Part I: The Landscape

With the backdrop of an environment that's becoming more demanding and intense every day, pioneering hospitals, medical groups and health systems are making performance breakthroughs that even a few years ago were thought impossible. They are making clear advances in improving patient care quality and safety, redesigning clinical workflow, making their clinicians and staff more efficient than ever, and reaching out to connect data and information across sites, physicians, and communities. The key enabler? The electronic medical record (or electronic health record), say industry experts and leaders at pioneering healthcare organizations.

In fact, industry insiders say, it is becoming increasingly clear that EMRs (along with other related clinical information systems) will be essential. They will be non-negotiable tools for achieving rubber-meets-the-road performance improvement in quality, efficiency, and connectivity. What's more, those in the vanguard of EMR development are learning that their work is literally never done, and it's never over. Instead, the path ahead is a one of continuous work, adjustments, and improvement, leading to a revised and revolutionized care delivery system. It is in the ongoing enhancements, improvements, and iterations to these systems where the "value-added" comes in, many agree.

Among the areas that hospitals, medical groups, and integrated health systems are focusing as they move from the just-implemented phase of EMR adoption to more mature phases, are:

• Intensive, iterative revision of physician ordering and clinical decision support programs, following first implementation of computerized provider order entry (CPOE) systems, in order to achieve improved care quality and more efficient clinician workflow.

• Detailed work on electronic medication administration record (eMAR) and full closed-loop medication administration systems, to reduce medication errors and improve medical management processes for all clinicians.

• Improvement of clinical documentation systems, for both physicians and nurses.

• Expansion and enhancement of physician and community connectivity to health systems' clinical information systems.

• Electronic connectivity with patients across the continuum of care, for enhanced patient education, medication compliance, and other benefits.

When the real work begins

Above all, many say, understanding that the initial EMR implementation is only the first step is essential to leveraging EMRs' performance improvement power. "Often, people will say, 'Let's implement, and we'll get it in, and we'll declare victory,’” says John Glaser, Ph.D., senior vice president and CIO of Partners HealthCare system in Boston. "And I say, it's hard work, and you have to keep redesigning. But the biggest thing learned is that you'll never be done; and what you've done so far, by going live, is to put in a tool that will help you improve care and processes. So be aware that implementation never ends, and that processes must be put into place to constantly make the data better and more useable. The real work actually begins after the point at which we define implementation as being over."

Among the many clinical care improvement projects that have been initiated at Partners hospitals have been initiatives to improve hemoglobin a1c level management in diabetic patients, and improving smoking cessation rates, while in the clinical workflow area, speeding the process of laboratory test results to patients has been a focus.

EMR facilitation is a basic requirement for making broad and sustained quality-of-care improvements, whether in the inpatient or outpatient arena, says Sarah Corley, M.D., chief medical officer of Horsham, Pa.-based NextGen Healthcare. "Before, if you wanted to look at quality data, you were forced to do chart reviews, and it was very time-consuming and clumsy," says the Washington, D.C.-based Corley. "Now, if you have structured data, that whole reporting process becomes easy. And you can't improve what you can't measure." Increasingly, she notes, physicians working in medical groups are participating in the broad-based quality-of-care improvement initiatives that hospitals are, as EMR implementation has made care quality measurement possible.

"You're going to have cycles of having to optimize the data," says Glenn Galloway, founder and CEO of Healthia Consulting, Minneapolis. "I tend to believe that with data warehouses, you don't just go out and buy a package. You buy a database tool, a data analytics tool. It's about how you organize the ongoing population of the data in that warehouse and promote its capabilities."

Still, says James Walker, M.D., "The EHR has enormous potential to improve the quality of care, care processes, patient satisfaction, and physician productivity. Those have all improved since we've gone live," says Walker, chief medical information officer at Danville, Pa.-based Geisinger Health System. "But it takes a tremendous amount of work," and is of course very expensive to implement. "This is really hard, and it requires the support of the CEO, IT, operations, and the clinicians, to make it work."

And those organizations making the greatest headway in levering EMR systems to improve quality, efficiency and connectivity are ones whose leaders work in concert and strategically to get things done, says Erica Drazen, a vice president in the Emerging Practices division of Long Beach, Calif.-based First Consulting Group. For senior IT executives, says the Boston-based Drazen, this means that "CIOs need to have an (IT) organization that connects them to the strategy and to the clinical side. There's a lot they can't do," Drazen says of CIOs; they have to engage others. So, having the right "governance structure" for performance improvement is vital, she says, as is broad collaboration. Patient care quality improvement "isn't an IT problem, and it isn't an IT solution," she points out; "you can't do it out of the IT department."