SPECIAL TECHNOLOGY SECTION
THE CONNECTED PHYSICIAN

Online clinical data: An update

The move online by hospitals, labs, pharmacies, health plans, and physician offices is continuing slowly. Here's where things stand now.

By Ken Terry
Technology Editor

More than half of the work that goes into making clinical decisions is just collecting the information," notes Brian Ralston, a family physician at MacNeal Hospital in Berwyn, IL. "When decisions aren't made effectively, it's usually because there's a piece of data missing."

Because of his online access to MacNeal's clinical data repository (CDR), Ralston rarely has that problem. "I saw a 10-month-old child today who had a skull fracture, and not all of the

information from her hospital stay had been sent to my EMR yet. So I looked her up in the clinical repository to check her X-ray results."

If Ralston wants to view results of tests ordered by other doctors, he opens the CDR, which also contains dictated reports and inpatient medications. Ralston's ability to quickly locate a thyroid stimulating hormone test or echocardiogram on a patient has prevented him from ordering unnecessary tests many times, he says.

Just a few years ago, electronic connectivity in health care was barely more than a glint in a dot-com's eye. But a number of connectivity initiatives have blossomed as technology has improved, costs have dropped, and imperatives to improve patient safety and to protect against bioterrorism have gathered momentum. The initiatives range from Web access to data within a single health care system, such as MacNeal, to community-wide and even statewide data networks.

At Swedish Medical Centers in Seattle, emergency-medicine specialist Meera Kanhouwa and her colleagues are using a community-wide system created by the nonprofit Patient Safety Institute of Plano, TX. PSI captures scanned-in ED charts plus inpatient labs, meds, dictated reports, problems, allergies, and diagnoses from the three Swedish facilities. It also provides results from two reference labs and problem lists from the EMRs of employed physicians. Of the system's 2,000 staff members, 360 are already logging into PSI, combing data from 15 disparate computer systems.

In Indianapolis, the Regenstrief Institute, which is closely affiliated with the Indiana University School of Medicine, has taken community connectivity much further. Its Indiana Network for Patient Care (INPC) has connected 13 of 15 area hospitals and supplies physicians with Web-based access to 90 percent of hospital discharge information, 95 percent of inpatient labs, and most ED data.

Three years after going live, INPC is still struggling to get data from reference labs and pharmacies. However, the information network has already improved care and reduced costs, says internist J. Marc Overhage, a senior Regenstrief investigator and a professor at the Indiana University School of Medicine. Access to community-wide data has cut ED costs by an average $26 per visit, he notes. And ED physicians can pull up a clinical summary of a patient's care all across the region, including the names of the doctors he's seen as well as recent lab and imaging results. More than half of the area's 3,000 physicians are using INPC, says Overhage.

The regional data networks typified by INPC are only one of several recent developments that are accelerating the connectivity trend:

• SureScripts, a company formed by the two leading pharmacy associations, has started rolling out its online prescribing system to doctors nationwide (see "E-prescribing: Closer now" ).

• A consortium of public and private groups called Connecting for Health agreed on national standards for clinical data transmission. A parallel organization, the Healthcare Collaborative Network, announced plans to start testing those standards in several communities.

• The US Department of Health and Human Services announced a campaign to persuade health care organizations to adopt standard medical terminology and EMRs. HHS also licensed the SNOMED clinical nomenclature system from the College of American Pathologists and commissioned the Institute of Medicine and Health Level Seven to create a standardized EMR.

• EMR vendors have begun to provide online links between patients and physicians for prescription refills, lab results, and disease management.

• In a big step forward for administrative connectivity, the HIPAA transaction rules require health plans to support all HIPAA-covered electronic transactions. When these become standard throughout the industry, medical offices should be able to obtain online data on eligibility and claims status and get payments automatically posted from all of their payers (see "HIPAA and online transactions").

In addition, nearly half of hospitals now supply clinical data online, providing doctors with instant access to a rich source of patient information. The moves on the health plan and e-prescribing fronts, meanwhile, offer new ways to increase the efficiency of physician offices. Here are some glimpses of where connectivity is going and how it will affect you.

You don't need an EMR to get connected

To get clinical data online, all you need is an Internet connection or a T-1 line. At MacNeal Hospital, for instance, Ralston is one of about 25 physicians who have EMRs. But the entire medical staff can view CDR data over the Web.

Of course, you can provide better patient care if this inpatient data is integrated with an outpatient EMR, so that you can see all of a patient's data in one place. But hospital information systems are usually incompatible with ambulatory EMRs, which often come from different vendors. Reference labs also speak a different language. So even if you have an EMR, you either have to pay big bucks to your vendor to write interfaces, or you have to persuade your hospital or lab to pay for them—not an easy task if you're in a small practice.

Some large groups and integrated delivery systems are tackling this problem by using the same vendor for inpatient and outpatient records. Wisconsin's ThedaCare system, which includes three hospitals and 23 physician offices, started by giving its 120 employed doctors, 140 midlevel practitioners, and 300 affiliated physicians access to its inpatient CDR. Over the past two years, it's gradually rolled out an Epic EMR that provides ThedaCare clinicians with a global view of inpatient and outpatient data and enables them to place and track orders. Non-ThedaCare physicians can also view parts of the EMR on the Web.

Community approaches to connectivity

This kind of data access is great for doctors who work for or are closely affiliated with a health care system. But if you deal with multiple hospitals and labs, as most physicians do, you need another solution. "There have to be enough providers participating to make it worthwhile to look at the data," notes Marc Overhage of Indiana's Regenstrief Institute.

Besides the hospital and ED information, Regenstrief's data repository also includes visit notes from physicians who use EMRs or transcription services, and will soon add imaging data and outpatient medications. Participating doctors access the data warehouse over the Web and can also have inpatient results sent to them by e-mail.

Clinical messaging vendors such as Axolotl and Medicity offer another route to community-wide connectivity. Axolotl, for example, provides connectivity between physicians, hospitals, and labs in about 15 communities across the country. In some cases, this connectivity is confined to a large group or integrated delivery network. In Santa Cruz County in California, Axolotl claims to have online data on nearly 90 percent of patients.

Axolotl usually enters a community by contracting with one or more hospitals to make data available to its staff online. It uses the same secure messaging system to send orders and results between physician offices and labs.

The Patient Safety Institute, formed by physician and hospital leaders and consumer advocates, is taking a third approach. Instead of compiling all of the community data in a single repository—which might invite criticism from patient privacy advocates and suspicion from competing institutions—PSI is using technology similar to that of the Visa credit card network to tap into clinical data streams. With permission from patients, doctors ask PSI to pull only the records they need without moving them to a central repository. The data can be "pushed" to their own desktops or handhelds or displayed on a Web site.

Besides linking providers in Seattle, PSI was recently hired by the Delaware Health Care Commission to build a statewide health care information system. During the six-month pilot phase, PSI will connect Christiana Care Health System—the largest hospital in Delaware—with LabCorp and a number of physician offices. Initially, it will provide data on medications, lab results, diagnoses, problems, allergies and immunizations.

Who's going to pay for this? Technology firms put up the $10 million in seed money for PSI, and federal antiterrorism funds are supporting the launch of the Delaware program, which will enable providers to alert the state about unusual disease patterns. In the long run, payers will support the connectivity system, because it will help them save money on unnecessary tests and care, says FP Joseph Lieberman, a member of the Delaware Health Care Commission.

Competition, lack of standards hamper connectivity

Meanwhile, moves are afoot to standardize clinical data transmission and medical nomenclature. One of the most important is the Connecting for Health initiative sponsored by the Markle Foundation. The standards adopted by CFH are supported by several federal agencies as well as physician groups, medical and pharmacy associations, health care systems, consumer groups, and technology vendors.

The Healthcare Collaborative Network, sponsored by the Foundation for eHealth Initiative, will demonstrate the value of connectivity using CFH-approved data standards in several communities. Among the health care systems involved are New York-Presbyterian Hospital in New York City, Vanderbilt University Medical Center in Nashville, and Wishard Memorial Hospital in Indianapolis. The CMS, the CDC and the FDA are also part of the collaborative.

The need for standardization is evident on many levels. Each health care system has many incompatible data systems, and many hospitals haven't interfaced or have only partially linked their databases. Moreover, hospitals with different systems can't share data unless they participate in a community-wide network. Even then, there are myriad differences in nomenclature from one system to another. Hospital and reference labs, similarly, use different standards for results reporting and are not interoperable. As previously mentioned, EMRs from different vendors are incompatible.

One reason to get vendors to standardize their products now is the low adoption rate of both inpatient and outpatient EMRs. Since less than 10 percent of hospitals and doctors have electronic medical records, CFH executive director Janet Marchibroda suggests that new products should be standardized as more providers acquire EMRs.

However, it's unclear why health care systems would invest in standardized software if community-wide connectivity would benefit competing hospitals, notes Keith MacDonald, a senior research manager for the First Consulting Group in Lexington, MA. In fact, it's very difficult to get hospitals to join any online data network that includes competitors, says Ray Scott, president of Axolotl.

The same is true of competing reference labs. To begin with, says MacDonald, they're interested in going online only with larger medical groups (although they will sponsor interfaces with EMRs used by smaller practices). And each lab wants to connect directly with physician offices or post results on its own Web site. That isn't an efficient way for a practice to deal with multiple labs, notes Overhage. "Labs may think it's a competitive advantage to deliver results on their own, but it's shortsighted not to work with competitors on a unified system."

Clinical connectivity has come a long way in a relatively short time. But only about 15 percent of doctors are using online clinical data today, says Overhage. Pressures to improve patient safety and guard against bioterror attacks will undoubtedly raise that figure significantly. Meanwhile, physicians should find out all they can about the clinical data that's available to them over the Internet.

E-prescribing: Closer now

Only 4 to 6 percent of physicians are using electronic prescribing programs, and few of those doctors send prescriptions online to pharmacies.

But the potential of e-prescribing recently expanded with the introduction of SureScripts' Messenger Services, which allows doctors to transmit scripts directly into pharmacy systems and receive online requests for refill authorizations. While ProxyMed and RxHub have also begun to offer some connectivity between physician offices and pharmacies, SureScripts seems positioned to be the dominant carrier of electronic prescriptions. Formed two years ago by the trade associations representing independent and chain pharmacies, SureScripts now claims the support of 75 percent of US pharmacies; at press time, 20 percent of the nation's pharmacies were said to have completed testing of its software for communicating with medical offices.

SureScripts has begun rolling out its service in Rhode Island, where nearly 60 percent of drugstores are ready to accept scripts and send refill requests online, according to the company. The next targets will be Connecticut, Massachusetts, Maryland, Ohio, and Virginia, says Kevin Hutchinson, president and CEO of SureScripts. The company also plans to expand into Arizona, California, Illinois, Indiana, Michigan, and Tennessee this year.

Which markets will be chosen depends on the readiness of local pharmacies. "We don't want to move into any market that has less than 50 to 60 percent of the pharmacies connected to our network," says Hutchinson. "The remaining pharmacies will accept faxes, so the physicians won't have to decide whether to send scripts to one pharmacy rather than another."

Besides improving patient safety, online prescribing allows physicians to be informed of medication switches so they'll have updated med records on patients. They can also use it to find out whether patients actually filled their scripts. And the communication channel will enable pharmacists to automate refills, saving time and money both for them and for physician offices.

Although doctors won't have to pay for SureScripts' service, they'll need dedicated prescribing software or EMRs equipped with e-prescribers. The standalone programs usually cost a few hundred dollars up front, plus $30 to $50 a month for updates.