Thoughts on EHR Difficulties and Failures – #2

The transformational character of introducing an electronic health record (EHR) into an enterprise must be well planned and based on foundational work. Because an integrated environment is so interdependent, the absence of policies coordinating the building of interrelated modules and applications can lead to wasted effort and create rework once the unworkability or excessive cost of supporting the configuration is recognized.


Another aspect of dissipating effort and resources are the adoption of deadlines without having contingency plans that allow for the flexible deployment of the EHR to occur after it has successfully passed testing and user acceptance. Often the deadlines are linked to some other events whose prime focus in not the EHR. Similarly, an organization’s executive management must ensure that the project scope is maintained and vigilantly stop or downgrade unassociated projects or unnecessary scope creep.


Establishing the methods for change management (in the integrated environment), coordination and scheduling of build and testing environments, and establishing a sercurity model for user and application access can lead to signigicant simplification of security maintenance while safeguarding protected health information (PHI). Planning for the vetted release of information to indivuals and other healthcare providers should be addressed as part of the architectural design of the EHR. The trend line is that health information exchange (HIE) is becoming one of the main tentants of ARRA HITECH Meaningful Use requirements.

Getting the Images to the Emergency Room

Normally, attention is focused on workflows that provide the emergency department (ED) physicians with images and radiology reports in a timely fashion. There are a number of discrete workflows (including communications) that address the interplay of patient, radiology and the ED staff. This can usually be handled by fairly straightforward means using the available technologies.

Things get more complicated when an outlying emergency room needs to transfer the patient to a trauma center. Whether an ambulance or helicopter is used, it will usually take valuable time to get the patient to the new location, very often along with a CD/DVD or hardcopy films of radiology images that were taken in the initial ER. More time is then spent in re-evaluating the images and the patient.

If we leverage the Internet to securely transmit such images before the patient arrives at the trauma center, then surgeons and radiologist can evaluate, plan and prepare treatment ahead of the patient’s arrival. At Hennepin County Medical Center (HCMC), I set up VPN connections with a few of the top referring ERs. This allowed these facilities to send diagnostic quality Dicom images directly to HCMC where radiology, the ER, and the surgeons could review them. Since its inception, this service has been expanded to half a dozen referring facilities.

New Mexico has a system called IMEDCON (NMsoftware) that allows for instant digital file sharing without giving access to PACS. The system has been a success, allowing hospitals to manage head trauma cases without transfer. It is currently set up for 12 or so hospitals around the state to be able to share images with the regional Level One trauma center. A similar coverage system for stroke patients is currently underway.

As we move to expanding health information exchanges (HIE) we must also look at how we can quickly route such time critical data. Ideally the image set can be bundled into a single file using lossless compression and sent to the destination facility where it would automatically notify the trauma center of its availability. The facility would then open the study with their PACS tools and proceed with evaluating the incoming patient.