John D. Halamka

CareGroup Health System

and

Harvard Medical School

Harvard has moved all of its clinical, financial, and administrative applications to the Web. The changeover began in 1998, when all clinical information was put online. Now one can have complete, ubiquitous, transparent, seamless access to all aspects of the clinical care process. The technologies are robust and secure, and all work flow processes take place on the Web. From an engineering standpoint, the change was made by taking all of the legacy systems that already existed for Harvard's patients and employees and wrapping them, using XML Web services, to provide standards-based information exchanges. Today, I will present this new system.

Everything in the system is secure, and everything is audited. When the system is accessed by a provider, the first screen provides access to the nine million patients in the CareGroup master patient index, reflecting 6 hospitals (Beth Israel-Deaconess, Mt. Auburn, New England Baptist, and three community hospitals).

One serious impediment to using computerized medical records is that there is no universal health identifier in the United States. To search for a patient's record, therefore, the Harvard system uses a statistical, probabilistic match based on demographic information. For example, using this model to gather information about a Martha Ford, one can see (Figure 1) that patients with that name have visited the East Campus, the Mt. Auburn Campus, and the West Campus, with different medical record numbers for each of those visits; but, with consolidated access, it is possible to see that all three Martha Fords are the same person (this patient has given permission for access to her medical records).

FIGURE 1

Patient record screen.

Next, one can assemble her entire medical record in real time from all of the places she sought care. Information is stored in very different ways, but, because the legacy systems have been wrapped in a standards-based package, it is possible to click on, for instance, medications, and get a complete look at the medications she is using. That information can be forwarded, for instance, to a drug interaction engine, that could list in order of severity the interactions of all the medications she has taken in the entire continuum of her care. It is possible to look at text data, such as her last echocardiogram, to obtain all of the echo parameters. It is also possible to pull out telemetry data, even data stored in an old, non-standards-based system, convert it to a standards-based display, and deliver it. This is truly a time series, scalable object that can be measured, printed, and manipulated.

All medical record images are also online and are DICOM based. Because Martha's chest x-ray is an object, it can be examined in many ways, and old films can be pulled up for comparison. Moreover, with this system one can also look at laboratory results over time, such as her CBCs trended over time for the last 10 years. This is the organizational context of information ubiquity, pulling together all of the data from wherever it is stored.

Provider order entry is also complete; there is 100 percent compliance throughout the entire organization. To achieve this, many processes had to be changed. Now, no voice or handwritten orders are done anywhere at Beth Israel-Deaconess Medical Center.

Here is an overview of how provider order entry works. Farr 2 is a typical medical ward. From a dashboard of all patients in that ward, one can click on any patient and get the patient record and a snapshot of the patient. All the standard orders that would appear on paper are available on the Web. When orders are entered, the system response includes queries as rules or reminders. One can, for instance, set rules that a flu vaccine has to be given to a patient per the standard protocol. One can then click a button to document that the patient has received the flu vaccine or click a button to order the vaccine. The system offers a quick pick list of all medications the clinician has ordered in the past for the patient, the most common orders, as well as overlays of some pharmacy and therapeutics standard formulary medications.

The physician order entry system has some fail-safe mechanisms. If a clinician orders something that might be bad for the patient—for instance cefazolin for a patient allergic to penicillin—the system notifies the clinician of a potential drug/drug interaction (Figure 2 shows a typical flagged interaction). If the clinician overrides the warning and continues ordering, the system queries the order. Let's say the clinician thinks the allergy history is questionable and wants to monitor the patient. The system then immediately fires off another set of care pathways or rules that advise about the drug. Based on the newest information about the patient's size and test results, it calculates the recommended dose of the drug, the dose frequency, and suggests body parameters that a clinician may want to follow while administering this drug. Thus, this system helps reduce adverse drug events.

FIGURE 2

Typical flagged drug/drug interaction.

If the clinician orders a different drug that may be restricted, an ID fellow may have to approve it. This is a form of consult. The system presents a built-in work flow: click on the button and the system pages the ID fellow via the Web to get approval for the drug. By the way, disapproval happens less than 10 percent of the time. The clinician may choose to default to the standard dose and standard route, which also requires only one click.

The system covers all aspects of ordering care plans and processes and contains standard order-sets for diseases, such as congestive heart failure and asthma. The system has also proven to be very helpful in the emergency room, where it has resulted in a 30-minute decrease in patients' length of stay. At the same time, customer and provider satisfaction has gone up a lot—before implementation, 60 percent rated the ER experience as excellent; after implementation, 85 percent rated it as excellent.

The system also gives the care team the organizational context to enable patients to take part in their care. Here is an example. In 1999, Harvard created a patient site, working with people in the patient-centered movement, that allows patients to have ubiquitous access to their own medical records, with secure, encrypted, doctor–patient e-mail and convenient transactions, such as appointment scheduling, referrals, and prescription renewal.

The patient site begins at patientsite.caregroup.org. (A typical screen shot is shown in Figure 3). For an overview, you just click on the “Take a Tour” button. This is how it works. A patient enters the system. The patient has a unique portal with access to messages of the day from the doctor; links to providers and websites; and life events such as appointments, a flu vaccine, or a colonoscopy. The patient can send secure—not standard—e-mails to doctors at any time. The patient sites are backed up with behind-the-scenes triage rules so that the medical staff can observe patient transactions and route messages appropriately, for instance, to a doctor, the appointments desk, or a nurse practitioner. The information on the transactions goes into the permanent medical record, where it is retained for 30 years. All of this happens in a secure, audited way. Patients can see the same medical records their doctors see, with certain limitations; patients can access information about their medications, visits, reports, x-rays, allergies, and problems, but cannot access laboratory reports, microbiology, or DICOM imagery. That happens across all institutions and outpatient facilities. CT, MRI, pathology, and psychology results are delayed for 14 days, to ensure, for example, that patients do not first read about a cancer diagnosis online; bad news does not transmit well electronically. The idea is to get information to patients as soon as possible without compromising the doctor–patient relationship.

FIGURE 3

Online communication between a patient and doctor.

One question about such a system is “cyberchondria.” It's midnight, say, and a patient decides to type in a complete 27-page medical history, including every brand new symptom, such as sudden chest pains. What is the liability issue? Harvard has not encountered this problem. First of all, the site is full of disclaimers and warnings, and patients are repeatedly told to call 911 in case of emergency. Patients have been extraordinarily reasonable when it comes to interplay with their doctors. They have been using the system correctly, even adding in their over-the-counter medications. For example, a patient came in with refractory hypertension. He was treated with ACE inhibitors, beta blockers, and calcium channel blockers, but nothing helped. At the patient site, the patient documented that he was taking ephedra five times a day for energy. That was good to know because that is like drinking 40 gallons of coffee a day. Of course, this exacerbated his hypertension.

In another example, a post-liver transplant patient who was feeling depressed took St. John's wort for the depression. One thing St. John's wort does is wrap up the liver's cytochrome P-450 system so immune rejection drugs are processed extraordinarily rapidly, leading to subtherapeutic levels and rejection of the transplant. This problem was picked up entirely because of the shared medical record, amendable by the patient and seen by the care staff.

The patient portal also makes available standard services, such as medication renewal. Patients go to the list of their medications, click on the one that needs renewing, and a prescription renewal request appears, querying dose, quantity, and pharmacy. After review by a doctor, the renewal is autofaxed to the pharmacy. The portal also has an appointments feature. Twenty percent of our doctors allow patients to self-schedule into their calendars. There is also compliance with the Health Insurance Portability and Accountability Act, so that patients can find out who has been looking at their medical records over time.

About 10,000 patients a month use this system, and 2.5 million transactions have been carried out. The average patient sends 1.2 e-mails to the provider every month. Ninety percent of those are triagable to extenders, such as nurse practitioners. Even in a busy practice, the doctor does not see more than five or ten clinical messages a day, which, moreover, usually replace phone calls. The system has become an asynchronous communication medium, allowing doctors to answer e-mails at will instead of having to place phone calls that break up the day. This makes the work flow much more efficient. As long as there is a framework with good engineering principles giving the patient and the doctor shared information and a mechanism for questions and answers, problems with excessive volumes of e-mail do not arise.

To ensure that the system is improving quality and using resources appropriately, the performance of the system is evaluated with metrics. This can be done because all data are warehoused; there are about 40 terabytes of health care data. Metrics based on good data, patient involvement, and control systems give doctors an understanding of how well and how appropriately they are performing. It is also possible to assess performance at the organization level.

The entire enterprise has really helped Harvard, as an organization, meet some of the challenges of the last few years. The Web is an ideal technology for connecting payers, providers, and patients. Creating this system did involve some challenges, which were mostly adaptive and organizational. The important thing about the system is that patients can access their information and participate more often in their own care. Consumer empowerment is a reality that is already redefining the practice of medicine.