Ambulatory Electronic Medical Record and Shared Access

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Project Details -
Completed

This project aimed to implement an ambulatory electronic medical record (EMR) across multiple and varied health care settings in a medically underserved region of east central Illinois. Sarah Bush Lincoln Health Center (SBLHC), a not-for-profit community health care corporation, served as the fiscal agent and lead organization for a collaborative partnership to deploy an ambulatory EMR. The goal of this implementation was to improve patient safety and assess provider and patient attitudes toward health information technology (IT) by: 1) providing shared access to patient records across hospital services, home health, hospice, physician practices, and non-hospital provider settings; and 2) integrating electronic tools for prescription orders and management of medications. Project partners included two private practice organizations and the Health Services Division of Eastern Illinois University, a regional, residential university. The purpose of this project was to offer providers and patients a seamless coordination of care across a continuum of services by sharing pertinent patient information between the emergency department, home health and hospice, family and internal medicine practitioners, and specialists throughout the rural community.

The ambulatory EMR, implemented at approximately one-third of the SBLHC practices by the end of 2009, provides a means to share a longitudinal medical record that contains, at a minimum, a patient problem list, medication list, allergies, radiology images and data, laboratory data, and a patient care plan. The long-term goals of the partnership are to:

  1. Successfully deploy an ambulatory EMR with shared access to patient records across hospital services, home health, hospice, and employed and independent physician practice settings.
  2. Use computerized provider order entry and clinical decision support systems to reduce medication errors and increase patient safety.
  3. Provide a method to utilize the EMR for data collection, analysis, and reporting of the number and types of medication errors and adverse events that occur.

The principal findings for the ambulatory EMR implementation show that both the emergency department and inpatient caregivers benefited from having access to the patients' ambulatory medication lists electronically. Overall, physicians, mid-level providers, and nursing staff in the SBLHC clinics believed that the system did not increase their productivity up front; however, the users will most likely appreciate efficiencies once the charts are more established. The users stated that they would prefer the system's shortcomings be enhanced rather than revert to their old processes.

Michael DeLuca
Imagine the following scenario: a patient experiencing shortness of breath and difficulty breathing visits a primary care provider and is prescribed one medication. The following week, the patient visits a cardiovascular specialist for high blood pressure and heart disease and is prescribed another medication. The patient regularly takes sleeping aids at night and takes ibuprofen for occasional headaches. Within days, the patient has a reaction to the medications and visits the emergency room.

Without knowing all the dosages of medicines a patient is currently taking, it can be difficult for attending clinicians to determine which medicines could be causing a drug interaction and how to treat it. This type of scenario could lead to a potentially life-threatening situation. In today's health care delivery system, it is not uncommon to be seen by a primary care provider in one physician office, a specialist at another office, or even to make routine emergency room visits.

The Sarah Bush Lincoln Health Center in East Central Illinois has implemented an ambulatory electronic medical record (EMR) software application that provides shared access to computerized patient health information across hospital services, home health organizations, hospice, and physician practices to prevent this type of medical error. Sarah Bush Lincoln Health Center is a not-for-profit community healthcare corporation that serves rural communities in east central Illinois. A significant number of the region's population lives below the federal poverty level, and a significant percentage of Sarah Bush Lincoln's patients are uninsured. Sarah Bush Lincoln has developed a network of employed physicians and mid-level providers over a seven-county area.

By 2003, the regional hospital operated a centralized EMR application that captured all patient health information resulting from hospital-based care. But area clinics had yet to do the same. With help from a $1.5 million grant from the Agency for Healthcare Research and Quality, the hospital began implementing a variety of technologies, including an EMR system, computerized physician order entry (CPOE), and e-prescribing in regional clinics and home health practices. To date, six clinics have implemented all of these electronic health systems. Sarah Bush Lincoln plans to implement EMR, CPOE, and e-prescribing systems in a total of eleven clinics, making it possible to share longitudinal electronic medical records for every patient that is treated in the hospital or these participating clinic locations. These records will contain, at a minimum, a patient problem list, medication list, allergies, radiology reports and images, laboratory data, and treatment plans.

Before the system was installed, hospital staff could not access any patient records during clinic off-hours, despite the fact that the emergency room treats patients on a 24/7 basis. Clinicians who treated patients in the emergency room during these times were not able to access critical patient information such as current medications or health history. As part of the new EMR system, each patient has a "problem list," to let emergency staff know if they have high cholesterol, joint problems, or any other diagnosis that clinicians may need to know.

"The interesting thing about the clinic setting is that the patient only has one medical record," said Michael DeLuca, vice president of information systems at Sarah Bush Lincoln Health Center. "If you go to a family practice clinic, then to an orthopedic clinic, it's a continuous patient record from all the clinics integrated into the patient's medical record."

Although the system provided many benefits to physicians and patients, one of the biggest challenges with implementing the EMR system was finding a way to afford the technology costs. Software license fees and changes in the supporting technology hardware were the biggest expenses followed by the purchase of new equipment. Clinics purchased laptop PCs for all physicians. Increased network capacity was needed to hold all of the newly generated patient data. To help offset costs, Sarah Bush Lincoln matched each dollar provided in the AHRQgrant to fund the project. Total project costs to date are $3.5 million, and DeLuca said he expects to spend another $2 million implementing additional system after the grant runs out.

Another challenge to implementing the EMR system was the learning curve presented to physicians in using the system. To make the transition easier for clinics, the project team tested all new systems before using them in a "live" environment. In addition, they regularly consulted physicians, nurses, and technology support staff during the planning process. During the implementation phase, the project team reduced the physicians' patient loads for three to four weeks, and worked with physicians on a daily basis to implement the new information systems. For example, the team reduced patient loads per physician by 50 percent during the first week the system was "live," so that the clinical staff could have more time to adjust to using the new computers and software.

"Having all of the information from the different clinical locations is really powerful for patient care," said DeLuca. "There was a tremendous amount of treatment time saved, care was provided faster, and clinicians had better access to radiology images. Minimizing all these steps enables better health care in the end."

Future plans to expand the implementation of the EMR system include a women's clinic and information technology applications to support better medication ordering processes and related clinical documentation as they search for more direct methods to electronically connect with pharmacies.