Will the real CPR/EMR/EHR please stand up

As healthcare turns its attention to automating patient information, the debate over the CPR heats up

While vendors and consultants spend precious time dreaming up new terms to differentiate their products, everyone else is just plain confused. One respondent to this year’s HIMSS Leadership Survey summed it up simply: "I have been walking around the HIMSS exhibit floor and I don’t know what the commercial definition of a CPR is, and I still don’t know if we even have a definition of a CPR."

We do have a definition--many definitions--and that’s part of the problem. For example, there’s the computer-based patient record (CPR), so named and defined by the Institute of Medicine (IOM), and the electronic medical record (EMR). These are the two most frequently used names, but there’s also the computerized patient record (also CPR), the electronic patient record (EPR), the virtual patient record (VPR), the electronic health record (EHR) and more.

There are two distinct camps: those who have a precise definition for a CPR, its characteristics and functionality and those who really don’t care what you call it--so long as it improves patient care and cuts costs.The first group has an ideal; the second, a practical model.

The term computer-based patient record (CPR) originated with the IOM in its 1991 report, "Computer-based Patient Records: An Essential Technology for Health Care." At that time, it defined a vision for the management of healthcare information. It remains that--a vision. From the Computer-based Patient Record Institute’s (CPRI) inception, reports Institute Chair Erica Drazen, vice president of emerging practices at First Consulting Group in Waltham, Mass., there were always those who wanted to define the CPR to the nth degree.

Some members of that early study group did a pretty good job. Their IOM gold standard for CPR is detailed and precise. But a structured, digitized and fully accessible record that meets all of the IOM’s criteria for the CPR is an ideal destined to be a long time in the making--if it’s made at all.

Meanwhile, most practical people don’t see a big difference between the CPR and the EMR and the many other terms that exist. "The important concept," says Drazen, "is that we don’t just want to automate current records; we want to create new systems that support improved patient care and reduce time and other costs spent in managing information. We call it a CPR because the Institute of Medicine identified it as a CPR in their study. Why argue with the IOM?"

Perfectly logical inside the CPRI, but the proliferation of names has persisted and a complete but inconsistent hierarchy of attributes assigned to various terms has emerged. Some, such as William Andrew, president of William F. Andrew & Associates of Winter Haven, Fla., define the differences between the CPR and the EMR by a criteria set that includes such attributes as support for dictation or diagnostic imaging. Others, such as Woody Taylor, partner in KPMG Peat Marwick’s Healthcare Practice in White Plains, N.Y., consider a CPR to be a fairly broad definition--different from an EMR, which is more closely associated with the ambulatory care environment and can be identified as a product.

And then there are those such as Peter Waegemann, executive director of the Medical Records Institute, Newton, Mass., who consider the CPR and the EMR synonymous terms. Not only is there no difference between them, he says, but even the term patient record may not be right. "Unfortunately, there is no one official name and no standards organization has the power to make a call," he asserts.

Who cares?
The terms are arbitrary to community physician Thomas Naegele, DO, of Albuquerque, N.M. "All of the definitions and the people who support them are non-physicians who don’t use computerized medical records. Who cares? I don’t care what you want to call them. That’s not my mission or my fight. I call them computer notes, but whatever you want to call them is fine by me."

Drazen agrees. "It doesn’t make a difference. We could call it a banana, and it wouldn’t make a difference. I attribute the many terms used to describe the CPR to the fractionalization of the thought leadership. In the early days of the CPRI, a number of participants were passionate about the definition and the terminology choice. When any group comes together, there are always some who disagree. What do they do? They split off, go on their own and start a new temple. And that has happened. It is very unfortunate because it confuses the market."

In the absence of industry consensus and with full knowledge of its political baggage, Healthcare Informatics has adopted the IOM’s term, computer-based patient records.

The IOM report provided a detailed definition of CPR attributes and functionality. Its precision and attention to detail is characteristic of academic endeavors. It was a vision--and it still is. In the end, the problems with definition, as with identification, may boil down to the difference between an academic definition and a practical one. That’s OK so long as the industry can easily differentiate between the two, but the line separating them isn’t clear. At this point, the CPR definition occupies a wide, gray swath running between two extremes.

At one end of the spectrum is Andrew, longtime and outspoken champion of the IOM model. To him, the CPR as defined by the IOM is a vision for the future. The focus is on achieving the true, vs. the pseudo, CPR--any computerization process falling short of the ideal is transitional. "We are now in a transitional mode," says Andrew. "I don’t know if we will ever really get to the true CPR. We won’t see it within the next 10 years. There is simply too much paper out there and too many other places to put dollars."

For community physician Naegele, the IOM study was an academic approach and he faults the study for its lack of representation from rank-and-file community physicians, citing this as one reason for its lack of relevance to the average physician’s needs.

Desperately seeking clarity
Referring to the ambulatory care-focus EMR, Richard Howe, senior vice president, Superior Consultant Company, Inc., Southfield, Mich. believes the name is more a process or a view within the enterprisewide information system than a "thing." The lack of clarity regarding what constitutes an EMR is a huge barrier, he says. With no common definition, organizations tend to identify their requirements for automation as a CPR or EMR, be they for document imaging, nurse charting or an order entry system. This complicates the whole process, requiring case-by-case evaluations for every implementation.

The absence of standards has always been a barrier to adoption of the CPR. Some standards are being addressed by recent legislative initiatives, such as the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA guidelines for electronic healthcare transactions, unique health identifiers, code sets, security, confidentiality and privacy provide a structured framework for standards adoption and for subsequent compliance.

But the lack of standards is not the only problem. The formation of integrated delivery systems, adding another layer of complexity to the IT infrastructure, is a slow-up, says KPMG’s Taylor, as is the current need for a master patient index. As the organization begins to automate, both the process of converting paper-based data to computer-based and that of decreasing the staff’s dependence on paper takes time. But right now, the biggest barrier has nothing to do with healthcare, he says. "The year 2000 bugaboo has diverted attention from very meaningful work--such as computerizing patient records--and has created a reactionary mode of fixing existing systems." He expects this to continue at least through next year.

CPR, prove thyself
The products have finally arrived and the market is ripe for the CPR, so say providers, vendors and consultants alike. It’s still an embryonic market but Taylor thinks the chances for success are better today than ever before, primarily due to the advent of the network computing model and Internet technologies.

Nonetheless, healthcare leaders participating in the 1998 Leadership Survey at HIMSS continue to report low rates of adoption. So what’s the hold-up? Even though Jeff Williams, vice president of sales and marketing, HealthPoint, Cary, N.C., is seeing more educated physicians, more serious interest and shorter sales cycles, the market isn’t ready to make the investment, he says. The technology is mature enough and the systems are ready, but return on investment hasn’t been demonstrated yet. Lawrence Borok, president of Vantage Point, Inc., Westchester, N.Y., agrees, adding, "With increased requirements for clinical documentation and cost containment, managed care will be the real kicker that makes CPRs successful."

While early CPR systems simply stepped up from financial billing systems, newer systems are putting much greater emphasis on clinical and point-of-care systems. These aim toward user-friendly, seamless integration, remote access and easy-to-use navigation tools. Some systems have eliminated icons, pull-down menus and the tabbed file folder approach in the name of efficiency and workflow. Physicians such as Naegele credit the new navigation tools as finally emulating the physician’s working style.

Enabling technologies on the hardware and software sides are coming together as well. Data entry and retrieval options have expanded as wireless point-of-care devices have gotten smaller, more user-friendly, and in some cases, cheaper. Pocket-sized handheld PCs operating with wireless LAN and/or digital wireless connectivity now are entering the market. Access to more types of real-time clinical data by the clinician at home or at the bedside is growing.

The ultimate value for the CPR will be to have data available in a structured format so that clinical practices can do outcomes analysis. That part of the story is still largely lost on a majority of the marketplace, says HealthPoint’s Williams. He predicts that the value of decision support not only will become apparent over the next few years, it will be the deciding factor in adoption.

Decision support applications lead right back to the issue of standardization--in this case, standardization of data input. Lawrence Weed, MD, president of PKC Corp. in Burlington, Vt., is vehement in his belief that "There is no point in doing any more on the computer-based record until we get control of the input."

Who’s in charge?
Without leadership to resolve the differences, no end to the confusion is in sight. The CPRI, the most likely candidate to coordinate a national effort, is seriously hampered by lack of funding and remains, basically, a volunteer organization. "The CPRI has an active role in helping to set standards," says Taylor, "but how active they can be beyond that is still in question. I’m not sure they have the political clout."

If not the government, then who? Taylor thinks consumerism will play a big role. "As consumerism becomes more apparent, the consumer--probably through employer groups--will really pull the need for this much more than a provider or payor base will be able to push it."

The industry is looking for a leader, just as it is waiting for standards. It is also looking for the keystone for better patient care and lower costs. "When the CPR shows value as a key component of the enterprisewide solution," says Vantage Point’s Borok, "it will be a gestalt where the whole is greater than the sum of its parts."

The NAME GAME

DURING A WALK-ABOUT AT HIMSS IN Orlando last February, an informal poll of exhibitors yielded an array of definitions to describe the CPR. CPR won the day as the most popular acronym, but EMR was a close second. Most HIMSS vendors fell into one of these two camps, but Wang Healthcare covered both bases by advertising a CPR/EMR. Free thinkers contributed the lifetime data repository (3M) and the electronic medical infrastructure (Siemens).

By a wide margin HIMSS presenters tended to choose CPR in their submitted manuscripts, while most vendors chose EMR. Interestingly, only five exhibitors--an unlikely mix including Fujitsu, HealthCare Suite 2000, JMJ Technologies, RDC Networks, Inc. and SNOMED--used computer-based patient recordor CPR.

By definition
Following are the poll results, defined:

Automated Medical Record (AMR). Early name for the CPR, sometimes refers to an early phase of computerization.

Computerized Medical Record (CMR). Synonymous with CPR.

Computerized Patient Record (CPR). Synonymous with CPR.

Computer-based Patient Record (CPR). Institute of Medicine (IOM) designated name. According to the CPRI, the CPR provides universal and timely access to a patient’s lifetime health information as well as knowledge sources to direct the patient to the appropriate type of care, help caregivers provide the best quality of care, and benefit care delivery through more complete and accurate information.

Computer-based Patient Record System (CPRS). "The set of components that form the mechanisms by which patient records are created, used, stored and retrieved… It includes people, data, rules and procedures, processing and storage devices, and communications and support facilities," as defined in the IOM’s "The Computer-Based Patient Record: An Essential Technology for Health Care."

Computer-based Patient Record-type system (CPR-type system). Designates a transitional stage with some degree of computerization moving toward the goal of an IOM-defined CPR.

Electronic Health Record (EHR). Sometimes used to describe the electronically stored record that includes both medical and health information.

Electronic Medical Infrastructure. Siemens Business Communications’ designation.

Electronic Medical Record (EMR). Name commonly given to a product for the ambulatory care market; often considered synonymous with CPR.

Electronic Patient Record (EPR). Often considered synonymous with CPR.

Lifetime Data Repository (LDR). 3M Health Information Systems.

Virtual Health Record (VHR). Comparable to Electronic Health Record (EHR); often considered synonymous with CPR.

Virtual Patient Record (VPR). Comparable to Electronic Medical Record (EMR); often considered synonymous with CPR.

SOR (Stamp Out Acronyms)

FOLLOWING ARE SUGGESTIONS FOR simplifying some of the CPR debate:

CPR and CPR-type systems. By calling anything short of the ideal CPR a CPR-type system, we have exchanged one umbrella term for another. Since the ideal CPR system does not exist, all systems henceforth are CPR-type systems.

Adoption of different but supportable names to identify the level of computerization. One example is the Medical Records Institute schema (See Point/Counterpoint, pg. 84).

Instead of identifying what we havewhy not identify what we’re doing. That is, rather than "we have--(or don’t have)--a CPR system," how about "we are computerizing medical records"?

Do you have more suggestions? If so, please share them with us.

Point/Counterpoint

Marietti: What is the mission of the Computer-based Patient Records Institute?
Drazen:To promote the effective use of computer-based patient record (CPR) systems in healthcare.

What is the mission of the Medical Records Institute?
Waegemann:To promote the creation and implementation of the electronic patient record as healthcare evolves. The goal for the Medical Records Institute is to shape the world of electronic patient records.

Do you agree with the Institute of Medicine’s definition of the CPR?
Drazen:We agree with the IOM definitions, but we also realize that the market now has examples of functioning CPR systems. They are redefining what a CPR is.

Waegemann:The IOM didn’t define the CPR--they just picked it. Politically it became a key expression and people have been focusing on that. There is little consensus about what it is. When I was on the executive committee of the Computer-based Patient Record Institute (CPRI), we often had discussions about the unfortunate name. The CPRI is stuck with computer-based patient record even though many people are now calling it the electronic patient record. The CPRI could not change the name for political reasons.

Outside the U.S., electronic health record is the more accepted term. Where U.S. conferences sponsored by the Medical Records Institute are called, "Toward an Electronic Patient Record," conferences held overseas in locations such as England, Brazil and Singapore are called, "Toward an Electronic Health Record."

Is there a benchmark for the CPR?
Drazen:I think the best benchmarks are the Nicholas E. Davies award winners--although they all admit that they are only part way through their journey to the CPR.

Waegemann:There are no benchmarks. Most people would probably agree that the benchmark is when you get rid of your paper.

How will the CPR change the delivery of healthcare?
Drazen:By eliminating distance barriers, providing clinical decision support to both providers and patients, and creating databases that will allow us to examine care and measure the changes.

Waegemann:The electronic patient record will fundamentally change the scientific database that every physician and caregiver uses. Learned and memorized in medical school, this personal database serves as a functional road map for the rest of the clinicians’ professional lives. We are talking about creating tools--about creating road maps--in healthcare so that people do not have to rely upon their memories.

Electronic patient records will enable the physician to retrieve and use patient information now trapped in paper-based medical charts. Electronic patient records can provide access to this immense knowledge bank in a matter of seconds. Now, the equivalent would be for the doctors to go to the medical records room every morning, look at the hundreds of thousands of medical records, close their eyes and think, "which one of the cases documented in these medical records are closest to the patients I am seeing today?"

The electronic patient record will enable providers to have direct access to patient information at all times. At this time, 28 percent to 32 percent of all leading facilities admit that when they see a patient, they do not have relevant patient information. This might compare to an airplane trip where, on take off, the pilot greets passengers with, "Welcome to our wonderful airline. I must admit that 32 percent of my flight instruments are not transmitting, but I’ll muddle through somehow."

Is there a prescribed path to implementing the CPR?
Drazen:No. There are some things that need to be done first, but after that, order is determined by local needs and benefits.

First, there must be a vision--but the vision is not sufficient. You must know where you want to be. The goal is not the CPR. The goal is to have data accessible in order to provide optimal care for patients and maintain the health status of the community for which you are responsible. The information must be accessible and there must be tools to use that information (for decision support applications). You must solve the problems encountered by the organization to take advantage of the opportunities to improve care and reduce costs.

When you combine those two goals, you have a migration path. One set is the vision; the other is the path.

The pathways people take are not standardized. The pathways chosen depend on the organization and on identifying problems and goals. Some organizations start with nursing systems without recognizing that physicians are really making the decisions that drive the care and the costs--and one of the high-cost resources. It may not make sense for a hospital to automate all of its physician practices. If it’s not a core business, they may not understand the problems well enough or have control over the implementation.

Some of the Davies award winners have been hospitals that have focused on inpatients; care centers that typically deal with critically ill patients. A financial incentive system, a reward system and the culture drives such an institution in the direction of decision support applications and helping people make good economic decisions.

Other award winners have done little on the inpatient side, rather focusing on the ambulatory care side. This is a very different path from the hospital on what was a high priority for them. Those organizations have typically done a great deal with scheduling, encounter management and patient reminders for appointments.

At Northwestern Memorial Hospital, a 1998 Davies award winner, they spent a lot of time understanding the flow of work in the provider practice--how a provider spent time and how it could be made more efficient. They also concentrated on ways to improve the provider/patient partnership.

Waegemann:Implementation to the electronic patient record is really a journey. We have identified five stages in the automation process throughout the care delivery system.

Stage One: Automated medical record system. Organizations often begin by creating automated systems parallel to the paper system at the departmental and sectional levels. Small organizations are more successful than hospitals--which are more complex--when starting with this approach. This stage is under way for many organizations now.

Stage Two: Computerized medical record system. Organizations use document imaging technology to scan in the whole patient record after it has been dictated, transcribed and signed. About 1,000 hospitals are at this stage.

Stage Three: Enterprisewide electronic medical record system. The organization upgrades its stage two computerized medical record system to create an integrated electronic medical record for the enterprise. At this time, the hospital or clinic links its legacy system with other systems with a single database. It also ensures that everyone is using the computer.

Stage Four: Electronic patient record system. As we move to this stage, also called the computer-based patient record, we want to connect all the systems from provider organizations. This is a long way out. Some hospitals have up to 17 locations for storing inpatient, outpatient, operating room, fetal, electrocardiogram, nuclear medicine and other medical records. It would be the greatest benefit to consolidate the hospital databases so that when I, Peter Waegemann, go into the hospital, the caregiver has all of my information no matter where my records are stored.

The reality of the electronic patient record linking information from the primary healthcare organization to a care site in another part of the country or outside the country is really stretching it. These are incompatible in hardware platforms, in software applications and in many other ways. It will take some time until we get to this point.

Stage Five: Electronic health record. This is the final and full transition from a patient record to a wellness record. In addition to medical treatment and care information, it will include the individual’s personal information such as sports activities, smoking and behavioral issues. The patient will control who has access to this information. Now we are not talking about a patient to whom care is given, but looking at the information on that person’s health.

What can we do in 1998 to move forward?
Drazen:Define data standards for terminology and coding.

Waegemann:Stages one and two can be done now.

What’s an achievable goal for the next five years?
Drazen:It is all achievable within five years.

The most hopeful sign for me is the government CPR project (G-CPR). This project can not do it without computer systems--just like no one else can--and if you want a CPR that will interoperate among the Department of Defense, Veterans Administration, Indian Health Service and Louisiana State University Medical Center, you must solve the problem of standards.

I think the G-CPR project will have an even bigger impact than the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA). Those participating in the project have a mandate to collaborate in solving this problem and, because this is a mission-driven project, they will have money to spend to do so. Of course, the CPRI is trying to ensure that the two efforts are consistent--that is, whatever the government comes up with for interoperability among the four participants is also compliant with what is coming out of HIPAA. (Since those agencies are not reimbursed by the Health Care Financing Administration (HCFA), it wouldn’t necessarily be true that the solution would be compatible.) Obviously, if the government-backed CPR project is not HIPAA-compliant, it won’t be the national standard.

Together, both the G-CPR project and HIPAA could create the standards that we really need to move this forward.

Waegemann:For most providers, building the enterprisewide electronic medical record system--stage three--is the task for the next five to 10 years. The main problem is that there are many types of medical records. The medical records in a community mental health clinic are very different from the medical records in a teaching hospital intensive care unit--in regard to contents, in regard to structure, in regard to standards, and so forth.

Are CPR vendor products meeting expectations?
Drazen:There have been great strides made--especially in ambulatory CPR systems. Vendor products are not the rate-limiting factor any more.

Waegemann: So much has been talked about the computer-based patient record and the electronic patient record. There is a market need. Vendors have responded by putting out computer-based patient record products. It’s not really one approach--just something to move along while they still have a paper record.

What is your relationship with the vendor community?
Drazen:Many vendors are members of CPRI and they contribute to all our programs.

Waegemann:We are not endorsing anyone, but we are supporting them. We are helping them and we are working with them. Vendors are key members of CORBAmed initiatives.

We are looking at the international market. Our goal also is to bring people together so that companies in the U.S. find marketing distribution channels in Europe, for example, and vice versus. Medical Records Institute conventions have 160 vendors representing electronic patient record products.

What are the implementation challenges?
Drazen:The redesign of processes--especially in physician practices--time to learn the system and money.

Physicians are not the barrier. In general, they don’t resist computers. If you give them a tool that’s better, they’ll use it. Some of the early systems really didn’t work for physicians mostly because the early tools had been designed for clerks, but they will do anything that makes sense to provide better care to patients.

Waegemann:While home healthcare and individual physicians’ offices are quite successful in implementing the electronic medical record at the office level, hospitals are more behind. It will be some time because they are still implementing systems within the department. Each department--I call them empires--is looking at its own budget and not at the complete and continuous healthcare system.

Organizations are progressing toward the goal of the electronic patient record at various speeds. They are making the journey not by layers, but by incrementally attacking each stage.

Is there a major issue holding up implementation?
Drazen:Yes. Funding. The recommendation in the IOM report was to establish the CPRI and to fund it as a public/private partnership. Unfortunately, of all of the funding that has come forth, the feds never put a dime into the CPR.

The problem with the lack of public funding is that some of the overarching issues that would have led to standards never have been addressed.

The major barrier--and the root cause of the problem--is lack of government support in the policy issues. Think for a moment. If there were no standards for telecommunications, we could not communicate by telephone across the nation. The issues regarding standardization for the CPR have never been addressed by the federal government--the only body powerful enough to do so. No individual supplier has the wherewithal to create national standards.

The lack of standards creates a huge problem. By definition, if vendor A goes with one standard, vendor B wants to differentiate itself by going with another--and it certainly doesn’t want to admit that vendor A was right. Without standards, you can not be certain that the investment you made in system A will allow you to operate in an integrated delivery system with systems B and C.

The HIPAA legislation is an opportunity for us to start addressing some of these tough issues. It