Easing shift from paper to computer

The physician was full of bluster, threatening to sue the software vendor that had landed his practice in a quagmire as it tried to convert from paper medical files to an electronic database.

"I'm feeling betrayed," he said last week, sitting in a crowded back office.

Office manager Liz Wiener listened, letting the sound wash over her as she slumped over a conference table.

Beth Schindele, Delaware's high-tech equivalent of the state agricultural extension agent, nodded her head in sympathy.

If ag agents work with farmers as they battle boll weevils, Schindele's focus is on other bugs: the debilitating glitches involved in trying to get new computer systems running in doctors' offices.

"It's hair-pulling," Wiener said, wearily. Schindele couldn't agree more.

For more than a decade, the idea of electronic medical records and the transfer of medical information among hospitals, doctors, pharmacies, and labs has been a beacon - a way, advocates say, to improve patient care, to flag dangerous drug interactions, to provide early warning of epidemics, to avoid costly duplication of tests.

If only the thing worked for Wiener's office even half as successfully as it had for other doctors' groups.

In the end, any big endeavor, in this case a $27 billion federal investment in the health-information-technology infrastructure, comes down to an office manager like Wiener coping with change on behalf of three doctors in a ranch-style house in Newark, Del.

Wiener needs help, and Schindele is the one who has to make it happen - her job depends on it.

For the most part, she has been remarkably successful. Her boss in Washington calls her a "rock star." That's because Schindele and her 18 staffers have made tiny Delaware the runaway national leader in moving physicians from paper to computers.

"A lot of it falls on personality and the individual's ability to get things done," said Kyle Nicholls, a U.S. Department of Health and Human Services project manager, who oversees 62 regional extension centers such as Schindele's in Delaware. "She gets it."

Schindele spent part of Wednesday driving to southern Delaware to personally congratulate several doctors and their staff for being early adopters of electronic health records. There were pictures and hugs.

The congratulations are part of a federal initiative under Nicholls' purview, designed to create peer-to-peer mentors to encourage other doctors, such as the ones in Newark, to follow suit.

These doctors not only buy the equipment, but they also have to figure out how to use all the bells and whistles to advance health care for their patients. For example, a doctor might use the software to generate a list of people with hypertension and then go over the list to make sure all of them are complying with their treatment plans.

Across the United States, there are 1,580 of these "Vanguard" doctors - an eye-opening 490 of them are from Delaware.

By comparison, there are just 165 in Pennsylvania and 27 in New Jersey.

Of the 62 extension groups nationally, only seven have met their doctor targets. Delaware was the sixth to do so, beating its 1,000-practitioner target by enrolling 1,021 out of 1,900 statewide.

Eventually the 1,021 will get up to $18,000 as a federally funded incentive to convert to electronic records. When pooled in a practice, the money can help finance the conversion.

Money talks, but Schindele has something else that gives her an edge.

Most extension groups are led by doctors, nurses, or professors, but Schindele's background is different. She started as a medical file clerk and advanced to practice manager before being recruited into this job. So when she visits an office like Liz Wiener's, she understands the dynamics.

Schindele knows about having to cope with the myriad insurance plans, the particular problems of patients, and, especially, the doctors who really don't want to think about computers, software, and medical records.

The docs want to take care of patients, and let the Liz Wieners of the world handle the details.

"I understand Liz because I used to be Liz," Schindele said. "I built my extension center based on that experience."

There are other reasons that Delaware is advanced.

Its small size made it easier for early health-geek apostles, among them some key politicians and hospital executives, to proselytize and fund the Delaware Health Information Network. The first such network in the nation, it allows the state's hospitals, labs, and pharmacies to trade patient medical history.

Doctors' offices are the missing link in creating seamless care throughout Delaware. That's Schindele's job.

To do it, she follows a few operating principles: First, work with the practices at their technical level, without judgment. "I've had to do Mouse 101," she said. "This is left click, this is right click."

Second is a staff assessment. The conversion is so expensive and challenging that a dysfunctional staff won't be able to cope. If Schindele detects a problem, she'll try to fix it, but if it's too toxic, Schindele won't take on the project of helping them convert their records.

Third is an all-level buy-in. "We always create a multidisciplinary team, from the file clerk to the nurse to the physician," she said.

Wiener's practice had all the right basics, but the office's billing system wasn't talking to the health-records system, even though the vendor had promised compatibility.

Thirty months of late nights and hand-wringing by Wiener, and the computers still couldn't reliably communicate. The conversion process was completely stalled.

From Schindele's perspective, it was time to switch to something different, but Wiener had put so much into it already, including $40,000 worth of equipment and software, that Wiener was reluctant to move on.

"In my business, you never give up on a patient," said Wiener's boss, Dr. William Funk, clearly frustrated. "When you are a computer person, when are you willing to decide when to quit?"

Schindele prescribed a visit for Wiener to an office where an alternative system was working well. Schindele promised that either she or one of her staff would stop by weekly until the systems worked.

"We're the local boots on the ground," Schindele said. "We are with the physicians, holding their hands."