Healthcare in the Electronic Age

IT has been playing a valuable role at the Cleveland Clinic and rightly so – for one, errors can be greatly reduced and patient safety improved as a result. Amongst the innovations the clinic has invested in is patient experience technology. Currently the hospital is investing in improving the clinical experience of patients through the use of Electronic Medical Record (EMR) technology and e-help service technology.

Harris is particularly enthusiastic about the investments made in the personal health records. “We have implemented a tool that allows a patient to remain connected to their physician after they leave the physician’s office,’ says C. Martin Harris, the clinic’s CIO. “They can log in 24 hours a day, seven days a week, and receive an automated service. They no longer have to write down their allergies when they are in the physician’s office. Rather, the information is provided to them automatically because the physician is documenting their allergies in the EMR.

“They receive their medication list automatically because the physician writes their prescriptions electronically. If a patient has work done anywhere in the Cleveland Clinic health system it will automatically update the health maintenance screen for them.”

Achieving interoperability

Last year, the Department of Health and Human Services issued a report on personalized healthcare and how the full potential of this depends on health information technology that is interoperable. With this in mind, Harris explains the importance of health IT in achieving the goal of greater individualization of care and being able to maximize opportunities, pathways and resources. “Interoperability is a sophisticated way of overseeing the exchange of information on behalf of the patient so that the next provider that sees the patient has the right information to make the best possible decision,” highlights Harris. “We’ve focused on this initiative for quite some time and there are two levels of interoperability that really need to be achieved.”

As Harris continues, the first of these is within the organization itself. The Cleveland Clinic operates 11 hospitals, 10 of them in Ohio and another one in Florida. These hospitals have been integrated and interoperability accomplished. As a result, a patient who sees a physician in any of the facilities can expect information about them to be available immediately at any Cleveland Clinic related facility. The real challenge is that patients choose their own healthcare team, which is often a mix of Cleveland Clinic physicians and physicians who practice independently of the clinic.

Information therefore needs to be freely exchanged between these two groups of providers. “This is a project that we have been working on,” says Harris. “We’ve been working with an organization capable of reaching out and connecting all 800,000 physicians in all 5000 US hospitals, along with all retail pharmacies and laboratories – a scale that the Cleveland Clinic could not make happen on its own.”

In order to achieve this level of interoperability, the team collaborated with Google Health. The result is that patients can move information even to providers who don’t practice in the same healthcare organization.

In order to demonstrate this a bit more clearly, Harris provides an example of the system in action: “About two weeks ago we had a patient arrive at the Cleveland Clinic to have their aortic valve replaced. This patient happened to be from another state. They used Walgreen’s and Quest Laboratories in that state and worked with a physician independent of the Cleveland Clinic. By having access to the Google Health service they were able to pull down all of their medication information from the Walgreen’s and Quest Laboratories system into a Google Health account, which they control. All their information is transferred to the Cleveland Clinic and over to the physicians who are going to see them while they are here. Therefore, before the patient even set foot on campus their medical information was in front of the physician who was going to care for them.”

This method accomplished two things, according to Harris. First, it allowed the physician to prepare the optimal care plan for that patient, beginning on arrival. They could see which tests had already been performed which they knew did not need to be repeated. The patient didn’t have to go through any unnecessary testing.

“On arrival home, the patient could go back into their Google Health account and pull any information that had been generated during their stay at the Cleveland Clinic from their Google Health account,” highlights Harris. “In this patient’s case, their local provider didn’t have an EMR so they couldn’t push it into the account, but what they were able to do was to print it all out in a nice, neat form. They had a comprehensive summary of all the care that happened to them here at the Cleveland Clinic.”

Net help

Currently there is limited online support to help healthcare professionals deliver the best care, and the wealth of information that could be obtained from millions of day-to-day encounters and medical practice remains untapped. Harris has two recommendations in order to rectify the situation. “We are just touching the surface of the value of health information technology related to the actual practice of medicine,” he says. “Our ability to affect best practice and provide tools to physicians and patients that allow us to support a new, optimum and consistent practice of medicine is just getting started. This can only be done if you think about the practice of medicine in the age of information technology. I want to take those best practices and hardwire them into the practice of the physician and into the minds of the patients so that we eliminate any unintended variations in our practice delivery.”

A further issue is how to address the challenge of reaching patients and referring physicians. As Harris affirms, this is not a new concern, and is a problem that can certainly be mitigated through the use of information technology. Reaching patients and reaching out to physicians has been an ongoing challenge and it’s where information technology can literally transform lives.

“An example,|” explains Harris, “might be a medication recall, such as a recent one regarding commonly used antibiotic. Although the FDA hasn’t formally announced their decision around this antibiotic it’s possible they could make a decision to restrict its use in certain situations. What you need to know immediately is what patients are taking that antibiotic.

“Through the use of health information technology we have the ability, and we have done this now for several medication withdrawals from the market, to make that an active process. We have five million patients in our electronic medical record database. Within two hours we can go through the database and identify every single patient who’s taking that antibiotic. I can tell which physician prescribed that medication, then get that list directly to the physician so that they can see all of their patients that are on it.

“For those patients who use the personal health record, we can send them an electronic notice within five hours telling them they need to contact their physician and be put on new medication. For those without a personal health record, we can send them a personalized letter from their physician explaining the same thing within 24 hours. For us, a medication recall in the age of health information technology is an active process.

We can reach out to the patients, engage them and give them specific direction about what they need to do so that they continue to receive the best care. Eventually medication recalls through pen and paper will become passive.”

Making connections

A further service that the clinic offers is ‘Dr. Connect’ – designed to reach out to physicians. Physicians caring for patients often decide that they need to refer that patient to the Cleveland Clinic either for a specific procedure or for a consultation. Historically this was a paper process – the patient came in, the physician saw them. The notes were then written up and transcribed and eventually sent back to the referring physician.

“Using health information technology in this Dr. Connect process, we have made this a virtual collaboration with the referring physician,” highlights Harris. “When the referred patient gets to the front desk the registrar notifies the physician that the patient is working with a physician in the community who uses Dr. Connect. The patient is asked whether they would like this information to be shared with the physician. If they agree, then we push the button and the physician instantaneously receives a notice letting them know that their patient is here at the Cleveland Clinic.”

Physicians can keep up to date with patient data via an email. As a result, they can sign on and essentially collaborate with the care of that patient. “They can see everything that happens to the patient, every test, every doctor’s note, every procedure that’s performed in real time with the physician here at the Cleveland Clinic,” enthuses Harris. “If they think something hasn’t been considered they can send a message to the physician who’s caring for them and have that addressed before the patient comes back.

“Our real goal is to ensure that the referring physician is an active participant in their care, and when that patient makes their way back to the physician all the information about their care here at the Cleveland Clinic is in front of them well before the patient can get into their office. This system has changed the standard of care in our community.”

Looking ahead

The President’s budget for 2008 includes $15 million in startup funding to create a new electronic network that would draw together data from major health data repositories. We asked Harris his opinion on this and how the funding is likely to further the goal of personalized healthcare and its impact on the average healthcare consumer. His response was that in the grand scheme of the US healthcare budget, $15 million will not stretch that far and that it is really a starter project.

“We need to think about how the US population could be better served through the use of information technology,” he explains. “What we are likely to see coming out of the project are thoughts about the role the Centers for Disease Control plays today when it comes to the population overall, rather than simply individual patients. Is the immunization program for the flu this year being delivered in an effective way? Do we have an outbreak of a particular virus like West Nile virus, and do we know where it’s starting and where it’s likely to affect next?

“If you imagine the entire US healthcare system having access to the same health information technology that we have here at the Cleveland Clinic, then you can imagine the ability for the CDC to be able to see an early outbreak of a new infectious disease. In addition to this, to be able to identify the population that’s at risk, to intervene and understand the cause of a new outbreak of a fever and whether or not there is a real risk for the US population overall so that they can intervene earlier.”

Martin identifies that rolling out technology as fast as possible is likely to be a future challenge. There are two areas that will need work to be overcome: “The first has to do with the independent practitioner. Most medical practices in the United States are still relatively small physician practices, with fewer than 10 physicians – in many cases less than five. Getting them to adopt to health information technology will be a challenge for the US healthcare system, as there are almost 800,000 of them. Their ability to implement this kind of technology is limited because of initial cost, and then ongoing technical sophistication.”

Producing the kinds of professionals who could deliver these services and creating services that remove the technical hurdles from the physician’s office will prove difficult to achieve initially, according to Harris. One measure that the Cleveland Clinic has taken is to introduce a program called ‘My Practice Community’. With this, the clinic offers essentially the same tools to an independently practicing physician over the Internet as a service.

“All the client needs is a desktop computer and an Internet connection, but they don’t need all of the back end hardware/software and integration sophistication. They lease the service, which allows them to get into the information age faster and in a way that they can depend on. As we begin to use these tools, we have to train a whole new cadre of physician professionals to be expert at the selection, implementation and use of these technologies, as they become ever more sophisticated.”