Primary care IT Manhattan style

Andrew Harrison, whose career change took him from computer programming to hospital medicine, continues his occasional series with some notes from a recent trip to the US where he visited a practice renowned for its celebrity patients and dynamic IT.

I have often wondered how America medical practices compare to those in the UK with respect to IT. To find out I visited Yaffe Ruden & Associates, a primary care practice in Manhattan, renowned for celebrity patients and dynamic usage of computer systems.

Dr Ronald Ruden explained some of the issues currently faced by American doctors. Health insurers are applying increasingly intense pressure for doctors to cut costs. Furthermore they no longer pay 100% of a patient’s bill, therefore patients also apply this pressure. And there is an ever-rising level of litigation, which makes professional indemnity premiums exorbitantly high.

Facing these pressures Dr Ruden sees good IT systems as fundamental to increasing efficiency without compromising the quality of care. The practice uses the Millbrook system for managing appointments and automated billing. Patient clinical data such as test results and treatments are stored in the Logician EPR system. More importantly the practice has three full-time programmers on site (compared with only five doctors).

Chief programmer Bill Hobrecht explains that Millbrook and Logician are good systems but they were produced by different vendors, so his team has had to write software interfaces between them. Billing is now automatic depending on what is in the EPR.

Another interfacing issue concerned blood results, which come from four different labs, each having a different syntax. He looks forward to the day when lab results are all presented in a standard format, such as LOINC codes delivered in HL7 messages.

He also designed the practice website[l1] [l2] , which allows patients to request appointments, update their own contact details, provides information about the practice and gives links to medical information sites. A new feature allows patients to type in their own description of a presenting complaint and medical history, before visiting the practice.

 During the consultation the doctor can then run through what has been written, asking additional questions. The doctor adds comments, and all the information is passed to Logician. Initial trials of this feature have been encouraging and terminals will soon be installed in the waiting room, for patients who have not entered their history from home.

Looking to the future Bill Hobrecht hopes to make further use of available coding standards. The American system for recording a consultation breaks it into four sections: Subjective view, Objective view, Assessment and Plan.

He hopes that all consultations will soon be recorded electronically using SNOMED codes for the Objective view, ICD9 codes for Assessment and CPT codes for the Plan. With this in place his ambition is to develop software which will read the EPR and check that the codes for each stage are consistent. When they are not, it will highlight the possibility of incorrect treatment.

If the website’s history-taking software proves effective, he dreams of developing his own set of codes to standardise the Subjective view.

Clearly Yaffe Ruden & Associates have successfully solved that fundamental problem of advanced medical IT systems: implementation. They have done so by having doctors who are extremely enthusiastic about using computers, and by employing determined IT specialists who are excited about the contribution they can make to healthcare. With these attitudes, the specific technical problems, particularly the omnipresent one of interfacing different systems have been relatively easy to solve. And they have been able to develop their own pioneering software tools.