Customer Solution Case Study
/ Medical Society Leads the Way with Easy to Share Patient Records for Practitioners
Overview
Country:United States
Industry:Healthcare and Healthcare Insurance
Customer Profile
Based near Boston and founded in 1781, the MMS is a physician group with 18,000 members and 400 employees. The MMS advocates for improved patient care and publishes the New England Journal of Medicine.
Business Situation
As more patients are referred to specialists and to multiple care settings, the need for portable medical records grows. Paper-based systems often introduce errors, and can be difficult to update, store, and share efficiently.
Solution
Working with professional medical and standards bodies and other stakeholders, the MMS created the Continuity of Care Record. Designed for electronic delivery, the CCR uses XML, Microsoft® Office, and InfoPath™ 2003.
Benefits
Gives doctors more time to treat patients
Reduces costs
Increases accuracy
Integrates with legacy systems / “With the CCR and InfoPath, we hope to provide doctors with a standard document and a toolset to communicate critical medical information at very little cost.”
Ted Blizzard, Vice President of IT and CIO, Massachusetts Medical Society
Relief is in sight for millions of people who must continuously repeat their medical history when visiting new doctors. A new concept and project known as the Continuity of Care Record, or CCR, aims to make patient records more portable, timely, accurate, and easily updated by all practitioners. Developed by the Massachusetts Medical Society and refined by medical and standards organizations, the CCR includes key facts about a patient's condition. Using forms developed in Microsoft Office InfoPath 2003, the CCR captures information such as current medications, diagnoses, recent treatments, and patient demographics. The forms can use XML and Web services to enable secure electronic distribution, update legacy health care systems, and much more. Advocates say the CCR will help enhance patient safety, prevent medical mistakes, reduce costs, and make doctor visits more productive.
Situation
Helping to find answers for some of the toughest questions facing health care today is standard operating procedure for the Massachusetts Medical Society (MMS). Based outside of Boston in Waltham, Massachusetts, the MMS is the oldest continuously operating medical society in the United States – and one of the most prestigious.
Comprising more than 18,000 physicians and medical students, the society's mission is both to educate health care professionals and the public. It advocates for improved patient care by running public health campaigns, sponsoring educational programs, and providing financial support to social action programs such as free-care clinics. The MMS also produces a number of well-known publications, including the consumer HealthNews newsletter and the influential New England Journal of Medicine.
One of the society's most recent projects to improve health care is particularly ambitious. Called the Continuity of Care Record, or CCR, this project aims to make the sharing of patient information among practitioners more accurate and cost-effective. It does so by using electronic forms that can be easily shared and updated by many different health care providers.
The problem the MMS hopes to solve is to address the lack of a standardized set of basic patient information containing the most relevant facts about a patient's condition. Working together with its colleagues at the Health Information Management and Systems Society (HIMSS), the AmericanAcademy of Family Physicians (AAFP), and ASTM International, the MMS recognizes this as an issue that can only get worse as the number of patient referrals to specialists continues to grow.
The need for more transportable patient records is rooted in a deeper national problem of medical computer systems that don't communicate with one another. Although many larger U.S. health care organizations have installed electronic medical record (EMR) systems, those systems often use proprietary file exchange formats. Meanwhile, only 5 to 10 percent of physicians use any kind of EMR in their own office practice. Many resort to handwritten notes when referring patients from one provider to the next.
Both incompatible computer systems and filling out labor-intensive forms contribute to medical errors. A 1999 report from the Institute of Medicine (part of the U.S. National Academy of Science) cited errors as the primary cause leading to an estimated 44,000 to 98,000 U.S. deaths each year, at an added annual cost of U.S. $2 billion. A follow-up report issued in 2003 recommended that health care organizations reduce errors by adopting IT systems that can collect and share patient information.
Solution
The CCR's origin can be traced to the three-page Patient Care Referral form developed years ago by the Massachusetts Department of Public Health and still in use today. "Filling out this form on paper is a huge pain for every doctor," says Doctor Thomas E. Sullivan, a well-known Boston-area cardiologist and President of the Massachusetts Medical Society. Still, Dr. Sullivan says the form has been successful because so many health care facilities in Massachusetts use it.
By late 2002, Dr. Sullivan's experience with this form and his growing belief in XML as the best way to exchange information among incompatible systems came together in what would soon become the Continuity of Care project. "I realized several years ago that XML was going to be like a Rosetta stone, in that you can create one set of data and then translate or use it in many ways," he says.
Then, in January 2003, Dr. Sullivan read that Microsoft was planning to introduce a new XML-based forms tool, code-named "XDocs," in the next Microsoft® Office release. Realizing that the tools needed to automate important paper forms were close at hand, Dr. Sullivan asked Ted Blizzard, the MMS Vice President of Information Technology and Chief Information Officer (CIO), to get an early copy.
Three days after receiving XDocs—the beta version of what would be released as the Microsoft Office InfoPath™ 2003 information-gathering program—Blizzard completed a working prototype of the CCR using all 250 fields of the tried-and-true Patient Care Referral form. The prototype even included various error-checking safeguards, such as drop-down boxes, to reduce data errors and enforce consistency.
"I turned the original Massachusetts paper form into an InfoPath form all on my own and in just a few days," recalls Blizzard. "But even then, we realized that in order for this new form to be used for transmitting data, it would have to be based on national standards."
Not content to use the CCR just as a proof of concept, Dr. Sullivan began to build alliances among other medical groups, IT vendors, and standards organizations. Hoping to make headway toward a national standard, Dr. Sullivan and Blizzard took the prototype to a major meeting of ASTM International, one of the largest standards development groups in the world. "They loved the idea," recalls Blizzard. "Their feedback was that we needed to involve more constituents, such as the AmericanAcademy of Family Physicians and HIMSS before they could turn this into a standard."
It soon became clear that the CCR had to work with other document standards before it could be widely adopted. This led Dr. Sullivan directly to Health Level Seven (HL7), the national group most responsible for developing health care messaging standards. Soon, the CCR would become closely coupled with the HL7's long-standing Clinical Document Architect (CDA) project.
Unlike the CCR, which aims to capture information in a single document for a specific purpose (patient referrals or transfers), the CDA provides metatags that health care providers can use to manage all their documents in an open, consistent, and standardized way. With the second major release of the CDA imminent, HL7 was looking for ways to highlight its work when the opportunity arose to work closely with the CCR. The teams behind both projects quickly saw the power and synergy in bridging the CCR's specific content requirements with the CDA's consistent metadata set expressed in XML.
"With the CCR, we have identified the requirements for standardization of a very important type of health care document," says HL7's Liora Alschuler, Co-Chair of the Structured Document Technical Committee. As it turns out, Alschuler's group was already immersed in a related project involving international patient referrals, so incorporating the additional specifications for the potential U.S. standard was timely.
Microsoft, a member of HL7, provides both coding help and consulting on the project. "Using the CCR's InfoPath form and schema as a head start, we're now well on our way to transforming the CCR's XML to the CDA," explains Roberto Ruggeri, Healthcare Technical Strategist for the Microsoft Industry Solutions group. "As the CDA continues to grow in popularity as a vendor-supported standard, this work will make the CCR better integrated with the overall health care ecosystem."
With feedback from the CCR's supporters now largely incorporated and CDA integration nearly complete, the form has grown from its original 250 fields to well over 1,000. What's also grown is the form's versatility and potential for adoption as a U.S. national patient referral or transfer standard sometime in 2004. Meanwhile, the combined CCR/CDA teams are working on a comprehensive demo to showcase the power and flexibility of open health care standards. The demo relies on XML, Web services, and the CCR to securely update and transfer a hypothetical cancer patient's records among various health care specialists. It will be unveiled in 2004 at the HIMSS Annual Conference and Exhibition in Orlando, Florida.
Benefits
The CCR lends support toincreasing the accuracy of medical records, reduces the opportunity for error, improves communication among caregivers, and gives doctors more time to do what they do best: treat patients. What's more, it cuts down on the time and paperwork associated with patient referrals and transfers and has the potential to reduce costs by avoiding duplicate tests. Compatibility with emerging XML document standards such as HL7’s CDA also helps to ensure future interoperability with systems from many EMR vendors.
Improved Continuity of Care
With many patient referrals still being processed by hand, mistakes and delays are inevitable as records are exchanged. By making current patient records more transportable between providers with incompatible health care information systems, the CCR reduces those risks by eliminating the need to transcribe and update medical records on paper.
Data already captured in InfoPath forms can be readily transmitted to other providers using Web services or secure e-mail. Alternatively, patients can carry their own summary in paper or electronic format. "The CCR provides the right information at the right time and for the right patient," points out the MMS's Blizzard. And Blizzard says that because the CCR can be linked to back-end Web services including knowledge repositories such as drug dosing and interaction databases, the opportunity to link with prescription-writing applications and help reduce medication errors is just beginning to be explored..
"From an efficiency and safety standpoint, it's a big timesaver," adds Dr. Sullivan. "Physician specialists save time by using the Continuity of Care Record, because it provides an up-to-date treatment history and list of current medications likely to be much more accurate and comprehensive than what patients themselves can recall." Patients can also spend more time in office visits describing their current condition without repeating old medical history and symptoms.
Reduced Costs
Although the CCR's primary purpose is to increase the quality of care in patient referrals and transfers, it clearly can help reduce health care costs as well. For example, cutting back or eliminating the need to send and receive paper transfer forms can substantially increase front-office productivity. "It costs on average something like $35 just to pull, reproduce, and send a patient's chart," says Blizzard, noting that the CCR can reduce this cost by automating the creation and updating of the transfer record.
Eliminating costs associated with redundant medical testing that has already been performed elsewhere is another potential CCR benefit. Additional cost savings may include:
Increased interoperability among disparate EMR systems with minimal or no custom programming required
Less reliance on standard or express mail services to transfer medical records
Reduced risk of legal exposure due to a lack of current or accurate patient information
Integration with Legacy Systems
Thanks to the MMS and its commitment to using open standards, the CCR has the potential to quicken the pace of EMR integration on a national scale beyond its intended purpose of improving U.S. patient transfers.
"The CCR is just a summary of a patient at one point in time. It's not intended to replace or compete with a full electronic medical record," points out Dr. Sullivan. "On the other hand, because many EMR systems still cannot communicate with one another, some of the vendors have seized on this small subset of data and the process we've used to bring this to a national standard as a proposed way for one system to talk to another."
Equally important, both large and small health care facilities stand to benefit. While big hospitals will be able to use the CCR and tools such as InfoPath to more efficiently integrate systems, independent practitioners and small doctor's offices should be able to at least partially automate patient records for the first time.
"Because physicians' insurance reimbursements are dropping, they don't always have the capital to invest in elaborate EMR systems," says Blizzard. "With the CCR and InfoPath, we hope to provide doctors with a standard document and a toolset to communicate critical health care information about patients to other health care providers at very little cost."
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