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Speeding Toward Better Health: Regenstrief Institute continues to fine-tune a medical-records system that many think could someday become a national model

July 16, 2007

Regenstrief Institute continues to fine-tune a medical-records system that many think could someday become a national model The Regenstrief Institute is a racing team.

Only instead of drivers and grease monkeys, the Indianapolis-based medical research group has doctors and computer geeks. And instead of a race car, Regenstrief runs a massive computer database with 35 years of medical records from Indianapolis-area patients.

But Regenstrief's mission is still all about speed. The not-for-profit is driving to discover better ways to care for patients and to help doctors use those discoveries sooner.

And now, just as auto racing draws international attention to Indianapolis, Regenstrief has caught the eyes of politicians and policymakers across the country and the globe.

In Washington, D.C., a network of electronic medical record systems spawned by Regenstrief is a model for a national network of such systems President Bush wants to create by 2014. And a medical record system is part of most presidential candidates' health care platforms. In Africa and Asia, Regenstrief staff work on and advise the rollout of similar electronic medical record systems.

"Regenstrief proved that it could be done," said Janet Marchibroda, CEO of the eHealth Initiative, a Washington notfor-profit that promotes greater use of information technology in health care. Now, she added, "What you're seeing is a groundswell of activity to drive toward what Indiana has done."

Regenstrief has hurdled the technological, human and financial barriers to link multiple, competing hospitals so they can swap patient information in a matter of seconds. Medical leaders hope such computer networks can save billions each year-at a time when health care costs are spiraling.

Regenstrief has a staff of 110 that supports 37 researchers, all of whom are professors at the Indiana School of Medicine and many of whom still practice medicine a few hours a week. Another 35 researchers are also part of Regenstrief.

The institute's researchers use its electronic medical record system to help them on myriad research projects, which range from improving geriatric care to preventing drug-resistant bacterial infections in hospitals to making it easier for physicians to prescribe drugs electronically.

"Health care has gotten to the point where you don't want it to fly blind," said Dr. Tom Inui, CEO of the Regenstrief Institute.

Regenstrief isn't the only organization to build a robust electronic medical record system. Partners HealthCare in Boston, Intermountain Healthcare in Salt Lake City, the University of Pittsburgh Medical Center and the Veterans Health Administration system are all nationally recognized for using computer networks to improve medical care.

But all those networks are contained within one health care system. In Indianapolis, Regenstrief manages a database with records from seven different hospital systems-Clarian Health Partners, Community Health Network, St. Francis Hospital, St. Vincent, Wishard Health Services, Morgan Hospital and Major Hospital.

That multi-hospital network began in 1994 as the Indianapolis Network for Patient Care, which joined hospital emergency rooms in Indianapolis.

In 2004, Regenstrief offered its database to BioCrossroads, an Indiana life sciences economic development group, to spin out the Indiana Health Information Exchange. Its goal is to link up doctors, laboratories, outpatient centers and hospitals all over the state. More than 5,000 physicians have signed up.

The Indiana exchange is one of a few self-sustaining regional health information organizations out of about 200 nationwide. Its CEO, Marc Overhage, is also the director of Regenstrief's medical informatics division, which maintains the medical records database.

Overhage is perhaps Regenstrief's most visible member nationally. He frequently testifies before congressional or government committees in Washington. Last month, he even spoke to a conference in Japan presented by Marchibroda's group, eHealth Initiative.

"We are smack in the middle of that national dialogue," Overhage said. "The experience that we've had, the concrete on-the-ground experience, really gives us a lot of weight in those dialogues."

Money at stake

Using computers to share patient records is rare in the Byzantine world of health care. Tangled financial incentives, technological hurdles, complex laws and privacy restrictions have so far stymied many efforts to bring medicine into the information age.

But health care providers' failure to embrace electronic records and data swapping is increasingly blamed as a major barrier to improving health care and cutting its cost. A 2005 study by Ontario-based think tank Rand Corp. projected that if Bush's goal were achieved, it could save the nation as much as $81 billion annually. That's equal to the entire economy of Utah.

There's money to save and safety at stake because patients see multiple doctors. They might not tell those doctors everything they need to know to avoid mistakes, such as dangerously prescribing drugs that interact, or needlessly ordering a lab test two weeks after another doctor ordered the same test.

Regenstrief's vision is to give health care providers the ability to see all the relevant information about any patient who walks in their doors-for the first time or the 101st time.

But some health care experts view the Rand Corp. estimate as far too high. They say information technology won't save much money until the broader health care system changes.

"Technology certainly has the potential to save a bunch of money, but health IT is not yet a sound business proposition for most health care providers," said Joseph Antos, a health care scholar at Washington, D.C.-based think tank American Enterprise Institute for Public Policy Research. "The leap from computers on the desk to real improvements in the health system is a series of huge tasks. It will take a lot of effort, a lot of time, and will involve nearly everyone in the country."

Roots at Wishard

Regenstrief's effort to use computers to transform health care goes back to 1972. That's when Regenstrief researcher Dr. Clem McDonald started a clunky electronic medical record system in a Wishard diabetes clinic.

By collecting medical records electronically, Regenstrief built a storehouse of information that others would want: researchers, hospitals, even insurance companies.

But to extend its database beyond Wishard, Regenstrief developed standardized codes to help the different computer systems used by different health care providers talk to one another. Because each hospital has a different computer system, they need a translator to help them communicate.

Otherwise, hospital staff call another hospital and request records be faxed. Those records might arrive before a doctor has to treat the patient, but they often don't, said Dr. J.T. Finnell, a Regenstrief researcher and professor of emergency medicine at the IU medical school.

"When we don't have data, we're going to do the most conservative thing-and oftentimes that means we hospitalize them," Finnell said. Or they do tests the patient might have had done just weeks ago.

The result is redundant care that is more expensive than it needs to be. That's one reason Rand Corp.'s savings estimate was so high. Overhage said the Regenstrief record system saves as much as $26 each time a patient visits an emergency room.

The Regenstrief system also acts as a translator between hospital staffs. They need it because one hospital might record high blood pressure on its charts as "HBP" while another hospital might call it "hypertension." Regenstrief's database uses a complex dictionary to recognize that those two terms describe the same condition.

When a patient walks into the Wishard emergency room downtown, the frontdesk workers enter his name in Wishard's computer system, which sends off a message to the Regenstrief database. While the patient is waiting to be seen, the Regenstrief system searches for that patient's records from all the Indianapolis hospitals.

It then generates a one-page report with the most recent medical records for that patient in 13 key areas-no matter which central Indiana hospital they came from. The report is organized to answer a doctor's typical questions in the order he would ask them.

When did this patient last visit a hospital? The report gives the date and the patient's complaint at that time.

What were his vital signs? The report lists levels of cholesterol, glucose, sodium and more than a dozen others.

Did he have any blood or urine samples taken? The report gives the results. It also gives the results of the patient's most recent heart and radiology tests, and, very important, current medication prescriptions.

This one-page abstract is printed out at the hospital before the doctor sees the patient. Doctors can also query the Regenstrief database to find records on a patient. Regenstrief has even created reminders for doctors to check their patients for certain possible maladies, based on the information about the patient in the database. Promoting sharing

In addition to those technical achievements, one of Regenstrief's most impressive accomplishments has been convincing Indianapolis' hospital networks to agree to share their information.

Regenstrief officials had to craft mechanisms and rules for information sharing that guarded against blatant stealing of customers. It also haad to make sure no data-swapping violated federal privacy laws.

For example, the Regenstrief database allows only doctors to access patient information from other hospitals and only when that patient is at the hospital. The access is good for only 24 hours after the patient's visit and only from a hospital computer-not from home.

McDonald, the father of the Regenstrief medical record system, said the real test for replicating such systems nationwide is overcoming the natural human resistance to cooperating with one's competitors.

"This is all people," said McDonald, who was director of the Regenstrief Institute from 1997 until 2006. He left last year to join the National Library of Medicine in Washington. "Indianapolis has a very high-minded group of health professionals."

Vince Caponi, CEO of St. Vincent Health, saw that community cooperation when he arrived in Indianapolis in 1998. He is now co-chairman of the Indiana Health Information Exchange

"The leadership came together and said, 'Well, there's certainly enough for all of us to compete,'" he said, adding, "I had great faith in the other [hospital] CEOs."

Making business sense?

Still, it hasn't been easy to make a compelling business case to health care providers. While cutting out redundant services saves money overall, it doesn't necessarily save money for hospitals and doctors. They typically get paid by insurers or the government for each procedure they perform.

Regenstrief has tried to show that hospitals can save on staff time and costs by cutting out the time it takes to request and fax documents from one hospital to another.

Also, by centralizing its database, Regenstrief can save health care providers the money they would spend to develop computer interfaces to talk to one another. A hospital only needs its computer system to talk to Regenstrief, then Regenstrief handles the interaction with everyone else.

Building a custom interface can cost about $50,000 a pop, said Dr. John Sparzo, vice president of medical affairs at Hendricks Regional Health. His hospital is one of four suburban Indianapolis hospitals joining the Regenstrief hospital network this year. The other three are Hancock Regional Hospital, Riverview Hospital and Witham Health Services.

Those hospitals have used outside grant money to reduce their costs to about $30,000 each.

Getting physicians to join Regenstrief's database is more difficult. For doctors to install an electronic medical record system in their offices, it costs about $50,000 up front and at least $10,000 annually to maintain, said Ashish Jha, assistant professor of health policy at the Harvard School of Public Health.

"Even in the most generous view of this, the vast majority of doctors are not using electronic medical health records," Jha said. But, he added, "it's not shocking that adoption has been slow."

Public health benefits

Regenstrief's leaders, however, are inpatient. So they are working to bring at least some of the benefits of electronic medical records to doctors and hospitals -even if they aren't connected to Regenstrief's full-blown medical record database.

Again, the reason is speed. The faster clinicians have information, Regenstrief figures, the better care and more-costeffective care they can deliver.

For example, the Indiana Health Information Exchange has signed up 72 hospitals to a public health surveillance system, which started back in 1999 as something called ICareConnect. As these hospitals receive patients in their emergency rooms, they send information to the Regenstrief database, which then sends the information to public health officials.

"If I was having a huge shigella outbreak, I could know it early instead of waiting for two weeks or a month," said Dr. Virginia Caine, director of the Marion County Health Department. "It just makes it faster."

The public health benefits of information sharing became real to the staff at Hendricks Regional in June. They ran a drill, simulating a case of inhaled anthrax. A dozen mock patients showed up at the Hendricks Regional emergency room, complaining of fever, shortness of breath and coughs.

They were dutifully entered into the hospital's computer system-but weren't coded as mock patients. Within seconds, that data was also in the Regenstrief database and available to other hospitals and public health officials.

So in the middle of the drill, the Indiana State Department of Health called to alert the hospital to an outbreak of a kind of flu.

"We wanted to simulate the ER being hit by a number of cases at once," said Sparzo, the Hendricks Regional vice president. "It just so happened that we tested the [Regenstrief surveillance] system, too."

Regenstrief's researchers are also trying to figure out how to get the benefits of electronic medical records to doctors in an everyday setting-even if they don't have a fancy medical record system.

It has focused the last two years on electronic prescribing of medications. According to the National ePrescribing Patient Safety Initiative, only 20 percent of doctors now have the capability of electronic prescribing and only 5 percent actually use it.

But Regenstrief is developing "paperbased electronic prescribing." Its goal is to create an easy-to-use interface for doctors to enter their prescription data and an easy-to-print-and-read form that displays all relevant information about a patient's medications-drug allergies, current prescriptions from other doctors, etc.

A doctor could access this information over a secure Web connection, even if he or she doesn't have an in-house medical record system.

The idea, once again, is to get clinicians to take advantage of computer technology as fast as possible.

"For various reasons, it'll take 15 years for doctors to adopt electronic prescribing," said Overhage, Regenstrief's informatics director. "But I don't want to wait."
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