(The following excerpt is from A History of the University of North Carolina School of Medicine, edited by James Bryan II, MD)
In 1991, Dr. Robert Berger became a full time member of the faculty at UNC. Prior to this, for ten years Dr. Berger had been in private practice in Chapel Hill with a 50% appointment as a Clinical Professor at UNC where he was the director of the Arthritis Clinics and taught students, residents, and fellows. In 1984 when the first personal computers were developed, Dr. Berger purchased one of the first commercial electronic medical records (EMR) for $300 (off the shelf at “Computerworld”) that ran his private office for the next 7 years. It actually provided many of the capabilities of current EMR’s today. When he returned to UNC full time, he was dismayed that the institution had basically nothing in the way of even the most rudimentary EMR. All that was present was ‘lab terminals” on the ward services to look up laboratory values. Everything else was paper based.
This Clinical Laboratory Information System (CLIS) in the early 1980s was the first major hospital-based computer system with clinically relevant data. John E. Hammond, PhD, a clinical chemist with a faculty appointment in Medicine and Biochemistry, took a sabbatical at Duke to obtain a masters in computer science and was the Director of the CLIS in the Hospital Laboratories. He was instrumental in working with the hospital information systems to demonstrate that patient demographic data could be transferred in real time from the large hospital computer "mainframe" (which then was only used for the patient master file, billing and appointments) to a clinically oriented computer system. This was followed by the installation of lab terminals on the wards so that physicians could look up laboratory values, thus demonstrating that clinical data could be made available electronically for physicians in patient care areas. At the time in the 1980’s this was a major step forward in creating the first electronically available patient data system. Dr. William McClendon from the Dept. of Pathology and Medicine, the director of the laboratory, and a major leader in the institution provided the needed support to Dr. Hammond and to the institution for creation of the CLIS. Over the subsequent years, Drs. McClendon and Hammond continued their invaluable support to the iterations of the maturing WebCIS system as described below.
As a result of having only the lab system electronic, a patient being initially treated in the Emergency Department (ED), or outpatient clinics began their interaction with care providers from “scratch” until a paper chart was ordered and available. At best, the chart would arrive within 10-20 minutes in the ED and much longer in the clinics and approximately 15-20% of the time, the chart could not be located at all. The result, of course, was that the physician was “flying blind” sometimes with a patient they had been seeing for years and would have to ask things such as “refresh my memory as to what I saw you for last visit” and other frankly unprofessional and embarrassing questions that made the patients’ feel that their physician was incompetent. Likewise, “on call” providers receiving patient or other physician calls while at home or out of the hospital setting would have no access to the patient record and would have to “fly by the seat of their pants” and try to glean as much historical information as possible from the interaction on the phone, i.e. “Doctor I am taking a blue pill and a green pill that is new and I am sick now”.
Coincident with Dr. Berger’s return full time to UNC, the institution was finishing construction of a beautiful new Ambulatory Care center. Dr. Berger was placed in the leadership role of coordinating the operations of this new outpatient center. The timing was therefore ripe for UNC to get into the computer age. Berger’s goal was to have an EMR in existence for the opening of the Ambulatory Care Center scheduled for 1992 (as well as in all other areas of the institution). He convinced the then CEO of the hospital Mr. Eric Munson to fund the development of an EMR. A team consisting of three physicians (including Dr. Tim Carey from the Dept. of Medicine, Dr. Berger, Dr. John Hammond from the Dept. of Pathology and Medicine, and a surgeon, Dr. Robert Rutledge who is no longer with UNC), the associate director of Information Systems for the Hospital (Mr. John Kichak, now the Chief Information Officer of the UNC Health Care System), and five contracted programmers from IBM was formed. Within six weeks, they had a working version of an EMR. This was tested in several outpatient clinics, and within 4 months was placed in service in all outpatient and inpatient areas.
Over the next 20 years, the EMR became more and more robust with added clinical modules and changes in infrastructure as the world of computing changed. As an example, the EMR began by using OS2 (the old IBM operating system no longer in existence), converted to the different Windows versions as they were released, and finally in the year 2000, the application was made completely Web based, therefore requiring only a Web browser to access it. The system is compliant with all privacy laws, and has multiple layers of security and logging of “transactions” to prevent malevolent attacks from the outside world. The EMR received an award from the Computerworld organization in 2007 for innovation, and in 2010 was sold to the Siemens Corp. in a multi-million dollar transaction that benefitted both UNC and Siemens. Siemens is a multinational conglomerate that is one of the major vendors in the Health Informatics and Health equipment realm. It is their intent to commercialize WebCIS and sell it to their large medical institutions both nationally and internationally. Here at UNC it continues to be used by every member of the institution practicing clinical medicine, as well as many researchers, administrators, financial personnel and many others who do not have direct patient contact. A version exists for referring physicians to see only those patients who they have referred to UNC (for security and federal regulatory reasons).
As of the year 2010, WebCIS now includes data from 100,000 inpatient admissions yearly at UNC Hospitals, and 800,000 yearly outpatient visits to on-campus ambulatory centers of the UNC School of Medicine, and owned and affiliated remote outpatient facilities of the Health System. Users include 1500 faculty and affiliate physicians, 800 residents and postgraduate trainees, 320 upper level medical students, and 1000 nursing and ancillary staff members. Approximately 7000 client PCs in direct patient care or medical faculty office areas have the WEBCIS access. Since WEBCIS is an Internet based, HTML, Internet Explorer (IE) compliant application, with the appropriate HIPPA compliant security, it can be accessed from any IE based browser connected to the Internet anywhere in the world.
WEBCIS among many other things, contains the following basic patient EMR viewable data:
- Patient demographics
- All Laboratory and Pathology information
- All radiology reports including real time images through link to PACS archive
- Problem, Medication, and Allergy lists
- Complete Visit lists for both Inpatient and Outpatient episodes of care
- Text reports of History and Physicals, Discharge Summaries, Operative Notes, Outpatient Clinic Visits, and many other report types
- Cardiac Graphics, Peripheral Vascular, Pulmonary Laboratory, and Respiratory Therapy Data
- Inpatient, Outpatient, and Operating Room Schedule and Census Data
- Individual and Group patient lists that are user defined and annotated
- Direct Links to Web Based Reference Materials such as Medline, Textbooks, Drug compendiums, and other Educational software
- A comprehensive concise “Rounds Report” that can be printed out with data for 3-4 patients per sheet and used for rounding or check-out purposes
Interactive Areas of WEBCIS include:
- Direct entry of coded medications, allergies, and problem lists with ability to keep a dated, annotated, record of active vs. inactive entries in these lists.
- Ability to print new and refill prescriptions both electronically and by printed prescriptions is included in the medication module.
- Direct entry of coded vital signs and nursing notes at patient check-in the outpatient areas
- Specialty specific automatic alerts and reminders for Health Maintenance, Immunizations, and Disease Management
- Automated alerts, generated on a daily basis, to view completed ancillary tests (including radiology reports) that have returned for patients currently being treated as outpatients.
- Alerts to internal Physicians that their patients have been admitted as inpatients or have expired on the inpatient services.
- Attending Attestation Fields in electronic signature of Clinical Notes for Medicare patients
- A robust Activity (to do) List for every provider that includes electronic signature of all text based notes, with automatic routing (either by direct electronic transmission to internal providers, or by centralized immediate Fax to outside providers; Correspondence to internal physicians generated by the electronic signature above; notification of required patient care documents that are in a “delayed status” (either in their creation or their electronic signature)
- A “phone message triage” module that allows for routing, documentation, and permanent storage to the electronic record of patient care related phone calls.
- “Smart templates for quick creation of direct entered clinical notes, flow sheets, and growth charts (for pediatrics), secure patient EMAIL, and direct linkage (maintaining patient and user context) to the existing UNC Inpatient Computerized Physician Order Entry System (CPOE).
With WebCIS, along with our other Siemens products including CPOE, an Electronic Nursing module, an Electronic Medication Administration Record, and our newly constructed institutional Data Warehouse, UNC is almost completely paperless, and is well positioned to move into the new age of electronic information exchange between providers from other institutions and private practices, as well as with our patient population who have come to expect their medical care to be digital, just as the rest of their daily life has become so. WebCIS has and always will be a system developed from the “bottom up”, rather than from the “top down”. This means that the care providers at UNC have charted what the software does and have iteratively tested and made recommendations on each addition or change to the system. This is in contrast to many other institutions that purchase a vendor based product and are basically locked into whatever that system provides. After 20 years, Dr. Berger (as Chief Medical Information Officer) remains the architect and leader of our electronic medical record endeavors.