Errors at the speed of light.

Since the well-publicized turn on, turn off of computerized physician order entry (CPOE) at Mount Sinai, the electronic medical record (EMR) has had some general negative press and lost some of its karma.

We have had components of an EMR at Central Vermont Medical Center in Barre, Vt., since 1995 when all laboratory data, diagnostic imaging reports and any dictated/typewritten records were entered into the computer system by various medical center employees.

Except for the ICU and birthing areas, all the medical/surgical nursing area care notes, physical therapy, dietary and similar notes were typewritten by the provider into the record for easy immediate access and review as well as guaranteeing a legible note, immediately accessible at multiple sites throughout the organization.

Admittedly, getting some physicians on board was difficult. I was still in active orthopedic practice and fairly young when the transition occurred but remember the joy at being able to find a complete blood count (CBC) quickly and review the prior CBCs with a keystroke.

Some older physicians were not so enthused and my partner of 25 years, who was nearing 70 when he retired in 2000, still had not learned even the fundamentals of the Meditech system we used when he passed from the practice scene. He circumvented the system and his need to learn by having the nursing staff or ward clerk print out anything he needed to see. So much for a paperless system.

Our physicians had become quite dependent on the electronic record for all but order writing and daily progress note functions when we began the next step of moving toward a truly total EMR in 2000.

We had developed a strategic plan outlining the steps we needed to take before we began the final push for a total EMR. Meditech, our longtime vendor, initially had storage capacity problems that forced the organization to purge data at various points in time. This was not a huge issue but did cause some problems when a record more than three years old was needed.

First step

Our first step was to assure an expandable, essentially infinite, write-protected storage system. One goal was to move to an electronic health record (EHR) that would include other patient-related information including billing, charge capture and other financial data elements that were patient specific.

Additionally, we wanted to move toward a record that would never need to be purged and would have the ability to access, retain and protect other institutional data elements such as policies, protocols and designated order sets--those approved by pharmacy and therapeutics committee as best practices, not the individual physician favorites that most CPOE software allows.

On a parallel track, a PACS (picture archiving and communication software) system for our diagnostic imaging department was also needed for a total EHR. This was an easier fix than might be assumed as most diagnostic imaging departments are already using electronic image capture in MRI and CAT scans. Radiologists are also already used to and engaged in the use of technology for imaging viewing, addition/subtraction techniques and image rotation.

This implementation amounted to little more than finding a vendor and converting current plain film techniques to electronic image capture, easily done with existing radiography equipment by changing the cassette technology.

Optical discs from Valco Data Systems and a FormFast electronic and paper form generating and bar coding system--both Meditech compatible vendors--were key underpinnings to the next steps.

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These were fairly straightforward determinations that required minimal training and acceptance on the part of medical center staff and none by physicians or nursing staff.

With these keystones in place, the information systems department began what became known as the paper gap analysis (PGA) to determine what paper was still being generated by the hospital for the remaining non-electronic portion of the medical record.

More paper

I had naively assumed that there wasn't much that wasn't already electronic when I began this process but I was very wrong indeed. We counted over 800 forms that were in use somewhere in the organization that needed cataloging and bar coding to be included in the medical record.

Central Vermont's commitment to an EHR was sorely tested by the next step toward CPOE. Finding a vendor for this next portion became somewhat of a search for pixie dust. We found, with great difficulty, a suitable vendor for an electronic medication administration record (e-MAR) and a bedside medication verification system (BMV).

The details of the latter were more difficult than one would initially imagine. Several on-site evaluations revealed significant issues with the wristband bar code readers and nurse workarounds of the drug bar code confirmations that need to be resolved.

Although a multi-disciplinary team was in place, it was key that several of our IS techs were RN's first. They knew the ropes, they knew the nurse workarounds and foresaw the problems. Their insight helped avoid some of the more common pitfalls of the medication administration side of an electronic record.

The underpinnings of the bedside medication verification and e-MAR at the pharmacy level were so important that we appointed our very IS savvy and engaged pharmacy director to implement this stage of the EMR.

With this final rollout of e-MAR and BMV, and with storage complete and scanning available at all sites, we can commence the true final and most daunting stage of our total EMR--CPOE.

Currently, the new Joint Commission on Accreditation of Healthcare Organizations regulations call for a diagnosis or condition to be written/associated with any medication order. Inasmuch as this is a relatively new mandate, no software vendors currently offer such a feature on their product. The CPOE products we had previously reviewed as we planned our EMR were fairly dismal in their organization and keystroking. Our Meditech vendor did have a reasonable product but has yet to address this new obstacle.

Though this new JCAHO regulation has slowed our progress, it gives us time to reassure ourselves that the current systems are working flawlessly and to regroup regarding a rollout of CPOE. Our initial plan was to introduce CPOE to the physicians and nurses in a small controlled beta site in our emergency department.

As in many things, this has been hampered by yet a different computer glitch. Some software programs embed their CPOE modules in other software products. Meditech is an example. Though the CPOE module can function independently, it is designed as a portion of their emergency department management (EDM) module for emergency room services. Getting nurse and physician buy-in regarding both CPOE and the EMR in the emergency room has proven to be more daunting than anticipated.

The JCAHO delay is fortunate, as it has given me time to establish the buy-in we need as an institution. I was unknowingly on a path to failure. I had not taken into consideration the strong feelings of the ED personnel and the need to really involve them in the process of choosing software even before the more obvious need to involve them in the software rollout.

The best software in the country, unused or worked around, can only lead to wasted time, dissatisfied patients and providers as well as the distinct possibility of poorer quality of care.

ED buy-in

As this is written, we are but a tiny step away from a total EMR/EHR, but that final mile may be the hardest travel. CPOE--once a suitable, JCAHO-compliant product exists--may be a difficult and somewhat dangerous path to tread. It will require a good deal of preparatory groundwork to gain initial acceptance. It would be a blatant lie to even attempt to suggest that it will save the physicians' time. It will not. It will, if done well, reduce medication errors without question, integrate care, improve documentation, legibility and hopefully quality.

The physician time factor is not trivial and it will be a hard sell to all but the real visionaries in the medical trenches of the emergency room and office practices. At this time. I have hired an independent consultant to set some real, measurable software performance benchmarks and requirements that we can use to pick an emergency room documentation product that will at least meet whatever actual or anticipated needs the emergency department folks have.

If we at least implement a product that the emergency room physicians and nurses have helped choose we may be able to circumvent the obvious implementation problems that an EMR will undoubtedly cause.

Despite the many challenges my goal remains the same: a totally paperless EMR/EHR in the next two to five years with the only paper at CVMC being the disposable drapes in the operating room.

Russell Davignon, MD, CPE, is vice president of medical affairs at Central Vermont Medical Center in Barre. Vt. He can be reached at 802-371-4215 or [e-mail]

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By Russell Davignon, MD, CPE