Photos by Stephanie Klein-Davis | The Roanoke Times

Kris Peters, RN (left), administers compressions in a simulated Code Blue with a 14-year-old patient. Terri Gregory, RN (tan middle) and Anne Wienke, RN, assist as the procedure is documented electronically by nurses in training on workstations on wheels.

(From foreground to background) Amy Brannan, RN, Women & Peds; Amy Robson, RN, Women & Peds; Karen Houghton, CCRN CSC (Critical Care Nurse and Cardiac Surgery Certification); and Ragan Farris, RN, Technology Services Group, document a simulated Code Blue procedure performed by nurses (at right).

A national push to bring medical records up to speed with rapid advancements in information technology has doctors trading their pens for keyboards.

Hospitals and physician offices are feeling pressure from the government and the medical industry to switch from paper charts to electronic health records.

Promises of improved patient care are luring some, but many are lagging behind, citing sometimes prohibitive costs.

Locally, both Carilion Clinic and Lewis-Gale Medical Center have used electronic record systems for years.

Lewis-Gale entered the digital realm of medical records in 1997. A year later, Carilion first implemented its system.

Still, technology used a decade ago isn't always compatible in today's world, and that has both hospital systems making changes to their electronic medical record technology to keep pace.

In September, Lewis-Gale will start using new technology that allows physicians to access lab and imaging results via smart phones such as a Blackberry.

Earlier this year, Carilion began the process of installing a new multimillion-dollar electronic medical record system to upgrade its former, outdated system.

'Investment in the future'

A little over a year ago, Carilion's board of directors approved a capital budget of $67.5 million over eight years to implement a new electronic medical record system called Epic. In May, the capital cost was revised to $65.8 million.

The capital cost represents a $37 million increase in the amount Carilion would have spent over the same period if the new system hadn't been purchased, said Dr. Ed Murphy, chief executive officer for the clinic.

In February, physicians at the Carilion Family Medicine-Daleville office became the first Carilion entity to get hooked up to the new system.

Carilion Roanoke Memorial Hospital is the first of the clinic's hospitals to go live. The switch was scheduled to take place Saturday, after newspaper deadlines.

To date, 14 ambulatory-care entities with Carilion have been switched to the new system.

Rolling out the program to all of Carilion's facilities is a two-year undertaking, said Dr. Brent Lambert, who is a doctor by training but has reduced his clinical hours to lead the electronic medical record project at Carilion.

Dr. Dan Jones said he jumped at the opportunity to be one of the first to test-drive Carilion's new medical record system.

He's one of four doctors and two nurse practitioners at the Daleville office.

"We are all pretty computer savvy and this is an investment in the future," Jones said. "It's a great opportunity."

Both government and industry accounts depict doctors such as Jones as the lucky ones, because for many physician practices, switching to electronic medical records requires a huge financial investment.

Jones said he recognizes that he is blessed, because he has access to the technology without having to pay for it.

"For many smaller practices, it's hard to afford," he said.

Besides the cost of the hardware and software, physicians often incur high costs for installing and setting up the new record-keeping system. Often, smaller practices, where staff are busy caring for patients, have to hire outside consultants that guide them into the digital age.

Enthusiasts of making the switch from pen and paper to keyboard and monitor argue that the benefits of electronic health records outweigh the cost.

Critics wonder if medical providers should have to incur the cost, when the beneficiaries are often the patients and insurance companies or the federal government through Medicare and Medicaid.

Some analysts suggest that electronic records could save patients and payers money by eliminating unnecessary care, such as duplicate diagnostic tests, and reducing the likelihood of medical errors, such as giving incorrect medication dosage or prescribing a drug that adversely interacts with another.

Slow to catch on

Like physician practices, hospitals are also weighing the benefits and expense of electronic records.

A decade ago, the world of electronic medical records was relatively new. Most hospitals and doctors offices were still relying on handwritten prescriptions and medical charts.

Those who were turning to electronic records were on the cutting edge and many were following the lead of the Department of Veterans Affairs, which began using computers to manage clinical data in the 1970s, according to federal records.

Today the VA is still light years ahead of many hospital systems, having put in place an electronic health record system that serves nearly 6 million patients in more than 1,400 hospitals, clinics and nursing homes.

That goes against the norm.

A report released in May by the Congressional Budget Office said that as of 2006, only 12 percent of physicians and 11 percent of hospitals have adopted electronic medical record programs.

Another survey released earlier this month by the New England Journal of Medicine reported that 13 percent of physicians in an ambulatory care setting use a basic electronic records system, while 4 percent used a "fully functional" system.

The journal's survey, conducted in late 2007 and early 2008, said practices with more physicians were more likely to have an electronic system than those practices with only a few doctors.

Three years ago, the Virginia Hospital and Healthcare Association conducted a statewide survey that showed more than half of the state's hospitals and 17 percent of physician practices were at least midway to deploying an electronic system, said Chris Bailey, senior vice president with the association.

"Virginia hospitals were well on the way towards having in place a hospital electronic medical record," Bailey said. "We were in the top quarter among all states at the time."

A follow-up survey should be out later this year, he said.

While the VA claims that its system has reduced costs and improved the quality of care, Bailey said that the benefits aren't immediate or always apparent.

"It's an expensive undertaking," he said. "It requires that you change how you work day-to-day and there is a pretty steep learning curve. And the payoff is elusive."

'It is not an IT thing'

Carilion's Lambert is adamant that updating to the new system will save money and improve care.

Under the old system, Carilion had been tracking patient care through a variety of methods.

There was an electronic program for the emergency department, and another for ambulatory care. Inpatient care was still charted on paper.

The methods weren't compatible with one another. A patient who regularly visited a doctor like Jones in the ambulatory setting would have one file there and an entirely separate file if the patient was treated in the emergency room.

While on the surface that may not seem like a problem, it has required that each department within the Carilion organization maintain a list of the patient's medical history, prescription medications and other medical information. Often one chart had information that the other didn't.

"In the early days, there were no enterprise-wide systems," Lambert said. "So we went to various vendors trying to carve out a piece at a time. It's what everybody did.

"We found what was best for ambulatory, what worked best for the emergency department and best for inpatient."

When it came time to integrate the various systems, Carilion hit a wall.

That's when the decision was made to scrap the old systems for one organizationwide new system.

The conversion of Carilion to the clinic model and the organization's interest in owning more doctor and specialist practices only heightened the need for one program for the entire system, Lambert said.

"It is not an IT thing, it's a clinical process," he said. "The idea is to have a single file for the patient that anyone in the organization can go to. ... It's truly a patient-safety initiative."

Jones said he has already seen the benefits of an emergency room doctor's having access to a file of one his patients.

When Rachel Poole, 84, had to go to the emergency room earlier this month, Jones was able to view the results of a test instantly while she was still in the emergency room.

The next day, Poole was in his office for a follow-up visit and together they went through the record from the visit to Roanoke Memorial.

"The hospital doctor and I were able to look at the record together and decide what to do. It was very smooth, seamless," Jones said.

Any information a doctor needed to treat Poole was just a click away. Poole said it was nice to know that the doctors could communicate so easily.

Old to new

That seamless access to data was possible prior to the Roanoke Memorial's using the revamped records because of the preparation to bring the 765-bed hospital online with the new system.

Besides spending nearly four weeks converting old records to the system, Carilion's employees had to be trained to use the electronic records.

Both training and converting records is ongoing, as the organization goes through the transition.

Training of the hospital's 500 physicians, 1,400 nurses and other staff began in April and required most clinical staff to spend between 12 and 24 hours learning the new system.

Learning to navigate the system not only meant clinical staff had to familiarize themselves with the various click-down menus and files, but also had to practice using it in training scenarios. Doctors and nurses spent several hours practicing on dummy patients before they had to learn to navigate the computer during a real-life emergency situation. Learning to care for the patient and to enter in data as quickly and as close to real time as possible is one of the goals of the system, said Tammy Kemp, senior director of nursing support services at Carilion.

In a world that doesn't allow a hospital to shut down for training, some experts suggest the time commitment required to learn how to use an electronic health record system is an obstacle for adopting the program.

"It's a significant investment of money and time of staff to go through these transitions," Bailey said. "It's a drain on capital. It's not like adding a new [medical] procedure or service. ... It's like paving your parking lot, you got to do it. Enthusiasts say there is a pay off, if you apply the tool effectively."

Carilion has had to deal with scheduling challenges as it tried to provide time for employees to train -- but also meet the daily demands of caring for patients.

"It's been a logistical challenge," Kemp said.

"But you have to take a step back and think how important training is and how it relates to the care of patients."

Cash needs

For smaller hospitals or physician practices not owned by a large clinic system, the cost and time can be prohibitive, said Jeff Odell, senior vice president with MedVirginia, a Richmond-based company that coordinates electronic record exchange between several different providers in central Virginia.

"Many physicians would like to see the payers of health care step up and help with the cost," Odell said. "Small and medium practices are running hard just to take care of patients. They don't have the expertise to handle electronic medical record implementation."

The Congressional Budget Office report cited estimates that a 500-bed hospital would pay $7.9 million in initial costs and $1.35 million in annual operating costs. A smaller 250-bed hospital would incur initial costs of about $3 million and annual costs of $700,000, the report said.

When it was announced in June that MedVirginia would coordinate for Virginia a five-year national Medicare demonstration project that pays physicians for using an electronic health record system, Odell said his phone began ringing.

"Physician practices are calling saying, 'We want some money,' " Odell said, adding that they wanted help purchasing a electronic record system. "But that's not what this is. It's an additional reimbursement based on Medicare billing."

Of the 200 physicians who will participate in the project, only 100 will be randomly selected to get the financial incentives. The others will be in a control group.

"People are kind of getting all upset about that," Odell said. "But there is a 50 percent chance and that's better odds than playing the lottery."

What it really speaks to, Odell said, is the understanding the medical community has for why electronic records are important but a reality of the cost burden.

Those following the change from paper to electronic charts, however, say the switch is inevitable.

"This eventually will become a standard of care and it will be very hard to practice without one of these systems," Bailey said.

Public health

One reason the government is pushing to bring the medical community into the digital world is because of the potential benefits to public health.

"This is the single most important public health intervention that the region is going to see," said Dr. Anthony Slonim, vice president of medical affairs with Carilion.

"With an electronic medical record platform we can start to manage population level outcomes. ... That's something we can't do today."

With more than 40,000 people admitted to Carilion annually and another 1.5 million outpatient visits a year, the applications of population data are numerous.

Slonim pointed to a few such as clinical research and keeping tabs on outcomes and best practices.

While access to Carilion data alone has excited Slonim and others about the potential for studying larger population health data, the larger goal is to find a way to pull data from different systems.

For instance, the ability to see combined data from Carilion and Lewis-Gale. Lewis-Gale already shares data with other HCA Inc. hospitals in the region, said spokeswoman Nancy May.

She added that there are some parts of the electronic record system that aren't 100 percent interfaced with the main system.

Besides accessing records for research, Bailey said the next goal is for a patient's record to be universally accessible at any hospital.

"The other piece is supporting the sharing of information across [health care] settings so the information follows the patient," Bailey said.

That's what MedVirginia is doing for patients in central Virginia, Odell said.

While there are some successes, a lack of universal standards has made it hard to manage health information, he added.

While many questions still remain, Odell and others said that the future is open to a lot of new possibilities, from wireless systems to patients' keeping their own records.

"The industry is moving so fast, I wish I had a prediction for you," Odell said. "The way it is done today isn't going to remain. It will look different in a decade, for sure."