April 1999, October 2001The Web is a particularly good resource for physicians interested in the political, technical and ethical aspects of medical records security. Just as important, the Web is also home to a number of specific computerized and electronic medical records projects. Once accessible only to conventioneers or readers of medical informatics journals, these works-in-progress are presented to the online medical community on sites whose Web tools vary from simple frames and hypertext to plug-ins and multimedia. Physicians contemplating the purchase of their own record keeping systems will probably benefit from perusing the Web first. Given computers' obvious impact on clinical practice, when we review these cutting edge projects on line we are peeking into our profession's future.Almost one fourth of family medicine practices with computers were using some form of computerized or electronic medical records by 1996, according to statistics from the Journal of Family Practice Management. One would expect the statistics to be similar, if not higher, across all specialties and in multi-group practices, MCOs and hospitals.
The terms computerized patient record (CPR) and electronic medical record (EMR) are often used interchangeably, but as defined by the Medical Records Institute there are several key distinctions. Computerized records generally refer to software wholly contained on a desktop or intranet server that at a minimum accepts straightforward input or scanned data from paper, whereas electronic medical records imply receipt from, and contribution to, a variety of databases scattered among several computers. Electronic transmission also introduces standards and legal requirements for confidentiality, security, accountability and data integrity that do not necessarily confront CPRs to the same degree.
The distinction between CPRs and EMRs should either become clearer or dissipate entirely with time. For now, there are many large commercial CPR and EMR products for physicians to select from, and an equally large number of hospital, managed care, and other organizational information systems with partial or complete medical record keeping modules.
A five-year-old online lecture presented by then Stanford medical informatics fellow William Detmer, M.D., WWW and the Electronic Medical Record, begins with a review of the Internet from the perspective of data transmission, and concludes with several screens from University of Minnesota's early EMR system. Two zipped files are available for downloading off Columbia Presbyterian's site: George Hripcsak, M.D.'s Using NII to coordinate health care as presented at the 1997 Meeting on Health Care Solutions at New York University, and Soumitra Sengupta, Ph.D.'s Transferring patient records on the WWW as presented at the 1997 AHIMA National Conference in Phoenix AZ.
Although not directly related to the Web, several interesting articles may assist physicians contemplating EMR systems for their practice. Dean Sittig, PhD's Advantages of computer-based medical records summarizes the key points from a recent article in the Lancet. . In the March 1997 issue of Postgraduate Medicine, Jeffrey Potts, M.D., discusses how Hennepin County Medical Center, Minneapolis, went about selecting The 'Best' Medical Record System. Last summer's article on Wireless LANs: Just What the Doctor Ordered, from the August 24, 1998, issue of InternetWeek, describes why computer mobility is critical for real time health care delivery. It portrays a number of portable data transmission programs in use at various hospitals, several of which are close precursors to an EMR system. Based on the article, it's a safe prediction that eventually EMR input and retrieval will involve palmtops as much or more than desktop computers.
Common Features
As several projects attest, many experts view the Web as a plausible medium for those medical record systems that need to mediate between two or more heterogeneous databases, that seek to speed up processing by redistributing a significant proportion of the workload from the server to the user's computer, that present different views of the same data to different users, or that attempt to tailor information to the needs of individual users -- all ideal features for any EMR system.
But to accomplish these tasks on the Web requires a programming language that goes beyond the present Web favorite, HTML. Options at this time include SGML or XML -- either of which would require more sophisticated programming and use of browsers other than Netscape and Explorer. Alternatively, proprietary code scripts embedded in HTML documents and delivered in conjunction with proprietary browser plug-ins or Java applets are options popularized by many nonmedical sites throughout the Web but, for EMR users, they add exponentially to server time and memory demands.
For more information on World Wide Web-based Electronic Medical Records, Frank Stitt, MD, president of Medix Software Systems, has posted his speech covering basic concepts and tools. The Intranet Electronic Medical Record and Medical Records and the Internet include several slide show lectures written by Bob Elson, MD, and John Faughnan, MD, and presented in a number of online formats.
Also on line are articles that discuss features important to medical record keeping in large organizations, such as universities and MCOs. Richard Rathe, MD, wrote the Minimum Features for Future Clinical Information Systems based on experiences with his OnLine Medical Records (OLMR) project at the University of Florida and Shands Hospital (see below). Duke University's Michael Lundy, MD, authored The Computer-Based Patient Record, Managed Care and the Fate of Clinical Outcomes Research published in the January 1996 Florida Family Physician.
Sherman Hope, MD's The Patient's Computerized Clinical Record: Features to be Included in a Successful System is a down-to-earth list of desirable features from the physician-user's perspective. Not surprisingly, Dr. Hope's company, Patient Medical Records, Inc., sells CPR and related software.
Projects with Web Demos
A handful of the more elaborate CPR and EMR projects that are particularly well described on the Web without an overt commercial stance are included here. Most of these projects exemplify U.S. medicine's trend toward joint collaborations with government agencies, private enterprise, and academic institutions, and are consistent with a national, if not international, view of electronic medical record keeping. Yet each confronts the present confusion surrounding medical, technical, and legal standards in a different way, and each uniquely resolves software limitation in data entry, navigation, interface design, and security problems.
W3-EMRS
W3-EMRS Project is a well-known collaborative effort of the Informatics Program of Boston's Children's Hospital, the Clinical Decision Making Group at the MIT Laboratory for Computer Science, and the Office of Computer-Based Education of Albert Einstein College of Medicine. This page links to both their W3-EMRS and ICU Demonstration Database, both of which are relevant and worth time perusing. A multi-institutional demonstration database is under construction.
Other readings present EMRS goals and a description of how EMRS sidestepped the lack of medical standards by adopting public-domain technologies to implement viewer/editors of multimedia compound documents and their transmission over the Internet without compromising confidentiality. Be certain to access the site's Publications for a good list of articles available as Web links and downloadable files.
The EMR online demonstration gives a good feel for how the project integrates a patient's clinical record with clinical resources. Navigation between and within records and clinical resources is especially impressive. Diagnoses on each patient's problem list, and on a Clinical Experience list of all the clinic's diagnoses, are linked to research options such as Medline, text retrieval services, and a Web search engine, and to a CAD page (where Java scripts prevented my further access).
CareWeb (times two)
It's dueling trademarks, as two University systems fly their TM superscript over each CareWeb system.
- The core of University of Michigan's CareWeb Web site is its slide show presentation that, while accessible en masse off the home page, is better navigated through its index. The online Demo is
buried in the eighth slide. It's worth uncovering, not only for its straightforward interface and good use of frames, but also to peek at the fun photos of the "patients." Curiously, the demo ED record does not note the recent visit or discharge medications from the patient's hospitalization one week earlier.
A February 1999 news item reported on accidental Internet access to portions of thousands of the University of Michigan Medical Center's patient records ö a situation that went undiscovered for two months. Although no patient's privacy was reported to have been violated, such breaches in security raise serious questions. (See NetView's EMR (In)Security). Presumably this was part of CareWeb.
- BIDMC's elegant CareWeb site includes a brief overview and online demonstration (called Patient Lookup) of Beth Israel and Deaconess Hospitals' linked databases, in addition to other worthwhile expositions, all accessible as ever present left-sided links. Funded in part by a cooperative agreement with the Agency for Health Care Policy and Research and the National Library of Medicine, and the Center for Clinical Computing, BIDMC uses Intersystems' Visual M and Microsoft's Active Server to permit Web access to patient
information data. The security system conforms to the March 1997 report from the National Research Council (NRC) of the National Academy of Sciences, For the
Record: Protecting Electronic Health Information, particularly with respect to patient consent and accessibility via SecurID cards. The demonstrations of audit trails and Web server log analysis are an especially nice touch.
WebReport
Supported by NLM research grants since 1994, The University of Pittsburgh Center for Biomedical Informatics Lab is developing a multimedia electronic medical record that integrates the textual features of a patient record with Image Engine, a program for accessing medical imaging studies. The Image Engine integrates clinical text and images such as radiographs and microscopic pathology into a single interface. Plans include incorporating audio, video, 3D graphics, and animation. A demo of an early prototype, WebReport, is available on line. WebReport will ultimately allow for accessing clinical information over the Internet.
Shrewd
Stanford Hospital Record Electronic Web Documents (Shrewd) was created in 1996 by James Cook as a prototype medical record and hospital information system using the World Wide Web and existing browser technology. Ignore the log-in box and just click the Shrewd button to interact with its text-based demo, including lab results from the famous Louis Pasteur.
The Medical Record
Duke University's The Medical Record is 25 years in the making. Most of the online material, including screen shots, is from 1995. A full demo is available for downloading.
WEBMIS
W3 Based Medical Information Systems vs. Custom Client Server Applications is an article extolling University of Minnesota's medical record virtues combining institutional SQL data repositories and Perl CGI scripts on the Web, as compared to their old custom NextStep-based client-server applications. This article will be of special value to those interested in the technical progression from a Cobol-based system to Unix, and on the differences between Web and non-Web-based applications. The article links to sample interfaces that illustrate well their underlying plan and philosophy, and also describes their system's limitations, some of which date the article to 1994-1995.
OLMR
University of Florida and Shands Hospital's OnLine Medical Records Summary from 1992-5 is the most recent update describing its project available on the site. It introduces the project, gives sample screens, and describes its clinical impact. OLMR has been in use long enough that its self-reflections on the system's strengths and limitations are especially valuable.
NYPH Infonet
With the recent merger of New York's Columbia-Presbyterian and N.Y. Hospital-Cornell Medical Center, a new electronic patient charting system has overwritten Columbia's Web-based CIS. Open the framed home page at NYPH Infonet, then navigate through Clinical Information to Eclipsys Continuum 2000, and finally to its Chart Review. The EMR's interface is sophisticated yet essentially browser-based, with expanding/collapsing tables of contents and seemingly straightforward manipulation of both single and multiple patient charts, or a single patient's chart through multiple visits. It also supports links to Web references. There is no online demo per se, but browsing through its User Guide provides a reasonable facsimile. Note that the Guide is available in Adobe Acrobat (PDF) format and so requires the freely available reader plug-in available at Adobe's Web site.
PCASSO
UCSD's Patient-Centered Access to Secure Systems Online (PCASSO) is designed to bring state-of-the-art secure communications to personal health information on the Internet. Like several other projects listed here, PCASSO is supported by the National Library of Medicine/National Institutes of Health as part of the national Telemedicine Initiative. Corporate support is also provided by Oracle Corporation and Data General Corporation. It has progressed significantly over the past year and now appears to be entering Phase II, the integration of PCASSO with UCSD's regional clinical information systems. Note that PCASSO is an information retrieval system for health care providers and patients÷it does not accommodate data entry, as do most EMRs. PCASSO emphasizes security; see chapter 8 and FAQ for more information on its multi-level user authentication system. There is no online demo, but the (alas, slow-loading) User's Guide provides a reasonable peek into the present system. Click on View Patient Data on the left frame in the User's guide to download sample screens of patient demographics, laboratory, and radiographic reports. Those designated as the patient's primary care provider can add or change chart access for other physicians, such as a consultant, and any of the patient's physicians can elect to exclude a patient's access to aspects of his/her chart, such as new test results or a mental health evaluation.
Bench to Bedside and Beyond
University of Washington's Bench to Bedside and Beyond (B3), is another NIH/NLM grant recipient. Using a browser-type interface, this regional telemedicine project links five Pacific Northwest states to electronic medical records, telecommunications, delivery, and storage of x-rays and other clinical images, and access to clinical resources. According to B3's online overview, "our ultimate vision includes creation of a comprehensive regional integrated medical network providing easy and secure access to quality, cost-effective health care for citizens of the Pacific Northwest÷an Academic Medical Center without Walls where research findings are transformed rapidly into improvements in clinical care and public health."
B3's site is nicely updated with lots of administrative information and interim reports. There is no online demo, but screen stills can be viewed starting with Slide 16, Sharing Patient-Related Data, within the November 1998 Evaluation Status Report. A description of the first Bench to Bedside project÷ before it went Beyond÷is available on line as well.
MedExplore
University of Colorado's MedExplore, their Web-based EMR system, is described online in general terms. I was unable to access the online demo although I agreed to the disclaimer and avoided Internet Explorer 4.0.
ComChart
The creation and growth of Hayard Zwerling, MD's ComChart is described in ACP's Computers in My Practice. Written using Macintosh's HyperCard authoring tool, ComChart is a good example of how one physician created his own CPR system and adapted it over the years to his practice's needs. On line, this article provides links for readers to sample form letters, chart interfaces and how ComChart maintains CPT and other codes. ComChart is integrated into patient care; for example, glucose fingersticks can be e-mailed into the physician To-Do list, then transferred to the RN's To-Do list for patient communication and chart incorporation. The author explains that lack of outside technical support makes it impossible to offer ComChart to the public.
VistA
As early as 1982 the VA Medical Automation implemented a national Decentralized Hospital Computer System (DHCP). In 1998 the name was change to Veterans Health Information Systems & Technology Architecture (VistA). Using Massachusetts General Hospital Utility Multi-Programming System (Mumps or M) as the primary programming language, staff programmers worked with user groups and developed integrated software modules as part of a complete hospital information system. To improve overall efficiency, the Hybrid Open System Technology (Host) program integrates commercial off-the-shelf and academic technologies with VistA.
Sixty-odd modules are grouped under Clinical, Management, and System/Database Management; a monograph explains the application of each module. The Medical Imaging Integration demonstrates the potential variety and quality of its images. Under development are Windows prototypes of automated clinical records. A browser plug-in is required to view the video demonstration.
TeraCLIN
Healthcare Solutions Center's TeraCLIN constructs a medical database using Data General AviiON servers running Microsoft Windows NT Server and SQL Server 7.0. A joint project of Microsoft and Data General, the database includes both business and clinical measures, serving not only as an archive of patient information but manipulation of data points as well. Specifically, five common identifiers define the TeraCLIN project: patient occupations, attributes, lab tests, medications, and cost/profit breakdowns across specific diagnoses. At present the site contains marketing and technical information, but it promises an interactive demonstration of a hypothetical large managed care network within the month.
Other Projects
A number of other projects are worth mentioning, either because they are well known or because they provide significant online information.
- To share Denver's National Jewish Center for Immunology and Respiratory Medicine's knowledge and experience with a wider clinical and medical education audience, the Los Alamos National Laboratory developed a multimedia online system: TeleMed. This system is essentially a distributed national radiographic and patient record repository through which physicians from around the world can submit and view patient information and radiographic
data. By matching their patients' radiographic information with data from the Center's repository and reviewing treatment history and success, physicians may be in a better position to determine the best treatment. Important to this project is that Los Alamos's Thinking Machines CM-5 and Cray T3D uses parallel (as opposed to serial) computing.
Although not strictly an EMR, TeleMed is included here because the project has essential components all EMRs share: mainstream information system, relational database, an accessible programming language (Java), object-oriented technology (CORBA), a client/server architecture, the Internet, Web browsers, encryption, portable hardware tokens, a master patient index, artificial intelligence, and other technologies. Just as important, its Web site provides an impressive amount of literature useful to those interested in EMRs, created from multiple databases stored within LANs and other intranets.
Online demonstrations are available from the home page under Capacities, which houses enlargable thumbnail images and supplies a good feel for TeleMed's strengths, particularly with regard to radiographic imaging. There is also a Java/CORBA Demonstration which, even if not fully functional, gives a sense of TeleMed's interactivity. Be forewarned; this Java program is slow-loading and uses a second window that may be minimized on presentation.
- The Medical University of South Carolina's Emerald project set the goal of implementing an EMR system for most of the medical center by the end of last year. This site emphasizes Emerald's administrative aspects. For example, look under Tech-Wire for an article describing their program and projected time line, and Team/Status for Emerald's organizational structure. Unfortunately, there is no online demo or technical information.
- Parallel Architecture for EPR (PAEPR) is a collaboration among England's Manchester Medical Informatics Group, the Centre for Novel Computing and the Medical Products Group of Hewlett-Packard Labs, Bristol. It is built upon the well-known Galen project and presently funded under the ESPRC AIKMS initiative. The home page describes PAEPR's objective as "to support smart semantic access to a large persistent subsumption-based knowledge store capable of representing asserted and implied intensional concepts." Those excited by this goal will find a number of links on the project's Web page.
- Virtual EMR is a partnership project between informaticians from the Virginia Neurological Institute and Hewlett-Packard. Concise information regarding their Web project is on line, and those with a PowerPoint plug-in can view their online slide show.
- IBM Health Data Network Express is an open architecture system that uses IBM's Lotus Domino Web Server to integrate EMR with business and administrative data, electronic communications, and general function features. There is no online demo, but the system is in use at Washington University's Barnes-Jewish-Children's Hospital.
- Hewlett-Packard's Microelectronics and Measurement, and Information Technology Centers are collaborating with the Mayo Clinic to develop an EMR system for the medical center. A sample screen of Mayo's EMR dons the top of one of their online press releases.
- England's Poole Hospital is using an XML-based EMR, as described in this 1.25 million Electronic Medical Records in XML at Poole, as presented at the 2001 Internationales Congress Centrum.
Those looking to purchase or learn specifically about commercial patient/medical records products are directed to Yahoo's EMR, or to online software directories that link to commercial home pages. Also, look mid-page on (MCToday's parent company) Healthcare Computing Publication's Online Directory of Medical Software for its search engine, then check off Medical Records/Systems to access 247 companies selling EMR-type software; the search can also be narrowed to include selected operating systems, LANs, palmtops, etc. To obtain the vendor's Web address and other contact information, from the Results page click on the product's vendor link. The URLs are provided gratis, and some vendors pay to link directly to their sites.
