California doctors pioneer e-medical records

With some 400,000 patients and the largest medical network in Northern California, Hill Physicians Medical Group Inc. faces a daunting challenge moving from paper to an electronic medical records (EMR) system.

Its provider network includes 3,000 primary care and specialty physicians working in about 1,600 locations across nine counties, making Hill Physicians the largest independent practice association, or IPA, in the U.S. But instead of being overwhelmed by the process of implementing an EMR system, Hill has become a model for how to replace paper records with electronic records -- it is a taking a very slow, steady approach.

Three doctors' offices in the network came online with the EMR system in 2005, the first year of implementation, and another five have been added so far this year, with the goal of 18 total by year's end.

"It took a year to figure out," said Craig Lanway, chief information officer of PriMed Management, which is Hill Physicians' proprietary medical management company, handling all of the network's administrative functions. "We've made great strides" in moving to electronic records, he said.

EMR systems save administrative costs, providing a more efficient way to store and handle records than paper. EMR also reduces the risk of errors in prescriptions because doctors, who have notoriously bad handwriting, can electronically send prescriptions to pharmacies. But perhaps most importantly, EMR pulls together all of a patients' medical records -- doctors can quickly call up the range of a patients' records, including those from hospitals, consulting doctors and specialists, as well as laboratory and test results. Over time, as more health-care providers move to electronic records, it should be easy for a patient's medical history to follow them as they move to new locations, change doctors or see specialists.

However, doctors haven't flocked to EMR. Some resist change, others are not comfortable with technology in the first place and are not keen to make it part of their practice. Some feel they can't afford to make the switch. EMR systems require that exam rooms be equipped with computers or that doctors carry mobile PCs, such as laptops or tablets or even PDAs (personal digital assistants) as they move from patient to patient.

Hill Physicians, through PriMed, chose an ASP (application service provider) model for its electronic system, with Tellurian Networks Inc. as the hosting site. It also turned to Sun Microsystems Inc. for integration of hundreds of disparate computer systems in place at the various doctor's offices. The SOA (service-oriented architecture) of Sun's SeeBeyond tools, including its eGate integrator and eInsight business process management, offered the scalability Lanway and his team needed. It also provided the Web-based framework to allow Hill's doctors to interface with third-party applications in use across the health-care network. NextGen Healthcare Information Systems Inc. was chosen as the EMR.

Hill Physicians established a committee to work on the EMR project, including which doctors' offices should be the pilot sites, and had a realistic picture of the challenges, according to Wayne Owens, senior vice president of health care at Sun. "Hill has been extremely well educated and well informed. When they came to us, they knew what they were doing," he said. "I think they are a pioneer."

While Lanway said that it has been a "tough learning curve" for doctors because the EMR system is so different from what they have been used to, he has been impressed with how well the system has performed from a technical standpoint. "We have almost no problems with any aspect of this [system] from a technical aspect," Lanway said. "The reliability is just amazing. It's just flat-out amazing."

The deals between Sun and NextGen and Hill Physicians forbid Lanway from disclosing the costs of the EMR implementation, but he was able to offer an example that a practice based in one location with three doctors would spend over five years, including hardware, a total of US$130,000 to $135,000 on the EMR. "That's really good," he said, particularly given that the system would likely allow such an office to eliminate one clerical position for a savings of about $200,000 over the same period.

Positions are generally cut through attrition rather than layoffs and doctors who spoke about the EMR said that it also allows their office managers to avoid the constant need to run ads and interview applicants because there is extremely high turnover among medical clerical staff.

The Family Practice Medical Group in Oakland is a pilot site for the EMR system, going live in March of 2005, and now "retires" between 10 and 12 paper record files in any given day, said Dr. Careen Whitley, a family practitioner there. The staff prioritized which patients' records should be moved from paper to electronic form first, with those who need the most ongoing care at the top of the list.

"On day one, it's a matter of knowing where things are and learning how to navigate the system," she said of the switch to using a tablet PC while she talks to patients. She used to dictate notes for transcription later, but now she types notes as she goes along. "It's splitting your brain in two," she said of the transition. "Part of you wants to take care of the medical problem the patient has and be compassionate and engaged and the other part of you is trying to figure out the computer."

But soon enough, the computer element of the EMR became more rote. Even so "there are times when you can't be on the computer and examining the patient at the same time," she said. "I need to grow two more arms to do that."

With a robust load of 25 to 30 patients a day, Whitley could probably use a couple of extra arms anyway, but overall she says she has adapted to bringing more technology into her practice and has found that she can engage her patients by showing them what is on the computer screen. "They really like the technology," she said of her patients' reaction.

Dr. Paul Wheeler, an internist at San Ramon Valley Primary Care, has found the same reaction from his patients after implementing the EMR in a phased approach starting in March of this year.

"It's been nearly universally positive," he said, adding that a lot of his patients work in IT and those are the ones who seem most appreciative. Otherwise, though, "most of them are just happy that I'm able to fax their prescription directly to their pharmacy, so they don't have to go and drop it off and come back for it ... They're just happy to see they've got a doctor who has joined the 21st century."