medical and nursing staffs."

Not to mention the accounting department. The estimated staff cost of pulling and shipping a single medical chart is $7.50—if it's in the record room, that is. Pulling a CareWeb record, on the other hand, costs an average of $2.50 in staff time, including the printing of pertinent information. In a system that has 1.4 million outpatient visits and 40,000 inpatient admissions per year, the savings add up fast. "You can justify a big investment in computers from those savings alone," notes rheumatologist Timothy J. Laing.

Currently, nearly 100 percent of UMHS house staff and 80 percent of attendings—a total of 1,800 physicians—use CareWeb regularly. Just as miraculous, the system is up 98 percent of the time. "It's a marvelous improvement in getting information," says internist Connie J. Standiford. "I feel much more confident in overall patient management when I have the information in front of me."

Turning data into useful information

CareWeb clearly demonstrates the potential of browser-based intranets to create an easy-to-use and fairly comprehensive electronic medical record from the dozens of different computer systems in the typical large health care organization. "The information was out there, but it had to be integrated," Bria says. "That's what CareWeb does."

But the development of CareWeb also illustrates some of the obstacles to extending intranet access beyond the health care system. So far, only information supplied by physicians and departments within UMHS are on the intranet. Connecting online with outside labs, pharmacies, and hospitals presents challenging problems, and security concerns have prevented UMHS from giving community physicians access to the system so far.

UMHS' employed physicians can view records of all patients, except for those in sensitive categories, such as psychiatric problems or AIDS. The organization permits this degree of access because it has the ability to discipline its own employees. But outside physicians would have to be restricted to viewing records of their own patients, and that's not simple to do. "It's a technical challenge that we'll have to work out before we can open up the system," says Bria.

Strict security measures apply to UMHS physicians and staff. They must log on each time they use the system. An audit trail shows who logs on, what information they view, and for how long they view it.

UMHS has taken special pains to guard terminals in exam rooms and other areas where patients might be left alone. The standard way to protect confidential files is for the physician to execute a one-key log-out when leaving the room; nobody can use the computer until another authorized user logs on. UMHS has also experimented with proximity switches that enable the computer to sense a badge worn by the physician. Only if the badge is within a certain distance does the computer function; it shuts down when the doctor leaves.

Speed of access is what doctors like the most

Physicians in the University of Michigan Health System give many reasons for the success of the CareWeb system: security, ease of use, physician involvement in its development. But perhaps most important is the system's speed in presenting information.

Before CareWeb, much of the data the system now supplies was available online; it was just harder to get. "You had to go on one system for labs, then log off and get on another system for radiology, and so on," Laing says. "It took only a few minutes to go from one to another, but it was impractical to use the separate systems in clinical situations."

The proliferation of databases also led to confusion. "People would ask, 'Why isn't this online?' and we'd say, 'It is online, you're just not looking in the right place,' " recalls Bria. Even when physicians knew where and what to look for, differences in the way the various systems were set up often made it difficult to locate data.

With CareWeb, a doctor need log on only once, and all the information is displayed in a consistent context. That's critical to making it usable, Laing says. "The people who develop systems tend to underestimate the need for speed. The reality is there's a threshold in a clinical situation. If you can't find the record within five minutes or so, you have to abandon the search because you have to move on to other patients. That leaves you with several bad alternatives. You can make a decision with no information, or you can postpone the decision and continue the conversation with a phone call or another visit. Not having the information in front of you has a direct impact on quality."

Before CareWeb, consultant reports and emergency department discharges were often unavailable when physicians needed them, says internist Linda Bjork Terrell. Because transcribed notes were corrected and signed on hard copy, it often took days or even weeks for the notes to make their way into the medical record, and reports were frequently slow in coming (see "Online consults: Faster, easier, more complete").

"I remember asking patients what the cardiologist said," Terrell says. "It's very awkward when you're standing in front of the patient and you haven't heard from the consultant and you don't know what his plan is."

Dictated notes get Into the record sooner

Today, visit notes are entered into the CareWeb system within 48 hours and often in less than a day. It's not that transcriptionists have gotten faster. But in the past, dictation tapes were mailed to the transcription service, and transcribed notes were mailed back to doctors' offices, which took days. If corrections had to be made, the mail process was repeated. Under the new system, physicians dictate to the service over the phone, and transcribed notes go directly into each doctor's electronic inbox, where they can be reviewed, edited, and signed with a digital signature.

"I saw patients until after 7 last night, and I'm already through with my notes and they're in the record," says ob/gyn Edward Goldberg. "It used to take so long to get notes back from transcribing that I'd lose track of them."

By providing online access to visit notes, CareWeb enables doctors to produce a more accurate medical record, Standiford says. "Sometimes dictation doesn't come out of your mouth quite the way you intend it. I find myself editing much more frequently now."

Goldberg concurs: "A lot of times, if there were errors in the record and if they were no big deal, you glossed over them instead of sending them back for corrections and maybe never seeing them again. Now when I have a couple of minutes I will call up my notes, correct them, and sign off on them, all at one time."

Getting information into the record quickly also makes for better care, especially in emergencies, Goldberg says. "Not long ago, one of my patients came in with a miscarriage while I was away. The ultrasound and HCG levels were in the system, so the physician on call was able to tell right then this patient was having a miscarriage, and he was able to go right to D&C without having to call the lab. This kind of thing happens regularly."

The system has also helped identify patients who were receiving narcotics from more then one physician, Standiford says. "I had a family physician call to tell me we were both prescribing narcotics to the same patient, and so was a specialist. We all got together and decided that only one of us would be the prescriber."

Quicker access to information also makes it easier to handle a growing patient load, says Terrell, who, like all physicians on the UMHS staff, has to balance patient care with a clinical teaching appointment. Gradwohl agrees. "I see 20 to 25 patients per day, in addition to teaching. CareWeb certainly makes it easier to see that many patients effectively, because I'm not flying by the seat of my pants."

Using CareWeb to enhance interactions with patients

Some UMHS physicians find that CareWeb enhances interactions with patients. "I had a patient with osteoporosis and hyperlipidemia on Fosamax," Terrell says. "She mentioned an article she'd read in The New York Times on lowering cholesterol and improving bone density. I was able to pull up the reference right in the room with her sitting there and make a plan."

Gradwohl also finds the system useful for coaching patients. "You can click on 'glucose' and it will show you a diabetic patient's whole history of blood glucose levels. I can show a kidney patient that he had a creatinine level of 1.8 a year ago, 2.1 six months ago, and 2.9 today. It has much more impact, in terms of compliance, than just talking to them."

Gradwohl and the nine other physicians at the Briarwood Medical Group in Ann Arbor have experimented with CareWeb in their exam rooms, using personal computers and portable hand-held devices. The group has polled patients on their reactions.

"They like it," Gradwohl reports. "They think it's high-tech."

As useful as the on-screen displays may be, many physicians find it easier to print out information from CareWeb before seeing patients or before doing dictation. "It's nice to use the computer when you're seeing patients," says Gradwohl, "but when I sit down to dictate the chart, it's much easier to use the printed version. Otherwise, I have to look stuff up while I'm dictating, which takes too much time."

Bria prints out notes and labs on critical care patients before making rounds in the morning and afternoon. "It gives me a good idea of how the patients are doing without having to hunt down the house staff," he says.

New capabilities keep coming online

As advanced as CareWeb's capabilities may seem to those who don't have access to an intranet or any type of electronic medical record, the system is barely out of its infancy. New capabilities are being added all the time. Online order entry, for instance, is one of the top priorities for UMHS. That will help doctors compare what they asked for with what they got from the lab, the pharmacy, and other services.

Further down the road may be bedside entry of nursing activities. Right now, nurses still handwrite their notes, which don't become part of the electronic record unless they're included, much later, in a discharge summary. Having those notes instantly available on CareWeb "would really close the loop," Bria says. But nurses need a way to record their activities on a computer terminal or handheld device in the patient's room, he points out. "It does no good if you wait until you get back to the nurse's station and record what you did."

UMHS also plans to automate the online creation of records on preventive services such as Pap smears and mammograms, using lab results as the trigger. The system will soon be capable of printing out prescriptions that physicians enter online, instead of writing them out by hand.

There are limitations to CareWeb, of course. Doctors must still use a separate video display system, for example, to view digital radiology films. "The typical desktop monitor doesn't have nearly the resolution required for that," Bria notes. In addition, transcribed notes are still nowhere near as searchable as discrete data entered into a more refined type of EMR.

But CareWeb's advocates say they can do many more things with it. Voice recognition software, could eliminate the need for transcription, further speeding up access to visit notes. Laptop or other portable computers might be ideal for this technology, since the program installed on a particular machine has to "learn" the voice of the user, says Laing.

The technical challenges of building something like CareWeb are formidable—which is why some systems and group practices have hired "portal vendors" to do it (see "Group practice intranets: Getting physicians to use them"). Currently, UMHS has six full-time programmers knitting the electronic "patches" needed to translate information from existing databases to the Web format.

"It's unusual to see this kind of intranet application outside of large health systems because of the resources needed to develop it," says consultant Jane Metzger, a Boston-based vice president of the First Consulting Group.

Still, the investment and effort required to create a CareWeb should be weighed against its value to physicians who use it in their practices every day. "I haven't pulled a paper chart for three or four months," Standiford says. "I see no reason why I ever will again."  

Howard Larkin. Clinical connectivity: The future is already here. Medical Economics 2000;22.