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Behind the Wires: Far From Finished

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Wisconsin's Marshfield Clinic is widely automated, but senior leaders say the group practice's homegrown EMR can do even more.

Patience is critical in the world of electronic medical records. Just ask John Melski, MD, practicing dermatologist and medical director of clinical informatics at Marshfield (WI) Clinic.

Since the mid-1980s, the 750-physician group practice has been incorporating information technology into the practice of medicine. Using mostly home-grown technology, the clinic has built a bevy of clinical documentation and practice management tools. In an industry where few medical groups use any form of an EMR, Marshfield stands out, having officially retired its paper charts last year. Getting there, however, has not been easy. For example, Marshfield's electronic clinical encounter worksheet for billing purposes was long in coming. "We got the mandate in 1991 and deployed in 2000," Melski recalls. "Of course, in 1991, there was no Internet and Windows was still primitive. This business requires a certain amount of patience."

True, Marshfield Clinic stands as testimony to the power of perseverance. But belief in a vision figures equally. "The clinicians here decided 40 years ago that they would lead with technology," observes Justin Starren, MD, director of Marshfield's Biomedical Informatics Research Center, which is expanding from 25 to 35 staff members in 2008. "We have always believed that an integrated electronic record is the best way to deliver care."

Recently endorsed by the Chicago-based Certification Commission on Healthcare Information Technology, Marshfield's EMR is what Chief Information Officer Carl Christensen describes as a full-bore application. The technology enables clinical documentation, e-prescribing, order entry and preventive services. Its practice management side encompasses billing and scheduling. Integration of clinical and business data abounds. For example, since 2005, physicians have referenced a patient dashboard that pops up overdue services, such as preventive mammograms or colonoscopies. Through an interactive portal, patients can access much of the same data, in addition to requesting appointments and viewing their statements. "If they are on an anticoagulant program, patients can see when their next blood draw is due," Christensen says.

Despite its considerable headway, the clinic has much left to accomplish, the CIO says. That's a common theme among clinic executives, who love to quote their CIO's image of "a race to the starting line."

In some ways, necessity has been the mother of invention at Marshfield, a sprawling group practice that operates 42 sites across central Wisconsin. Connectivity has streamlined communications across the group practice, although for years it maintained paper charts as the official record. Now, 95 percent of the clinic's documentation is generated internally through the EMR, estimates Melski. The remainder--which includes paper from the outside world--is scanned and appended to the chart.

Marshfield also has advanced because it has not left progress to chance. The clinic has a highly defined governance structure that oversees IT and determines strategy on future direction. Each major business line--including the group practice, the insurance plan and the research foundation--has its own IT steering committee, notes Christensen. Rather than lean exclusively on volunteers, Marshfield pays for physician IT leadership. For the past four years, Melski served as clinical informatics director, with 30 percent of his pay coming from the formalized IT role. That frees him from the day-to-day chores of practicing medicine while respecting the commitment to IT. Melski participates on four of the steering committees, including clinical system, quality care, practice management and Web communications. Participating physicians have official committee roles based on job title, Melski says.

As a result of this organizational push, Marshfield clinicians enjoy a host of automatic tools that are in short supply in many other healthcare organizations. Using what Melski dubs "digital ink over forms," Marshfield staff and physicians document on the fly, using the 2,500 wireless tablet PCs from Fujitsu that the clinic has put into operation during the past three years. Using a stylus, doctors can denote items on a checkbox form. However, there are multiple other ways for them to enter data, including voice dictation and template reports.

The tablet PC gave IT adoption a real boost at Marshfield. For example, for several years the clinic tried to adopt electronic prescribing, but small handheld devices did not work well, and stationary workstations did not accommodate the peripatetic medical staff. "You need lots of information to prescribe," says Melski. "The tablet gave us the tool to provide it. If you are going to compete with the prescription pad, you want to offer all the interactions, the reference database, the compounds and so forth."

Now, when physicians write electronic prescriptions, they pull up a two-pane screen, Melski explains. The left side inventories all the medications the patient is taking. The right is the prescribing pane, which features drug interaction alerts. The inventory panel is critical for specialists who are less interested in the details of, say, tablet size, than knowing what the patient is already taking, Melski adds. Marshfield mandated e-prescribing in November 2007.

Support staff benefit from all the automation, as well. Melski describes a patient visit as "multithreaded," his term for concurrent work on a patient file during a visit. "Each visit calls on two computers: mine and the support staff's," he says. "As I am doing an exam, I may be looking up a lab score. At the same time, I am giving my staff instructions to prepare a refill or make the next appointment."

Like other features of the EMR, the e-prescribing function is only just beginning to be fully utilized, adds Christensen, the CIO. The clinic conducted a pilot study around prescribing the drug coumadin, an anticoagulant medication. "It was a small study that included genomics, diagnosis, age and sex. It is very Buck Rogers. We got funding for a follow-up." At Marshfield, the 40-year climb may open up into even more spectacular vistas involving genomic medicine and proactive care management. "We are just scratching the surface of what we can accomplish," Christensen says.


Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at gbaldwin@healthleadersmedia.com.

Top Three Projects

Marshfield's senior technology executives each have major projects under way. Here is a glimpse at a few of them.

Project: Integrate archive databases
Carl Christensen, CIO
The clinic has a vast digital archive of images that spans multiple departments, including cardiology, gastroenterology and radiology. The goal, Christensen says, is to build an integrated database of images that could be accessible through the EMR. "It is not sustainable to keep them separate," he says. Marshfield deployed a Siemens PACs in 1998 for its radiology department, but it does not accommodate all modalities, he says. The clinic is working with a local software vendor to create what the CIO describes as "an intelligent broker of data." The resulting system, he says, should be able to display images that are compatible with the industry's DICOM standard, as well as images that are not.

Project: Deploy clinical trials management system
Justin Starren, director of biomedical research center
Beginning this year, Marshfield hopes to deploy a clinical trials management system that would bridge the gap between the research division and group practice clinical data, Starren explains. "Clinical research computing is 10 years behind clinical computing," he says. "Clinical research departments usually run their own systems. But a greater percentage of patients are simultaneously receiving both conventional care and research therapies. Maintaining the illusion that clinical and research data are unconnected is a fallacy we can no longer support." In Starren's plan, the new software will be integrated into the clinical system. He is serving on the vendor selection committee. "The vendors all say that Marshfield's vision of integrated research and clinical computing is an exciting project, but that no one has pulled it off yet."

Project: Devise best practices curriculum
John Melski, medical director of clinical informatics
Although Melski is a deft user of the Marshfield EMR, he realizes that many physicians and support staff do not appreciate all of the system's features. "Our modules are so sophisticated, we have this problem throughout the organization," he says. "We have a lot of features, but people don't understand they are available." Melski's plan is to develop a curriculum that will define how to use the software for maximum effectiveness. "We have the tool set," he says. "We just need to help people use it." For example, Marshfield can build up its use of chronic disease management features. "We need to seek out those patients who should be coming in but who are not."


Problem Solved: Screen Design
This July, Marshfield will unveil a new "digital video research lab" as part of its Biomedical Informatics Research Center. The lab, explains Justin Starren, MD, director, will tackle longstanding problems in user-friendliness of the IT applications. "It is a place to watch people use computers in a formalized way," he says. Users will navigate various applications, their actions both recorded on video and monitored by software. The idea is to analyze why users have problems with applications; Marshfield's health plan has a little-used risk calculator tool, for example. "We are designing a study to figure out why patients are having trouble finding and using the software," Starren says.

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