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Cutting-edge telemedicine services enable University of Texas Medical Branch at Galveston Texas (UTMB) to treat an average of 60,000 patients a year. The heart of its UTMB Electronic Health Network service is a powerful electronic medical record (EMR) system based on Oracle Database 10g. UTMB's Electronic Health Network combines EMR with networking technology, remote diagnostic equipment, and videoconferencing.
Dr. Glen Hammack, assistant vice president and executive director of the UTMB Electronic Health Network, reveals that the EMR used by the system is very complete and contains everything from dental care to mental health services, as well as information on chronic conditions such as diabetes or heart disease. Everything is documented in the daily electronic medical record system. Currently, the system handles over a million interactions a day and averages over 3,000 simultaneous EMR users.
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Healthcare
A Picture of Health
By Jeff Erickson
UTMB connects doctors with patients all over the world.
What do a NASA astronaut in Star City, Russia, and a pregnant woman in rural Texas have in common? They both can receive world-class medical care from physicians and specialists at the University of Texas Medical Branch at Galveston (UTMB). The UTMB Electronic Health Network provides telemedicine services to clients as far away as Antarctica and as close as a few blocks away from the UTMB campus. At the core of the service is a powerful electronic medical record (EMR) system built on Oracle Database 10g.
UTMB got its start in telemedicine while serving patients in the Texas prison system, where it leveraged technology to provide inmate care at one-third the cost of what other states typically pay, saving the state of Texas more than US$1 billion since 1993. Along the way, UTMB fine-tuned its case management system and centralized its pharmacy system and then migrated these into a simple and useful EMR. Now, by combining its powerful EMR with networking technology, videoconferencing, and remote diagnostic equipment, the UTMB Electronic Health Network has built a telemedicine program that has more than half its clients outside the corrections system and is poised to take on new markets.
Profit spoke to Dr. Glenn Hammack, assistant vice president and executive director of the UTMB Electronic Health Network, about the network's telemedicine business and the technology that makes it possible.
PROFIT: What information is stored in your EMR system?
HAMMACK: Every patient we see has his or her entire healthcare cycle documented in the EMR. It contains everything from dental care to mental health services; to chronic healthcare like diabetes, blood pressure, and heart disease; to acute healthcare, such as emergencies. We see more than 1,000 patients a week, so we average 60,000 patients a year through remote technologies linked to the EMR. We average more than 3,000 simultaneous EMR users. We handle way more than a million interactions a day, and at the end of every day there are more than 50,000 new clinical notes in the EMR.
PROFIT: What technology supports the EMR?
HAMMACK: It is the enterprisewide, very reliable, and robust Oracle Database 10g that underlies the EMR system. For hardware, we're running on IBM P570s that are using IBM's fast T700 optically connected storage on IBM AIX UNIX. We've been using Oracle Database 10g and the IBM P570s for 16 months, and we're still happy.
PROFIT: How does the EMR affect the way a doctor works?
HAMMACK: The doctor or specialist sits in what we call a virtual physician's office and sees patients on a large plasma screen on the wall. We have doctors in 11 studios at UTMB. The patient is in one of several hundred remote clinics worldwide. The EMR is on four smaller screens. The doctor sees a patient summary, notes from the previous visit, and special studies like EKGs or X-rays. During the examination, the doctor uses voice recognition to create a note back into the EMR.
Voice recognition is an important part of our culture. Literally by the end of the day that a patient has been seen, a doctor's verbal notes have been typed in the EMR, electronically signed, and made available at the patient's location. We have a dedicated team of about a dozen physicians. They don't have brick-and-mortar practices, and they have no duties other than to see patients by telemedicine. Their specialties include emergency medicine, psychiatry, cardiology, primary care services, and orthopedics.
Snapshot
UTMB Electronic Health Network
www.utmb.edu/telehealth
Location: Galveston, Texas
Number of employees: 74
Annual revenue: US$7.1 million
Oracle products and services: Oracle Database 10g Enterprise Edition, supporting integrated electronic medical records and telemedicine
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The doctor can cycle through patient after patient. The beauty of it is that the first patient may be at a clinic in Louisiana; the next might be at the South Pole; and the next might be at a clinic by the Mexico border. For the doctor, it's just another virtual exam room. The EMR includes a powerful scheduling system that allows a very high utilization rate, which really makes it cost-effective.
PROFIT: What's it like at the patient's location?
HAMMACK: The patient will be with a specially trained attendant or nurse with a UTMB-designed telemedicine cart or in a dedicated telemedicine exam room, both equipped with an Oracle-based EMR workstation. We equipped the exam room and the cart with digital diagnostic and examination capabilities, and a videoconferencing system. A digital stethoscope sends live heart and lung sounds back to the physicians at UTMB. A fiber-optic illuminated, high-resolution medical camera links to an otoscope for looking in the ear or nose, a special scope for viewing skin lesions, or a device called a laryngoscope for looking down throats and into other parts of the body. Last-minute EKGs are scanned and shared in real time with the physicians at UTMB, so no one has to run to a fax machine. The exam rooms and the carts are also equipped with a backlight for viewing locally shot film X-rays.
PROFIT: Who are your patients?
HAMMACK: We support the scientists with the National Science Foundation at the South Pole and flight surgeons at Star City Cosmatrol in Russia. We do rural health and various forms of special-needs care at schools for the disabled and have telemedicine stations in fire halls here in Galveston. We serve the offshore oil industry and the U.S. Army. We won the Focus on Innovation Award from the Homeland Defense Foundation for the applications of this technology in biodefense. We are the biggest player in telemedicine. The Veterans Administration says that they're the biggest player, but they count e-mails and phone calls as telemedicine—we don't.
PROFIT: Is it cost-effective?
HAMMACK: Take our work in the Texas correctional system. We frequently get compared to the California system. We both have about 160,000 patients under our care. In 2004 California spent more than a billion dollars for offender healthcare. Texas spent less than a third of that.
PROFIT: Is this good healthcare?
HAMMACK: In 2004 the University of Texas chancellor paid for an independent audit by the Texas Medical Foundation—the same group that audits Medicare and Medicaid for accuracy, fraud, and quality. The bottom line of their report is that the healthcare we provide with this system is as good as or better than public healthcare in Texas.
PROFIT: Any HIPAA issues?
HAMMACK: We have had several HIPAA audits and never had a problem. Everything is either done over private lines, which are inherently HIPAA-compliant, or over a VPN [virtual private network] connection. To tell you the truth, the greater risk is from organizations that print stuff out and don't destroy it correctly.
PROFIT: Is the broader commercial environment ready for telemedicine?
HAMMACK: We already provide preventive and supportive healthcare right into company locations. Here in Galveston, the American National Insurance Company is only seven blocks away from the university medical center campus. They found it so advantageous for their employees to run down and spend 30 minutes in a telemedicine clinic, as opposed to four hours on the road and in the waiting rooms on our campus, that they even started paying the copay for the employee to encourage use of the telemedicine system. If you have more than 300 employees at a location, it's a good idea to look at telemedicine. This is an exciting innovation. It offers some additional value to patients, improving access and their health and helping to control costs.
| Retiring the Clipboard
IT and Process standards ARE the key to connecting healthcare records.
Why, when a person goes to the hospital, must she tell a medical aide with a clipboard, from memory, medical information her family doctor has been collecting for years? Government and industry groups have been asking the same question," says Marc Holland, program director for health provider IT research at Health Industry Insights, a subsidiary of International Data Corporation (IDC). "The solution," says Holland, "lies in establishing broad IT and process standards so health record systems in physicians' offices can talk to those of other physicians or hospitals." But while interoperability standards are critical for success, there must also be financial incentives to encourage investment in electronic medical record (EMR) systems. This could be a combination of subsidies, tax incentives, or changes to reimbursement models. In addition, the U.S. government must agree to modify provisions of the Stark Amendment that constrain hospitals from helping physicians invest in technology. Congress and the Department of Health and Human Services (HHS) are pushing initiatives on all these fronts.
A Delicate Operation
In 2004 President Bush challenged the healthcare industry to provide an interoperable electronic health record for every U.S. resident within 10 years. The goal: establish the National Health Information Network (NHIN) by 2014, thus improving the continuum of care and cutting administrative costs.
In response to Bush's challenge, the secretary of health and human services established the Office of National Coordinator for Health Information Technology (ONCHIT) to drive the standardization process. In November 2004, ONCHIT published a request for information asking for ideas on how an NHIN might work. Oracle joined other major healthcare IT vendors such as HP, IBM, and Intel to form the Interoperability Consortium, which provided the government with some broad IT guidelines for the NHIN.
In November of 2005, ONCHIT awarded pilot contracts to design and implement a standards-based network prototype of the NHIN. The contracts went to Accenture, Computer Science Corporation, IBM, and Northrop Grumman. Oracle provides underlying technology for both the Accenture and the Northrop Grumman pieces of the system. "The government has come up with the money to kick-start the standardization process and encourage participation to evolve toward the goal," says Holland, "but they've been very careful to date not to make public comments about how the whole process will ultimately be funded." According to Holland, neither the government nor industry groups want federally mandated standards. "In the end, the pilot projects will be vetted by the industry and true interoperable network standards will evolve."
A Stark Reality
In the near term, hospitals that may want to help local physicians' offices install and support EMR systems that will interoperate with the hospital's system are legally blocked from doing so by provisions of the Stark Amendment. "The Stark Amendment was originally designed to prevent Medicare fraud," says Holland, "but it also prevents hospitals, who have the IT expertise that many physicians in small private practices lack, from supplying, installing, and supporting systems in the physicians' offices."
"It's the small, independent physician practices that must invest in technology before a meaningful NHIN can emerge," says Holland, who notes that these practices provide the overwhelming proportion of routine healthcare services, such as documenting immunizations and allergies, that will make up a national health record.
A recent HHS proposal would create exceptions to the physician self-referral provisions of Stark and allow healthcare organizations to furnish hardware, software, and related training services to physicians for e-prescribing and EMRs. "By repealing elements of Stark," says Holland, "the hospitals will be allowed to go to the physicians who are on their staffs and say, 'We're going to set up systems in your office that will facilitate the communication between you and us.'"
Standardize or Perish
"All of these government initiatives are designed to ensure that on a technical level, on a nomenclature level, on a database level, and on a process level there is consistency of care from the doctor's office to the hospital to the nursing home or the rehabilitation center, to the home care agency," says Holland. "Data sharing between providers is an essential ingredient to ensure this consistency."
"Look at the VISA and MasterCard networks as an example," Holland explains. "There's an instance where the industry said, 'It's in everyone's interest to standardize. We have to do this.' I think ultimately, in the next five to seven years, a meaningful standard will evolve in the healthcare industry and an NHIN will begin to be a reality."
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Jeff Erickson is a technology writer for
Oracle Publishing.
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