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Electronic medical records (EMRs) are poised to take hold, grow in importance, and alter the practice of medicine. Physicians and private payers know this. President George W. Bush has announced the goal of having an electronic health record available for every U.S. citizen within the next several years. Implementing this strategy will be difficult, and will involve adoption by oncologists of an EMR that will fit into this electronic health record.
In this article, we examine an EMR implementation strategy in use by several large institutions that have the institutional commitment and resources to develop an EMR of their own—the “homegrown” approach. We offer the perspective of former ASCO President David Johnson, MD. Johnson is director of the Division of Hematology and Medical Oncology and deputy director of the Vanderbilt-Ingram Cancer Center (Nashville, Tennessee). This article describes Vanderbilt's homegrown flexible EMR and Johnson's thoughts on where EMRs may fit in for small to mid-sized oncology practices. In this context, he is among those calling for “improved systems for record keeping, communication, and for enhanced efficiency” on the part of physicians and others.
Vanderbilt's medical school includes a Department of Informatics that is largely staffed by MDs who are physicians first and “computer geeks” second. Johnson thinks that many EMRs suffer because they were created by “computer people thinking in computer terms who know little or next to nothing about medicine.” In his view, such teams often include a token doctor, but that only leads to an EMR based on “the biases of one individual,” he says.
The Vanderbilt EMR, which has been refined and updated over time since work began on it in the 1980s, has three major elements:
This EMR spares both doctors and nurses from an enormous mountain of manual busywork and greatly boosts efficiency. “We have more things to do than ever for patients, and [we] maximize every minute,” Johnson says. “Our EMR is much more than a warehouse of patient data. It's vibrant, like an air traffic control system for medicine.”
“‘Never be the first doctor to try a new drug and never be the last.' It's the same with an EMR. You might not want to be first. … But you don't want to be the last either.”
—David Johnson, MD
The EMR simplifies the assignment of patients to clinical trials and participation in those trials. “Our EMR isn't designed for this purpose, but its elements are critical for the good conduct of trials,” Johnson says. “It makes it so much easier for research nurses to pull up records and piece together times and dates of lab draws and X-rays.” Enhancements now underway (such as the creation of electronic flow sheets similar to those customarily used in trials) will make the Vanderbilt EMR even more useful in research.
The EMR, says Johnson, helps his practice avoid errors of both overbilling and underbilling. “The EMR makes it much easier to document the level of service that we have provided in an unambiguous way.”
Johnson admits that his academic situation differs greatly from that of community oncologists with regard to the resources available for EMRs. He explains some of the factors that have deterred many physicians in small to mid-sized practices from using EMRs:
Other hurdles include the instability of vendors and the variety of EMR products, with a wide range of functions that make comparisons difficult. “It's natural for community oncologists to be fearful and often paralyzed into inaction,” Johnson says. I sympathize with these practitioners. Medicare says, ‘You will use an EMR,' but they won't say which one because they don't know which one.
“Some doctors buy off-the-shelf products. They sometimes jam a square peg into a round hole, using what's there with existing products and making the best of it,” he explains, “Others try and can't hack it. If I were in the community, I'd be paralyzed.”
Experience with this homegrown system in a resource-rich environment has made a believer of David Johnson. Living through the development and the implementation experience brought to mind advice he received as a medical student, from a mentor: “He told me ‘Never be the first doctor to try a new drug and never be the last.' It's the same with an EMR. You might not want to be first. You might wait until the bugs get worked out. But you don't want to be the last either.”