Could paper files have an advantage over electronic medical records?

In a limited sense, the answer is yes, says Dr. Mark Graber, chief of medical services at the Department of Veterans Affairs Medical Center in Northport, N.Y.

"Every innovation has its surprises," he said. For instance, "having an electronic medical record makes it easier to choose the wrong patient's chart." The mistake, while not forgivable, is understandable: to call up a patient's electronic record, Northport providers must choose the correct record from a list of more than 50,000 patients.

"If you blink or are distracted, you can click on whoever is above or below on the list," said Graber. "Once you open the chart, they all look the same. In addition, many of our patients have similar medical issues."

That's why Graber came up with the idea of displaying patients' mug shots prominently on the first page of their electronic charts, with smaller thumbnails appearing on subsequent pages.

Graber's was one of 26 winning ideas submitted in the Veterans Health Administration Office of Information and Technology Innovation Competition announced by Secretary of Veterans Affairs Eric Shinseki earlier this year. The department has earmarked $15 million to develop pilot projects with an eye toward an eventual national rollout of the successful ones.

Graber believes that his idea will "repersonalize" VA healthcare. "Northport providers take care of an average of 1,200 patients," he said. "There is no way they can remember everyone."

Electronic records require providers to spend lots of time in front of a computer screen. "It's great to have all that information right at your fingertips," said Graber. "But at the same time, it can be overwhelming and tends to depersonalize care. We shouldn't be treating charts or numbers, but patients."

Providers entering notes on the wrong electronic chart is not a rarity. Providers need special permission to delete a note once it has been entered. "We get five to 10 requests like that every week," said Graber. "That's hundreds every year."

Smarter decision support
The innovation competition winners were not necessarily characterized by technological originality. Instead, they sought to incorporate existing technologies to make VA healthcare better.

For instance, Dr. Clayton Curtis, a clinician and medical informatics expert in Jamaica Plains, MA, won for his idea to develop better and more sophisticated clinical reminders in the VA electronic record system. The VA competition, "offered an opportunity to incorporate emerging standards to build applications that will help patients," he said.

Curtis' winning idea was to take advantage of standards"known as Arden and GELLO (see box)"developed to represent clinical knowledge and interface with an EHR.

"Without these standards, you're faced with finding a bit of knowledge in the system and connecting logic to where the data is located," said Curtis. "If you can interface with an EMR on a standards basis, you don't have to invent a new interface every time. We will work with both to construct reminders and connect them to VistA," the VA EHR, "in a way that would have been difficult to do before."

Among the applications Curtis envisions are a replacement for VA's current clinical reminders scheme and a scorecard tool that would be provided to patients. Additional applications could be developed in the future.

Reminders could prompt clinicians to order a mammogram for an appropriate patient or to follow up with a diabetes patient based on blood test values or the interval since the last lab tests.

The VA EHR includes such reminders today, but Curtis is striving for a set of "smarter applications with more expressive power in representing clinical logic," he said. "This is an area in which the availability of development resources has not kept pace with demand."

By incorporating standards, Curtis hopes that providers will create specialized reminders that are particularly meaningful to them and have those easily incorporated in the system.

Curtis also intends to develop a patient scorecard application. "It would provide an assessment based on the current standards of care to let patients know in plain English where they stand," he explained, "and what they should discuss with their providers."

Wireless "˜code blue'
From Martinsburg, WV, emerged an idea to use wireless devices to streamline communications to and from providers and their medical emergency teams. "My idea involves incorporating existing technology into the hospital's infrastructure," said Jason Barnard, associate chief information officer for Veterans Integrated Service Network (VISN) 5, which includes medical centers in Washington, DC, and Baltimore.

Barnard's idea was in the works before the announcement of the innovation competition, and he was able to make a contract award to Vocera Communications Inc., soon after the winners were announced. Vocera, a San Jose, Calif.- based company experienced in providing wireless hospital communications solutions, will be providing devices to a pilot project at the Washington Veterans Medical Center.

The device, the size of a small, oldschool cell phone, could dangle from a nurse's neck. "A nurse entering a patient's room can push a button and say "˜code blue,'" said Barnard. "The device will recognize the nurse's voice and then broadcast the message out to all code blue teams in the vicinity." At this point, code blue teams often carry separate devices.

"This is going to streamline communications between doctors and nurses," said Barnard. "It could also change nurses' workflow."

Today, a nurse might have to make multiple calls to find an empty bed. The Vocera device can be programmed so that the bed request can be communicated to all necessary parties. A digital readout on the back indicates that all calls have been made and whether an available bed has been found.

Barnard estimates the system will go-live in the DC VA Medical Center in the fall.

Each of the projects will be conducted as a year-long pilot after which they will be subject to an evaluation and a thumbs up or thumbs down on a further rollout. "We will try to get as much feedback as possible from users," said Graber. "I think it would be easy to get this implemented nationally." The VA already has a database of patient photos.

Barnard and Curtis are already thinking about enhancement to their projects. Barnard sees wireless devices benefiting families as well as patients. "They won't have to tied down to a waiting room," he said. "They can move around the campus or go to a store or coffee shop and they can be called when information is ready for them."

SIDEBAR 1:

Jason Barnard surveyed potential users to develop characteristics for his wireless communications idea. Among the feedback he received:

1. Eliminate additional pagers for internal emergency committees, such as code-blue teams.

2. Report critical clinical alerts such as lab tests, cardiology studies, radiology studies, within four hours.

3. Immediately identify the appropriate provider to receive reports in the case of a handoff.

4. Support logistics processes to improve bed turnaround and decreased emergency room delay times.

5. Notify personnel of key actions without relying on multiple mediums of communications such as cell phones, pagers and e-mail.

6. Decrease spread of infection with hands-free technology.

7. Improve communications in the operating room by replacing aging devices.

8. Support the role of the Rapid Response Team (RRT).

SIDEBAR 2:
Standards

The Arden Syntax for Medical Logic