The Department of Defense is continuing to roll out an EMR system that has been in continuous development since the late ’80s.
Serving almost 10 million military personnel and families, the implementation of and lessons learned from this project could provide some clues as to what lies ahead for the broader usage of electronic medical records in the United States.
Last year, the Bush administration said it will set the ball rolling so that a national electronic medical records system can be established within the next decade. But the path to reaching this ambitious target is still relatively obscure.
The Department of Defense has several advantages in implementing its electronic medical record system, in comparison to what will be required for a national EMR system.
First, the military has been working on electronic medical records for more than two decades.
In addition, it has a strong, hierarchical institutional structure that could make some of the necessary decision-making and implementation processes easier.
The first version of the EMR system, Composite Health Care System I, was an electronic medical record system limited specifically to individual hospitals.
Sharing data between health care facilities is a feature that came about with the initiation of the next phase of the project, CHCS II (Composite Health Care System II).
The ambulatory portion of CHCS II, which deals with outpatient interactions, is expected to be complete by the end of 2007.
“Currently we have the ambulatory portion of our electronic health record deployed about a third of the way across our enterprise,” noted Dr. Robert Wah, a Navy captain and reproductive endocrinologist who serves as the director of information management for the Military Health System.
Already, 15,000 physician interactions are recorded daily into the system.
“We’re currently rolling out the ambulatory care outpatient portion; that’s 50 million encounters a year,” according to Larry Albert senior vice president at Integic, a long-term contractor on the CHCS project that has been recently acquired by defense company Northrop Grumman Corporation.
“Soon we’ll add pharmacy system and anatomical pathology. We’re in the process of finishing up the acute care which will be rolling out next year.”
“In some hospitals, it’s in all of their clinics; currently we have 32 operational hospitals using the system. About 2,000 physicians are using the system,” Albert said.
Now and over the next few years, disparate back-end systems will continue to be integrated via a common interface, but eventually these will be upgraded.
“We’re going to keep the front-end of the system the same, but in the back the way we’re organizing laboratory, pharmacies, and other ancillaries are on legacy systems,” Wah said. “These will be replaced in the next three years. It will be transparent to the user; the most that they’ll know is that they’ll have additional features.”
The primary advantages of the system have been relatively straightforward so far.
“Having a legible record that’s almost always available is a huge advantage over a paper record,” Wah said. “Availability is one of the first big advantages that we see, making it patient-centric rather than institution-centric.”
Universal availability is particularly crucial for a highly mobile patient population such as that of the military.
Currently, a laptop version of EMRs that stores records locally and connects intermittently with the server is being deployed with some mobile units.
“We have a lot of different requirements and missions,” Wah said. “In the traditional setting, the laptop version is not beneficial. In the field, the laptop version is critical in an intermittent communications environment.”
Enabling multiple providers to have simultaneous access to the record has also been a fundamental advantage.
“In the old paper record framework, the paperwork goes with the patient. Now several people can be looking at the chart at the same time,” he said.
When it comes to developing the technology, Wah stresses provider feedback.
“We’ve worked very hard to make sure we’re getting input from the front lines of the doctors and nurses that use this. It’s been developed for physicians, by physicians.”
But integrating the technology into the workplace has still proven a considerable challenge.
“As hard as the technological development is, it’s the business process change that has proven even more difficult.”
“For instance, in the paper world a physician simply has to have a pen and paper to take a history. With an EMR, it requires them to put down a paper and pen and use a workstation,” Wah said.
“The flexibility of how you use the pen and face the patient changes. There is a need to adjust how we do the rather mundane process of the care that we’re providing.”
Basic processes of how a medical office works needed to be revised.
“When we went electronic, there was no more chart behind the front desk,” he notes.
“Initially, the person tasked with getting the vital signs didn’t know there was a patient waiting. Their first impulse was to put a cardboard card in the place of the chart. There are alerts built in, but you have to look at the computer screen.”
Wah believes that the DoD can serve as a model for the implementation of EMRs, beginning with related agencies.
The agency is starting to transition its medical records to Veterans Affairs when military personnel leave the DoD.
There are currently more than 25 million living veterans, making this another substantial and challenging population for the deployment of EMRs.
The DoD has also been sharing information with the Centers for Disease Control and Prevention, which monitors the diagnoses by ZIP code, looking for anything indicative of biological agents or potential epidemics.
In the future, the CDC will be able to directly monitor symptoms, rather than diagnoses, which Wah believes will speed up detection of any systematic problems by two or three weeks.
“We believe that we have been ahead of where the rest of the health care community is in reaching the presidential mandate to have an EMR,” Wah said.
The DoD reportedly has the largest scale EMR initiative worldwide; the Department of Veterans Affairs, with its 20 million patient records, is currently in the process of migrating to a more modern system.