Once embarked on an EHR journey, Ministry needed to develop supporting corporate infrastructure, tasks such as finding a Chief Information Officer (CIO) and Chief Medical Information Officer (CMIO). While those efforts were underway, we pulled together a team of clinicians and staff who were using or had used an electronic medical record in the past. This team gathered virtually on a regular basis to develop a joint vision of what practicing clinicians need in an EHR.

I have found clinicians who have used EMRs in the past possess unique insights as to how an EMR can be used to improve provision of care. Clinicians who have not used an EMR, tend to develop workflows duplicating their paper flows rather than finding new processes to leverage the technology.

We gathered over the noon hour once a week via a telephone conference. We generally talked about a topic and flushed out our functional specification.  Offline, we developed representative screen shots depicting the functionality we desired. Screen shots and functional requirements were shared using PowerPoint Presentations sent via our internal e-mail server. Today we would collaborate using WebEx as the communication tool.

By the time Ministry had hired a CIO and CMIO, the clinicians had formed a very clear vision of our functional specifications.

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Stevens Point, Wisconsin

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In a previous post, I stated there are there three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database

A data exchange provides a mechanism where information from disparate data systems is collected and then presented for viewing.  The data, while useful as a reference source, is of limited value because of a restricted ability to package the information in meaningful ways or be used as a driver of decision support. Patients are often not uniquely identified in the database resulting in duplicate records.  Some entities maintaining data exchanges do not adhere to the same patient confidentiality standards as the organizations that contribute the data. These exchanges are expensive and ongoing funding to support continued use has been problematic.  A data exchange can be useful when regional providers of care use either different electronic medical records or EMRs where the database can be unilaterally altered. It’s value will be high in the short term when entities merely wish to view data, but will be limited in the future when those same entities wish to use the data to provide decision support at the point of care.

A few EMR vendors offer a standard data base across their user base. Separate health care entities can utilize these records and have an identical database structure allowing alignment of patient records.  The resulting structure can allow the data to drive decision support or common determination of clinical benchmarks. Since the database has a standard format, custom programs for decision support can be easily shared between users. Though more useful than an data exchange, this format is limited in that patients may not be uniquely identified in aligned systems.

A single common medical record with a single patient database used by independent regional health care entities provides the most robust structure to share medical data and drive decision support.  Governance can be a real issue but the improvement in patient care is worth the effort. Data can be packaged and presented to meet the needs of each individual user.

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This image is a HDR, a composite of several images taken several f-stops apart. An off camera fill flash was used to brighten the back side of the bull thistle. The images were captured just prior to sunrise on a very still morning.  The ridge line 3 miles in the distance is the terminal moraine from the Wisconsin Glaciation.

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Think of an EMR as the equivalent of a patient’s paper medical record, the accumulation of one business unit’s information about the patient.  Typically, patient health care information is found in multiple paper medical records (or EMRs). Even in small isolated communities with a limited number of care options, records are kept in multiple locations. The hospital has medical records, most often organized as episodes of care. Even if all medical practitioners use the same outpatient medical record, dental and psychiatric records are often segregated. 

Some systems of care have taken the step of combining all the regional medical records; consider the result to be a combined medical record. The step involves considerable effort as each patient will need to be uniquely identified and the various health care entities will need to establish a common form and governance of the medical record, not an easy task.

If the system of care takes the concept one step further and embraces the concept that the medical record should be the complete record of the patient, they are on the path to an electronic health record.  The quest to obtain a complete record will never be finished as there will always be more information that can be gathered. However, the quest results in a record with ever increasing value to patients and caregivers.

An EHR is considerably more complex than a combined medical record because systems of care that are not directly aligned business units need to agree on common patient identifiers, common structures and governance. 

There are three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database.

I will discuss these types of EHRs in a future post

Our use of the term EHR, signified our intent to move towards a single health record for a patient. As you can imagine, the vision of having an EHR had major significance for selection of a vendor.

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The Buena Vista Grasslands in central Wisconsin is a wet lowland. Many mornings it is shrouded in fog when the rest of the countryside is clear.  This image was captured looking up a former sand dune formed from the run off of melt water from our last glaciation. The ground fog hung just a bit off the ground making for a spectacular sunrise.  I great way to start your morning. 

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Where does one start on the EHR journey? At the beginning.  Where is the beginning?  The beginning should be squarely focused on the business needs of the organization.

Our journey grew out of series of strategic development sessions.  Our two major medical groups had been acquired within the past 10 years and each had developed a business model centered on a regional hospital.  Each regional business unit had developed the basics necessary for a functional EMR but there were no true links between the units.

A number of tactical initiatives grew out of our strategy sessions. We discussed how we might achieve the various initiatives and came to the conclusion a system wide EHR was a prerequisite.  

Lesson: The EHR (or any other initiative) has to be based on the business needs of the organization.

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The Buena Vista Grasslands just south of Stevens Point, Wisconsin is a great place to find butterflies. These two had spent the night on a bull thistle and had not warmed up enough in the early morning light to take flight as I approached. The pre-sunrise dawn provided a neutral back drop and an off camera flash was positioned to the right and a little above.

The location is along Taft Avenue within Prairie Chicken habitat. The grasslands is a broad expanse of flat land extending about 20 miles south.  The Green Bay Lobe of the Wisconsin Glaciation extended to within 2 miles of this location. Runoff from the melt water contained great quantities of sediment that was deposited over the future grasslands and leveled the terrain.

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We have been on a two year journey to select our EHR product, Marshfield Clinic’s CattailsMD^TM .  My intent over the next few months is tell the story of our journey and provide details of the work ahead of us. I hope this work will be of value to others. Governor Doyle’s press announcement is below.

Friday, June 20, 2008

Contact: Carla Vigue, Office of the Governor, 608-261-2162

Governor Doyle Announces Creation of Largest Patient Database in Wisconsin

 New System Will Improve Safety and Health Care Quality for 2.5 Million Patients

Governor Jim Doyle announced today that Ministry Health Care will begin using an electronic health record (EHR) software suite developed by Marshfield Clinic - CattailsMD^TM - for the majority of its hospitals and Ministry Medical Group, creating the largest patient database in Wisconsin.

“This is an important step forward in our efforts to reduce medical errors, increase patient safety and decrease health care costs,” Governor Doyle said. “With better use of information technology, we can transform our health care system to improve the safety and quality of health care.”

“We are confident this significant IT investment will meet the health care needs of the patients we serve in northern and central Wisconsin,” said Nick Desien, president and CEO of Ministry Health Care.

“I am gratified that the longstanding relationship between Marshfield Clinic and Ministry Health Care has been further strengthened by this agreement to extend our CattailsMD^TM system to Ministry facilities, which will also greatly benefit our shared patients in the region,” said Karl Ulrich M.D., M.M.M., president and CEO, Marshfield Clinic.

More than 1,000 providers in the Marshfield Clinic system, at Ministry Medical Group and Ministry hospital locations will share access to 2.5 million patient records. Implementation of the EHR for Ministry will occur over three to five years.

The EHR makes all patient medical information immediately accessible via computer to medical personnel involved in a patient’s care regardless of where they are located. Currently, paper charts cannot be viewed by more than one person at a time and often need to be physically transported from one location to another, wasting time and adding cost.

Not only will the EHR improve access to patient records, it will provide clinicians critical information in an easy-to-read format.  The EHR will also be more secure. It will allow access only to those providers involved in a patient’s care, as well as track what information was accessed when and by whom.

As part of this agreement, Marshfield Clinic will provide planning, project management, implementation, training, customer service and technical support services to facilitate the installation of these clinical software applications.

Marshfield Clinic’s Cattails MD^TM is the first provider-developed ambulatory EHR in the nation to achieve Certification Commission for Healthcare Information Technology (CCHIT) certification.  It is used daily by more than 13,000 providers and support staff.  For more information about Cattails MD^TM, go to http://www.cattailsmd.com.

Widespread implementation of EHRs has been a top priority of Governor Doyle since he took office. In 2005, he created the Wisconsin eHealth Care Quality and Patient Safety Board, which is charged with developing an action plan for the statewide adoption and exchange of electronic health records. Governor Doyle has provided millions of dollars in tax credits for automating medical records and he ordered Act 108 to reduce barriers for providers to access electronic health information, while still maintaining appropriate privacy measures.

Stevens Point grew up along the Wisconsin River.  The area was initially inhabited by Polish immigrants who built St. Peter’s Catholic Church in 1897. Recognizing the strong Polish roots, Polish Cardinal Karol Wojtyla visited the church in 1976.  He later became Pope John Paul II. 

This image is an HDR and looks over the Wisconsin River as St Peter’s tower is back lighted by the rising sun.

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