E-Records Bill of Health

By Paula Musich  |  Posted 2006-07-30

E-Records Bill of Health

What does it take to bring a multispecialty medical practice into the 21st century of technology-based automation? The answer for Fallon Clinic, in Worcester, Mass., turned out to be a lot of planning, a physician champion with vision and drive, and $24 million.

The group practice, with 250 physicians and 20 locations in central Massachusetts, is implementing Epic Systems group practice management solution, including its EHR (electronic health record) system. The aim of the system is to streamline manual tasks, improve patient care and save money. But getting to the point where such an implementation was possible took some doing.

Like most medical practices, Fallon had done little to improve its infrastructure five or six years ago. In 2002, many of its sites still used shared-hub Ethernet LANs to connect servers and PCs. And although a small, home-grown EHR system existed, IT executives knew it would not provide the scale and functionality required to meet Fallons needs.

As more health care providers move to EHRs, infrastructure also becomes important in terms of compliance, security and accuracy. Fallon also expects to see fewer errors as a result of the Epic implementation. One study published July 21, for example, found that more than 1.5 million people in the United States are injured each year by drug errors, according to the Institute of Medicine, in Washington.

Meanwhile, technology vendors are eyeing EHRs. On July 26, Microsoft said it had acquired Azyxxi, in a move that could give entrenched players such as Allscripts competition.

Click here to read more about Microsofts acquisition of Azyxxi and what it could mean for the health IT industry.

"When we started talking about doing this, we assessed everything from the phone system to file-and-print servers in all clinical sites to the LAN and WAN links between the sites," said Tom Harrop, project manager for infrastructure systems and network management at Fallon. "None of [our equipment] was in a position to support an e-health record system from anybody. We have done an extraordinary amount of work in the past [several] years getting ready for this implementation by completely redoing our infrastructure," Harrop said.

Dr. Larry Garber, medical director of informatics at Fallon and the driving force behind the EHR project, has had a long-standing commitment to using computers to help physicians be more effective.

"Weve done studies looking at adverse events, and I know that one of the biggest causes of adverse events is not having all the information when you need it," Garber said. "We always want to take better care of our patients. With the e-health record, it lets us get information to people when and where they need it to give better care. The computer can monitor things in the background, so if I miss something, the computer wont."

Despite that value, which other physician leaders at Fallon were quick to recognize, the $24 million price tag did make Garber blink.

"I personally find that [number to be] scary," Garber said. "But we knew we were likely to [recover] that cost over time. To stay competitive in the market these days, we knew this was something we had to do. Its what you have to do to practice medicine."

Fallon is a leader in this area, though all health care organizations are being pressured to follow suit. Currently, less than 20 percent of all prescriptions today are electronic, according to the Institute of Medicine study. But the institute recommends that all prescriptions be written electronically by 2010, said Hedy Cohen, vice president of the nonprofit Institute for Safe Medication Practices, in Huntingdon Valley, Pa.

In addition, Fallon could see increased reimbursements as more insurance companies implement pay-for-performance reimbursement programs, said Scott Lundstrom, an analyst at IDCs Health Industry Insights, in Framingham, Mass. Such programs "direct their members to providers that have the best outcomes. Payers will actually give them better reimbursement terms for implementing those," Lundstrom said.

The federal government is considering a bill that "could reduce the medical reimbursement for visits or any treatments to organizations that dont have electronic health records," said Susan Paul, director of IT infrastructure at Fallon. A bill in Massachusetts, proposed by Gov. Mitt Romney, would require that cardiac surgeons publish "box scores—data on how successful they are," said Lundstrom.

Given those trends, and the maturity of the market for EHR systems, Fallon is ahead of the curve. The market last year for provider electronic health care records reached $1 billion, but it is expected to grow to $4.2 billion by 2015, according to Health Industry Insights. That represents a 15.3 percent annual growth rate, said Lundstrom.

Next Page: A major, and very expensive, infrastructure upgrade.

Major, Very Expensive Infrastructure


To make sure an automated group practice management and EHR system would succeed, Fallon began by opening its wallet and embarking on a major infrastructure upgrade, moving from the shared hub LANs and 256K-bps frame relay links to 100M-bps switched LAN links and a 10M-bps TLS (Transparent LAN Service).

Fallon, already a Cisco Systems data center switch and router customer, opted to stick with the network equipment supplier and deploy Catalyst 3550 switches in each of the 20 sites, giving users switched 100M bps links to each desktop at all locations.

At the same time, in the data center, Fallon set up dual Catalyst 6509 switches to ensure high availability of the EHR system. Each remote site, which had either linked to the data center via a 256K-bps frame relay link or was daisy-chained to larger offices via point-to-point T-1 links, was upgraded to 10M-bps TLS services from Verizon—backed up by a combination of redundant link types from Charter Communications and DSCI. A Cisco router in every site connects to the TLS, and the Cisco LAN switch in each side connects to the backup links.

"We looked at the network and tried to eliminate as many single points of failure as we could," Paul said. "We have dual cores [switches] in the [data center] so that if a card or a whole switch should fail, all our servers will automatically fail over to [the redundant core]. Were also building a hot site at another location for disaster recovery and replicating the electronic health record system over to that site. If the data center were to fail, we could move everyone over to that hot site."

For security, Fallon implemented redundant Cisco PIX, or Private Internet Exchange, firewalls as well as Ciscos Intrusion Prevention System. Each site also includes an open-source IDS (intrusion detection system) that reports to a Cisco console for monitoring and alerting.

To present the application to what will eventually be 1,300 users, Fallon chose to implement the Epic system on a 24-server Citrix Systems farm dedicated to the Epic software. "We wanted to make sure nothing else affects the availability of Epic," Paul said.

The database supporting the Epic applications, Intersystems Cache database, runs on an Itanium-based Hewlett-Packard HP Integrity rx7620, a 10-processor box running HP-UX with 20GB of memory. That, too, is clustered for redundancy, and the cluster is linked to an EMC Clariion storage network as well as to the Cisco Catalyst 6509 switch via Gigabit Ethernet.

"The reporting piece of Epic is on another [Integrity] 7620 with an EMC storage network," Paul said. "That ensures that any reporting activities would not affect Epic."

Fallon also upgraded 1,600 PCs that will be used exclusively to access the Epic software. The PCs are either 1.8GHz or 2.3GHz systems, and they are installed at every station as well as in offices across Fallons 20 sites. By years end, every examination room will have a PC to provide physicians with fast access to patients charts and records.

"Included in [Epic] are interactive communication tools the physician [can use] to show the patient details of what their condition is and where its affecting them," Paul said. "We also [implemented a filmless] radiology system [last year], so the physician in the exam room [will be able to] show the patient their [X-ray] electronically."

Fallon officials had considered giving physicians tablet PCs but determined the technology was not ready for widespread use, and Epic is not yet a "tablet-friendly" system, Paul said. "Tablets are not ready for docking and undocking. Were [anticipating] 10,000 docks a year. Were not sure theyd [tolerate that]; they are still too hefty to carry around from one exam room to the next, and the battery life isnt there yet," she said.

Unlike many new application deployments, managing the new EHR system was not an afterthought.

"When the decision was made to go to the electronic record, we knew we could not [continue to take a passive] approach to monitoring that system," Harrop said. "The object of the game was to get ourselves to a point where we could monitor and alert prior to the point where users would see [a problem and act on it]. We wanted to head off that call [to the help desk]."

Even before the Epic software was rolled out, IT staff at Fallon gathered requirements, put out an RFP (request for proposal) for a management system and carefully selected its tools.

Although several of the major enterprise systems management players—including BMC Software, HP and CA—responded, Fallon chose the smaller Heroix and its eQ and Longitude application and system performance monitoring tools.

Next Page: Making communication and decision-making easier for everyone.

Making Communication, Decision

-Making Easier for Everyone">

"It was considerably less expensive than the others, it largely covered what we wanted and it was easy to implement," Harrop said. Both the agent-based eQ and agentless Longitude tools were chosen so that operators could monitor all systems associated with the Epic software—even those systems deemed too sensitive to handle the installation of an active agent.

"For systems that we require more granular data from, we tend to put an agent on those boxes, and well monitor that way. Longitude we use for more ad hoc reporting or if we need to take a quick look at something," Harrop said.

The Heroix software, already in use for managing other servers such as Fallons Microsoft Exchange mail servers, has proved its mettle.

"We learn of problems before the end user sees it." Paul said. "The system pages our engineers for critical problems, sends us informational messages about mounting problems such as a CPU that has too many processes running, and will restart stopped services on a server and let us know it did that."

Records system in place as the infrastructure up­grade progressed, another team at Fallon in early 2005 began the implementation planning process for Epic. A Fallon project team was selected, trained and certified on Epic, while Epic put together its own team of support people and system integrators to help with the implementation. Both teams developed a project plan and then came together with key stakeholders—including physicians and nurses—to dive into the details of the workflow that would be automated through Epic.

"You document the workflow and apply it to every variation of the patient encounter," said Richard Morel, director of Epic implementation at Fallon. "You have to build into Epic the workflows to enable the electronic transfer, create the blueprints for building a production system, [and] then move into training, actual implementation and support."

The first phase of the implementation—the practice management system rollout—took place in April, when IT staff with the help of Epic consultants deployed the Epic Resolute billing system, Prelude patient registration program and Cadence scheduling program. The second phase, the actual EHR system called Epicare, is broken up into three stages. The first stage—lab order entry and results—was implemented in May, when existing data was converted to Epic.

"One of the things I find most marvelous about what were doing [is that] when most organizations turn on their e-health record, its empty," Garber said. "As we turn this on, we have 22 years of medications, allergies, lab results, radiology reports [and] progress notes completely populating the e-health record from Day One."

The second stage, telephone messaging and electronic prescriptions, began in June and is expected to be completed in November. That involves moving historical pharmacy data to Epicare; new pharmacy data will be available in Epicare as well.

"The phone messaging piece of Epic allows a [staff member] to take a phone message for a physician, enter it in the system [and] it goes to the physicians in-basket, where they can respond," Paul said. "They can create a prescription electronically, and the system can fax it to the pharmacy. He can make a call or give a medical assistant instructions on how to deal with the patient. Thats all electronic. Before, it had been all manual."

The third and biggest stage, with full provider documentation in the exam room, will begin in early 2007, said Morel.

The benefits expected of the system are numerous. Even in the short time the practice management system has been in place, Fallon has already seen that "charges are starting to flow through a lot faster, and were [experiencing] a reduction in payment delays," said Paul. Beyond that, the system promises to streamline workflows; deliver better information in a timely fashion to improve decision making; reduce errors; and, ultimately, lower costs.

Lower Costs

In general, EHR systems benefit patients because fewer mistakes are made, so patients have better outcomes, and they receive more efficient care, "which means they may be able to leave the hospital a day early," said Barry Hieb, research director at Gartner Healthcare Group, in Tucson, Ariz. "You get better communication between all providers. A lot of times, it takes days to get information back to a private physician. Now that information can be transferred electronically, so there are no delays, omissions, errors."

A recent survey reports that hospital CIOS are getting on board with EHRs. Click here to read more.

"With an e-health record, a specialist has access to the primary care record where he needs it, when he needs it. It cuts across a confusing communications conundrum," Morel said.

The advances made in EHR systems, such as those from Epic and Cerner, begin to make it possible to put new research into practice much faster. That concept, known as evidence-based medicine, can be used to help guide physicians in decision making.

"So as they are entering an order, the system will check that order and come back and say, Did you know theres another drug that does this better at half the cost?" Hieb said.

In cases of medical malpractice, 80 percent of the cases are attributed to errors of omission, "where the doctor forgot to do something or something slipped through the cracks," said Hieb. "This is where things like the information systems now are getting to the point where they can really kick in and make safety rails for medical practice."

The whole system will pay for itself, although it will take time for that to occur. Seven years from now, Fallon expects to save about $6 million a year in reduced costs for transcription and paper medical records, malpractice insurance, entering visit and procedure charges, paper supplies, shredding disposal and courier costs, as well as in fewer rejected claims.

As an early adopter, Fallon has a leg up on other providers still working with paper, although it took a lot to get there. While IDC says the average provider organization spends about 3 percent of its revenue on IT, Fallon is spending 13 percent on IT during the Epic implementation. But Fallon and its patients will reap the benefits.

"Were not bleeding-edge. This isnt going to kill us. But were leading a wave of physicians moving into a new form of health care," Garber said.

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