TechSectors: EMRs/EHRs: One Patient, One Chart

In 2002, MaineGeneral Health (MGH) launched an electronic medical record (EMR) implementation project for ambulatory practices in Maine’s Kennebec Valley. Determined to use the system to achieve community-wide improvement in healthcare quality, safety, access, and cost, MGH made two key decisions: first, MGH would make the system available for all providers affi liated with the health system, whether owned by MGH or independent; second, MGH decided a patient’s chart would be shared across all practices. All physicians caring for the same patient would share the same medication list, allergy list, problem list, and repositories of notes, documents, and results—one patient, one chart—to make things safer and more efficient.

Implementation began in seven primary care pilot sites in January 2003. In September 2004, the project was augmented by a $1.5 million grant from the Agency on Health Research and Quality (AHRQ).

Today, there are 29 participating practices, 130 clinicians, 500 users, and 70,000 patients registered in the shared medical record system. Participating practices include primary care practices, specialty practices, and ancillary services, including the diabetes selfmanagement training program and a community care management program. Local lab and X-ray departments can directly access the repository of orders for any specifi c patient that presents without the paper copy of the requisition. Emergency room and hospital admissions staff can directly access the medication lists, allergy lists, and problem lists to help treat patients safely and effi ciently and to perform medication reconciliation.

To promote adoption, MGH has taken advantage of new safe harbors in Stark rules and anti-kickback legislation to subsidize software licenses, implementation services, and support services for participating practices affi liated with MaineGeneral hospitals. The hub of the system is the TouchWorks electronic health record software developed by Allscripts Health Solutions. The application and data reside in a centralized database within the MGH network. MGH operates the EHR as an active server page; the system is accessed by users through a secured sockets layer (SSL) connection. Most practices connect through a virtual private network for full support of interface, faxing, and printing functions, but any user with an Internet connection and an active username and password can connect to the system from anywhere at any time.

HIPAA requirements are addressed by a business associates agreement between MGH and each practice participating in the project. In addition, all participating practices are aware of language in the practice HIPAA disclosure form that describes the sharing arrangement. When a patient selects a doctor and registers for care, the registration action unlocks the chart for sharing with the new physician. Additional, break glass-type security is routinely applied to certain classes of patients and content and can be added to any content when desired by the clinician or the patient.

In 2007, participating practices documented 185,000 appointments in the system, worked 850,000 tasks, and generated 221,000 electronic prescriptions. Reports that are automatically generated and distributed have helped practices understand their processes and improve quality. Reporting from the data has also helped practices meet pay-forperformance goals, which has generated income to substantially off set system costs.

By using a single platform in a single database across practices, MGH has achieved interoperability in advance of interoperability standards. Sharing clinical lists has improved patient safety and practice efficiency. Providing reports and reminders from the system has improved quality. Integrating practice data is seen as the fi rst step toward standardizing and integrating care. Next steps include embedding cost-eff ective standards of care in the system, increasing investment in collaboration to share responsibility for all the care for the patients, and using this foundation of informatics in a transformative manner.

Dr. Mingle is the Director of Ambulatory Clinical Informatics at MaineGeneral Medical Center.