Single System Electronic Medical

 Records Coming To Northern

 California Kaiser Permanente

 Facilities

By Michelle B. Caughey, M.D.

The debate over Electronic Medical Records (EMR) makes headlines every day. Which one? How soon? How will they be paid for? Is the $150 million in the president’s budget enough to explore a nationally compatible record?

But I believe the debate is largely over and that CMS will make decisions for health care providers and hospitals. In his recent Shattuck Lecture,1 William Frist, M.D., Senate majority leader, states: “A 21st-century health care system requires electronic health records.” And later in his paper, he says that Medicare should lead this effort, presumably by supplying incentives or conversely lower reimbursement for physicians and other providers who do not join in a nationally standardized EMR. He believes that EMR use will reduce errors, improve quality, and maximize efficiency.

   Large medical practices such as the Palo Alto Medical Foundation, the Veterans Administration, and Kaiser Permanente (KP) have implemented versions of an EMR. Smaller practices will find the initial investment frightening, but necessary. Most systems have a billing component, appointment systems, and quality reporting. Many have patient messaging and direct medical record access.

   At KP, we are moving to a single system, from a clunky but for its time great bunch of interconnected mainframe databases. Northern California Kaiser has an ambitious timetable for rollout. Every physician computer workstation was upgraded in 2004. By the end of 2005, the registering and billing functions will serve all 5,000 physicians and 3.2 million members. This month the first totally paperless system moved into the pediatric department in Elk Grove. It involves charting, order entry, in-baskets for lab and radiology, coding, and embedded knowledge, to name a few features. By the end of 2004, four (of 19) medical centers will make the switch. Kaiser South San Francisco EMR implementation is slated for early 2005, Redwood City a little later.

  When physicians imagine an EMR, they think about charting and chart note retrieval, with connection to ancillary systems. But a truly comprehensive EMR has five basic components:

(1)   Clinical Care with clinical data, not just from M.D.s, but also from          nurses, therapists, and medical assistants with ORDER ENTRY for     absolutely everything. Such documentation and ordering does change the work flow and initially lengthen the time per encounter. Knowledge can be   embedded for improved clinical decision making.

(2)  All ancillary systems such as lab, EKGs, pathology reports, and ideally digital imaging retrievable for patient encounters.

(3)  Secure Web access for E-mail communication, chronic disease  management, and patient chart access.

  (4)  Insurance and business information linking patient insurance information to the cclinician and allowing proper billing and coding.

(5)    Retrieval of information for quality demonstration or population management, to ultimately improve the health of all persons by using appropriate outreach and tracking.

  Dr. Frist begins his lecture with the description of a patient in 2015. While the patient is away from home, he develops chest pain and travels to a local Emergency Room. There, the physicians access all of his up-to-date health information; the hospital cares for him and bills the insurer and his health savings account.1 (And, as an aside, he gets a 10 percent discount on his deductible because he met his “health goals” for the year.)

As an integrated delivery system, KP can and will make the most of an EMR. Patients want safe, convenient, personal, and effective care for their problems. Their goals will be enhanced.

I believe that Dr. Frist’s support for an EMR is a good start for a national database. Unfortunately, it will be unfunded and therefore difficult for small institutions, especially public hospitals and clinics, to fully participate. I believe that hidden in his plan is an effort to transfer the cost of care to those who are unable to pay and completely disadvantage patients with “bad habits” or whose immigration status cannot be verified at presentation for services. He speaks of catastrophic health insurance and sharing risk in a way that may prove the opposite. I encourage you all to read the article, as I expect the Congress will work through his agenda in the coming years. 

Footnotes: 1 Frist, William H., M.D., “Health Care in the 21st Century,” NEJM 352(3): 267 – 272, Jan. 20, 2005

Dr. Caughey practices internal medicine and is physician-in-chief at Kaiser Permanente Medical Center S. San Francisco.