Clinical Leadership

Clinical Leadership

Medical Records Make the Leap from Paper to Terabytes

Medical professionals at Harborview Medical Center, Seattle Cancer Care Alliance and UW Medical Center soon will be saying goodbye to old-fashioned paper charts in favor of a more efficient digital alternative.

The three institutions have started to replace paper patient charts with a new electronic medical record. The Online Record of Clinical Activity (ORCA) will support between 5,000 to 6,000 simultaneous users and cost approximately $40 million. Full implementation is expected to take four years.


	Dr. Tom Payne enters information into an electronic medical record.

"We're replacing at least five different systems with one application," said Tom Martin, director and chief information officer in UW Medicine Information Systems. "ORCA will have the information contained in the past in medical charts, pharmacy records, the clinical information system, MINDscape, and others. By including all of this information in one application, we can provide a single place where a health professional can view the clinical activity of a patient. By reducing paperwork and streamlining the system, we can positively impact patient care and satisfaction."

Dr. Tom Payne, clinical associate professor of medicine, medical education, and health services, is the leading medical executive on the project. Payne was director of clinical informatics at the Veterans Affairs Puget Sound Health Care System when it won the 2000 Nicholas R. Davies Award for its paperless, interactive, online medical record system.

In hospitals and clinics across the nation, paper charts going the way of manual typewriters and rotary-dial phones. The change is partly due to recommendations from a 1999 Institute of Medicine (IOM) report and the Leapfrog Group, which represents more than a hundred Fortune 500 companies that provide health benefits for 32 million Americans. One of the Leapfrog Group's recommended three initial "leaps" in patient safety is computerized physician-order entry, a method that can reduce error rates by more than half. An article in the Oct. 21, 1998, issue of the Journal of the American Medical Association reported that computer entry reduced error rates from 10.7 to 4.9 per 1,000 patient days.

MINDscape, the electronic system most familiar to UW clinicians, was not designed to provide computer physician-order entry.

"The prima facie argument for the electronic medical record is that it is necessary for patient safety," said Dr. Edward Walker, associate dean and medical director of UW Medical Center, "but there is also a common-sense argument in terms of managing the cost of care."

The ORCA system has a one-stop electronic inbox for physicians, outpatient nurses, pharmacists and other health professionals to read lab results, and to transcribe and edit documents. Most hospital rooms and some clinic rooms have now been set up with the appropriate computer equipment. Web-based and hands-on training in each department will instruct the staff on the use of the system. Faculty leaders at both Harborview and UW Medical Center have given feedback and are helping fine-tune the final form of this system.

"Change is always a relative comfort state," said Walker. "After an initial investment of time getting to learn the new system, I think most people will agree it's a helpful tool. In comparing the search capabilities of the paper versus electronic record, it's like the difference between using a computerized search and the old card catalogs in a library. Computerized searches are a net advance in our ability to organize information."

Twenty years ago, a typical imaging exam was a chest X-ray, which consisted of two films. Today a physician might order a CT scan containing over 60 images, a three-dimensional reconstruction and a video representation of the patient's chest. The new electronic inbox could help organize such a wealth of patient information.

"Many of the patients we see at Harborview and UW Medical Center have complicated diseases such as trauma, organ transplant, cardiac surgery, HIV infection, or burns," said Scott Barnhart, associate dean and Harborview medical director. "The explosion of diagnostic and treatment information for patients such as these is extraordinary."

The electronic medical record helps organize what would otherwise be information overload. For instance, physicians have had to remember which tests were ordered for each of their patients. The physician was then responsible for checking to see if the results were ready. Now the results will be automatically delivered to the doctor or the unit via the electronic inbox.

"The electronic record gives physicians immediate safety information," said Martin. "Redundant physician orders, patient allergies, and drug interactions are flagged instantaneously, as are contra-indications from lab tests. The electronic record also eliminates the confusion of illegible handwriting."

The system also supports many of the features that facilitate UW Medicine compliance with the Health Insurance Portability and Accountability Act (HIPAA). The act is a set of federally mandated privacy rules, which took effect April 14, 2003, and security regulations that take effect in April 2005. The online record system requires authentication by login and password. Views of patient data are restricted by the user's role in the patient's care. The electronic record keeps an audit of who looked at what information and when.

"Hospitals cannot manage the cost of care without providing better information to the physicians, nurses, and other staff who are at the patient's bedside," said Barnhart. "These electronic systems provide better information. None are perfect and change will be a challenge."