Getting the Record Straight

Baldwin Louie — Mon, 10 Apr 2000 18:00:00 -0400

SEATTLE- Heart surgery resident Alex Farivar is 30 hours into his shift at the University of Washington (dossier) Medical Center when he finishes his rounds and retreats bleary-eyed to the residents' room with a handful of barely legible notes that detail patients' conditions.

In the past, these notes would have gone straight into Farivar's patients' files, leaving subsequent caregivers to puzzle over his handwritten observations and directions. Instructions that were still unclear might have led to a time-consuming round of phone tag as doctors and nurses tried to clarify what Farivar jotted down. Worse, his notes might have been misinterpreted and patients given the wrong treatments.

Now, instead of adding to the sheaf of papers in a 70-year-old heart patient's chart, Farivar sits at a computer in the small room where residents catnap and calls up an electronic version of the woman's medical record. Made by Seattle-based Elixis, the WebCoder online medical record provides a complete - and readable - treatment and medication history. Farivar adds his observations and directions for treatment by clicking on a series of menus with titles like Vital Signs (VITL), Current Medications and Assessment and Plan, then digitally signs the record. Authorized doctors and nurses can access the record online from any location.

"Before, I would have scribbled this, leaving off 25 percent of the information," says Farivar, 26. "Some of it would have been completely illegible." He picks up a piece of paper and scrawls his signature. "Someone who was consulting on the case would have looked at this and said, 'Who is this?' It's not uncommon to page two to three people just to find the right person."

And it's not uncommon for mistakes to be made. Charles Jaffe, a San Diego allergist, witnessed early in his career the consequences of bad handwriting when a hospital's medical staff misread another doctor's instructions for administering chemotherapy to a child. "I was the physician on call and they cried for help, 'What are we going to do? We've given 10 times the dose,'" recalls Jaffe, who now uses an online medical record made by Hillsboro, Ore.-based MedicaLogic.

Recent research indicates that as many as 98,000 people in the U.S. die each year just in hospitals as a result of medical errors. A report released in December by the National Academy of Sciences' Institute of Medicine estimated that death by medical mistake is a leading cause of death in the U.S., with more people dying from medical errors each year than are killed by AIDS, breast cancer or car accidents. The death toll is equivalent to a jumbo jet crash every other day.

Figures like those have fueled interest in online medical records as a way to reduce mistakes caused by bad handwriting, improper drug prescriptions, misuse of medications or incomplete information on patients' conditions.

Further impetus has been added by a Clinton administration proposal that would require doctors and hospitals to report medical errors to the states. If approved, such a mandate could drive more doctors to adopt online medical records as a way to collect information and reduce preventable medical mistakes, say health care industry observers.

Previous electronic medical records, or EMRs, never caught on because they generally used proprietary technology that was expensive to buy and maintain. But the Internet has stirred new interest in EMRs, with the prospect that any doctor with a Net connection and a Web browser can access an online medical record.

Still, the online medical record industry remains in its infancy. A dozen physicians are testing an EMR from iMedica that runs on handheld devices. Only about 1,000 doctors use Elixis' WebCoder. MedicaLogic declined to say how many doctors have signed up for its Logician Internet online medical record, but about 8,000 physicians use an intranet version of the product. The growth of the industry will depend on how fast doctors take to the Internet to practice medicine.

Florida internist Ken Ponder learned the lifesaving value of online medical records in January, when the Food and Drug Administration warned that a new heartburn drug, Propulsid, could put some patients at risk of heart attack. Ponder, who uses MedicaLogic's Logician Internet online medical record, called up his database to quickly identify his patients who use Propulsid, then brought them in for an electrocardiogram. "Before Logician Internet I had no way to tell which patients were on Propulsid. It would have taken a manual review of literally a thousand charts."

Molly Coye, a former director of the California Department of Health Services, sat on the Institute of Medicine committee that wrote the medical errors report. "There was no question in the committee's review that electronic media and Internet technology will transform the issue of safety," says Coye, a physician who's now a senior VP with the Lewin Group, a health-consulting firm. "It has the potential to reduce the errors associated with just being human. The problem is that most [health care] providers are practicing in a cottage-industry setting. They haven't even gone though the Industrial Revolution."

Online medical records are likely to get a boost from national health care provider Kaiser Permanente's plan to give each of its 9 million members a digital medical chart. But it's still common for a person's medical records to be scattered in paper files kept by several different doctors and specialists. As a result, different physicians may not know a patient's complete medical history, medication use or reaction to different treatments and drugs. For instance, it may not come out during an eight-minute doctor's visit that a patient is taking an herbal remedy like ephedra, which might interact dangerously with her blood-pressure medicine.

Mistakes made in the prescription and use of medications are among the most common medical errors, according to the Institute of Medicine report. It found that the death rate from medication errors more than doubled between 1983 and 1993, and the problem is likely to worsen as Americans age and use more prescription drugs.

"Every individual elderly patient has multiple diagnoses, sees multiple caregivers and carries around a bag of pharmacopoeia," noted Stan Pappelbaum, CEO of San Diego's Scripps Health, at a medical conference in February. "It's a setup for medical error. The Internet is the ticket for reducing that."

Medication errors usually happen when a medical record fails to list all the drugs a patient uses or to give a complete medical history. "Physicians do not routinely screen for drug interactions, even when medication history information is readily available," the Institute
of Medicine report found. Fatal mistakes may also occur when patients don't take their medicines or take them improperly.

Online medical records can help avoid such problems. For instance, Internet health care companies Allscripts and CareInsite (which has agreed to be acquired by Healtheon (HLTH)/WebMD) have developed online prescription services that list patients' medication histories and alert doctors when one medication would cause problems if used with another.

The online medical records offered by Elixis and MedicaLogic are located on the companies' respective servers and allow doctors to record a patient's medical history from any computer. The records also provide physicians with the proper billing codes for various procedures and treatments to ensure they get the right payment from insurance companies. Elixis is targeting specialists such as cardiologists; MedicaLogic's online medical record is tailored to general practitioners.

Other online medical record companies like WellMed and PersonalMD offer consumer products that require individuals to obtain medical information from their doctors, pharmacies and laboratories; understand those diagnoses; and enter the data into their online medical record themselves. Some industry analysts question whether physicians and other health care providers will accept the legitimacy of patient-created online medical records, particularly as they pertain to medical histories and diagnoses.

At a Providence Family Medicine clinic in Wilsonville, Ore., physician Karl Magsarili uses an intranet version of MedicaLogic's Logician. The clinic, located in a strip mall about 30 miles south of Portland, has a computer in each examining room. When Magsarili examines patients he can call up their medical records and enter their vital signs, complaints and conditions simply by pointing and clicking. "It checks for drug interactions and will alert me if there's a potential allergic reaction to medication I'm prescribing," Magsarili says.

As part of a pilot project, the clinic's patients can view their medical records online and communicate with doctors on MedicaLogic's AboutMyHealth.net site, now called 98point6.com. Patient Michael Kennedy has been using the service since August. He says reading his medical record and e-mailing Magsarili has cut his visits to the clinic. It's also improved the accuracy of his records. "I noticed they had listed a medication I was not on anymore. I told Karl and he took it off," says Kennedy, a 34-year-old health policy analyst for the state of Oregon.

Elixis, which supplies its WebCoder medical record to the University of Washington Medical Center, also plans to give patients online access to their medical charts.

Whether online medical records can ultimately make a dent in medical errors will depend on the extent of their use by physicians and the adoption of standards that allow doctors and hospitals to share information regardless of which online service they're using. If a patient's primary physician uses online medical records but his specialists do not - or if they use a different service - the benefits are reduced.

While potential cost savings from the use of online medical records could be huge, their limited use so far has not generated any hard data on whether they improve patients' health or cut costs. But Richard Gibson, Providence Health System's chief medical officer, says preliminary surveys indicate that giving patients an online medical record has at least reduced the time staff members spend answering phone inquiries.

The immediate challenge will be to persuade physicians to trade their pen for a mouse. "Doctors still will write a note that I can't read and then dictate it, and it'll take four days for the transcription to come back," says Edward Boyle, a University of Washington Medical Center surgeon and Elixis cofounder. Case in point: As a nurse updates a patient's online chart by pointing and clicking, a doctor stands nearby and dictates his notes into a tape recorder. Physicians who use Logician Internet can use a voice-recognition system to record their notes directly into the medical record.

Another hindrance to doctors' adoption of online medical records is that they're tethered to a desktop PC. That will change this year as Elixis and MedicaLogic introduce versions of their records that can run on PalmPilots and other handheld devices.

Heart surgeon Farivar believes patient demand and a new generation of doctors will drive a change. "Look at this," he says, flipping through a paper chart filled with handwritten notes. "Can you read this? I can't. There's a complete change of paradigm coming."
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Getting the Record Straight