Indiana dishes out EHR services

The first electronic health record system, installed in Indiana in 1972, still serves as a model for other health systems.

What does the front-loading dishwasher have to do with health care information technology? The answer, if you practice medicine in Indiana, lies with an individual who led a quiet revolution.

In the late 1960s, Sam Regenstrief, whose D&M Manufacturing in Connersville, Ind., manufactured a third of the world's dishwashers under brand names such as Lady Kenmore, Admiral and Norge, set up the Regenstrief Institute for Health Care at the Indiana University School of Medicine. The institute's mission was to apply manufacturing technologies and processes to improve the efficiency and quality of medical care.

The institute developed the first electronic health record (EHR), the Regenstrief Medical Record System (RMRS), which was installed in 1972 at Wishard Memorial Hospital, the safety net hospital in Indianapolis, said Dr. Clement McDonald, the institute's director. A safety net hospital provides health care to everyone regardless of their ability to pay.

A wide range of health IT vendors are vying to serve markets globally with their products, but "I don't know anyone who has done all we have done," McDonald said.

Dr. Marc Overhage, associate professor of medicine at Indiana University and chief executive officer of the Indiana Health Information Exchange (IHIE), formed in March 2004, agreed. Wishard, two other hospitals, a medical center on the university's Medical Center campus in Indianapolis and 30 inner-city clinics use RMRS, he said. Eight primary care neighborhood health centers and 27 public health clinics supported by the state's Marion County Health Department also use RMRS.

Wishard uses RMRS to capture and store all diagnostic studies, including lab tests, cardiograms, surgical pathologies, bone marrow biopsies and obstetric ultrasounds. RMRS also captures clinician/patient encounter information, including notes, dictation and discharge summaries, Overhage said.

RMRS stores the results of every cardiogram done at Wishard in the past 13 years and every digital radiology image taken in the past six. Clarian Health Partners, which operates three hospitals in the Indianapolis area, also uses the system to store information on more than 3 million patients and more than 420 million computerized clinical observations.

Regenstrief also developed the Logical Observation Identifiers Names and Codes database for chemistry, hematology, serology, microbiology -- including parasitology and virology -- and toxicology. In May 2004, the Department of Health and Human Services added the database to its standards for the electronic exchange of clinical health data to be adopted across the federal government.

Outside the hospital arena, Regenstrief developed Docs4Docs, a clinical information system that served as the basis for IHIE's first product, a clinical messaging system designed to initially connect the doctors and hospitals in central Indiana and eventually the state.

The system, built on Health Level messaging standards, facilitates the exchange of laboratory, radiology, pathology and electrocardiography reports among clinicians and five major hospital systems in central Indiana. The system's partners are willing to pay for the service. Asked why IHIE did not tap a vendor for this product, Overhage said simply, "No one else can do what we do."

Betty Eads-Hall, director of physician information services at Community Health Network, which operates five Indianapolis-area hospitals with more than 1,400 beds and 7,090 doctors, said the IHIE clinical messaging system provides one central point to deliver and receive messages from clinicians. That information is then used to fill in EHRs.

Dr. Virginia Caine, director of the Marion County Health Department, said she became such a believer in the usefulness of IHIE, Docs4Docs and the clinical messaging system that she backed IHIE with $300,000 of the county's money, a commitment to health IT unmatched by any other county nationwide.

In addition to facilitating information exchange between clinicians and institutions -- which she believes will help cut health care costs by reducing paper flow -- Caine said IHIE can provide biosurveillance data, giving the county early warnings of a possible epidemic.

For example, the exchange will enable Caine to receive timely emergency room data to get information quickly about a spike in the number of new patients with respiratory complaints, indicating the onset of flu season or an epidemic. IHIE provides her with accurate, detailed clinical and geographic information -- down to a two-mile radius -- of a potential outbreak, a system far quicker than sifting through phone calls or paper reports, she said.

Health care engineering

The latest Regenstrief spin-off is the Regenstrief Center for Healthcare Engineering at Purdue University in West Lafayette, Ind. The center was launched with a $1 million grant from the Regenstrief Foundation in July 2004.

"Our mission is to take a global look at health care as a system and to look at health care business processes," said Joe Pekny, the center's interim director.

The center will work to apply business process re-engineering principles, such as supply chain management and just-in-time manufacturing, to health care delivery, following the flow of information and funds through the system to achieve better efficiency. The center will apply these principles in long-term projects with health care partners and also in shorter projects -- perhaps 10 to 20 days -- focused on discrete slices of the health care system, Pekny said.

One of the more unusual short-term projects the center has undertaken was a request from an unnamed hospital for taking a hotel approach to food service, including offering better menus and service, he said. Although this may seem far removed from typical health care challenges, Pekny said there is a correlation: Better food means improved patient morale and quality of care.

Following a more conventional approach to business process re- engineering, the center also took on an assignment to study and improve emergency department workflow and staff scheduling, including analyzing room configurations and equipment usage. Most likely, the project did not differ much from the kind of study Regenstrief used to improve dishwasher manufacturing.

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