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Converting to Electronic Health Records: fits and starts

The people of the United States are finally pulling together around the
goals of reducing health care costs (by far the highest per capita in
the world) and improving outcomes (we have the worst health of any
developed country). Everyone seems to recognize the critical
importance of data and communications in these efforts. So several of
us at O’Reilly Media, having been involved with information
technologies for some time, are tracking the issues that come up in
deploying computer technology in health care–not just to streamline
payments, not just to facilitate access by doctors to records, but
actually to create new ways to deliver and track health care.

I recently attended a forum on how my state, Massachusetts, is
facilitating the move to Electronic Health Records, a prerequisite for
many things doctors, patients, and insurance companies can do to
improve health. It’s notable that the chief sponsor of the event, the

Massachusetts Health Data Consortium
,
derives a lot of its support from insurance companies. Lots of invective has be
en
thrown at these companies recently, but the questions of technology
can pull together the insurers, providers, and patients in a common
quest.
[AO: My original blog said that insurance companies set up MHDC,
but this was incorrect.]

My own understanding of the progress and frustrations in deploying
heath care technology was enhanced by the conversations I had that day
and the statistics bandied about.

Smallness is not nimble

Small doctors’ offices went along with other industries and services
in the 1970s and 1980s by computerizing–but certain parts stayed in
the 1960s. So now, the big stumbling block that doctors face–adapting
their workflows to computerization–is reminiscent of the problems
other industries had in the 1970s and 1980s.

A typical scenario in those other industries was to use the waterfall
development model (or something even less structured) and setting
aside a requirements phase during which managers confidently told
application designers, “This is our workflow.”

OK, requirements phase over and done with. The applications were
deployed, and it turned out that hundreds of little things the line
staff did every day were left out of the workflow. In other words, The
official workflow that the manager knew about was not rich and subtle
enough to encompass reality.

Doctors are more aware than those managers of how hard it is to
formalize their workflows, but the mismatch between current practice
and computer ideal is just as great. I can understand doctors’
reluctance to install electronic systems because in their work, more
than most, when one standardizes their data ands fit their
observations to the structure of the electronic record, lots can
easily get lost in translation. Not only is every patient and every
symptom a bit different, but every doctor is different in the manner
of observing patients and recording results.

It would seem, therefore, that the unique individuality of the
doctor–as well as the patient–would make digitization of records a
problem that was independent of the size of the provider’s
organization. But still, some aspects of conversion are easily when
it’s done on a large scale. Thus, speakers at the conference suggested
that the biggest barrier to adoption is the fragmentation of medical
practices.

According to the president of the Massachusetts eHealth Collaborative,
Micky Tripathi, 80% of US medical practices consist of just one or two
physicians, and small practices handle 90% of all outpatient visits.
Given the difficulties of electronic record conversion and the
reluctance of doctors to put in the effort, only 1% of these practices
currently use electronic health records.

I suppose that small practices may improve care the way small
restaurants cook more gourmet food, but the structure of medical
practices clearly reduces efficiency. But electronic records hold out
hope as well. Doctors can use computer technology to accommodate their
preference for small practices.

The division of the industry into tiny segments also increases the
risk of lost records (especially when they’re on paper, but even
electronically). Forum speakers said the patient must ultimately be
the steward of his or her own records.

It’s great when a new practitioner can start up an office tightly
oriented around electronic health records. Converting an existing
paper-based site is much harder. And I wonder whether EHR proponents
are willing face the cost (in time as much as money) of training.

Issues arise when large institutions adopt electronic records,
too. For instance, who gets control and the right to use the data, the
employer or the doctor who actually generates the data? As we’ll see,
resolving questions about who benefits are critical to adoption.

Always somebody else’s job

Tripathi made another impressive point: doctors don’t see the benefit
to them in digitizing. In fact, they see it as benefiting everybody
else but them. I think this is because they don’t know of any killer
app that would make the change not only desirable but indispensable.

This is the same reason Linux hasn’t taken over on the desktop, even
though its applications and interfaces are quite easy to use and
highly functional. Linux can do everything Windows does–but for the
average computer user, it doesn’t do anything more than
Windows does. After looking over the applications provided on a common
desktop distribution such as Ubuntu, one could well ask–why bother
switching?

In short, if a system just does the same thing as the one it’s
replacing–even if it does that thing more efficiently and with fewer
errors–it won’t generate enough excitement to drive adoption and make
adoption seem worth the pain.

The move to electronic records seems to have garnered support from the
leadership of all the important stakeholders: the medical profession
(as illustrated by the participation of the American College of
Physicians and Massachusetts Medical Society today), insurers,
governments, and patient advocates. But as I’ve mentioned, support in
the medical profession hasn’t penetrated to the grassroots.

I wonder whether doctors could be swayed by stories of promising
apps–such as the one used by the Army’s mCare Telehealth initiative
for Wounded Warriors suffering from Traumatic Brain Injury (TBI). As
described to me by Stuart Vaeth of Diversinet Corporation, which
created the mobile platform underlying the application, doctors can
use this little utility to remind soldiers to follow treatment plans.
Better health, fewer doctor visits, lower overhead–all in one small
app.

Another expert I talked to claimed that wouldn’t suffice. What doctors
need is to be offered an array of useful applications that are
guaranteed to work with the platforms they choose to install. This
suggests that standardization is even more important than is usually
thought, because it will create a platform for new applications. That
leads to my next point.

Government’s role

Without speaking about current health care bills, I’ll focus for a
moment on the medical part of the stimulus package, which suggest ways
government intervention can help fix health care.

First comes standard-setting. The most obvious role here is to promote
standards that ensure the different systems adopted by different
providers fit together. As reported by Ray Campbell, executive
director of the Massachusetts Health Data Consortium, the
Medicare/Medicaid part of the bill requires conformance to
requirements that will force conversion. God is still in the (yet to
be worked out) details concerning meaningful use.

Second comes actual investment. When up-front expenditures are high
and it takes years to recoup them, and especially when most sites are
small, somebody has to provide incentives. Campbell said the best
stimuli are actually up-front. In the case of the the American Recovery
and Reinvestment Act (ARRA) stimulus, the up-front stimuli aren’t even
direct cash bonuses (which make up the bulk of the stimulus, but after
conversion is complete and judged to conform). Rather, the up-front
stimuli are research centers that provide expertise to sites that want
to digitize.

Although I am still holding back on commenting about the current
health care bills, I should reveal that I worked on grassroots efforts
to pass the 2006 Massachusetts health care bill that inspired
others to push for the current efforts by Obama, Pelosi, and Reid.
With all its problems, the Massachusetts bill put all of us on the
line in this state to work together to solve our health problems.

So instead of fearing a takeover of health care by government (it’s
strange how Americans tend to view “government” as some homogeneous
monstrosity, like the mysterious obelisk in the movie 2001),
the public can view legislation as a way to stand together as a
country.

The one thing of which I am convinced is that we need to replace the
current adversarial model of allocating health money with a
cooperative one. Only if providers and patients get lots of data, and
are willing to use it creatively, can we lower costs.

It worked with the energy utilities. Until recently, they operated
under a simple model where the more energy the sold, the more money
they made. Regulators and utilities worked together to find new models
that rewarded them more for conservation than for consumption. Health
care is a more complex problem–more levers and pulleys to the system,
and subjects who face a diversity of diagnoses–but with all that is
at stake, we should find a way forward.

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  • http://ahier.net Brian Ahier

    A very thoughtful analysis Andy. There is another issue that particularly affects small practices, aside from the front loaded capital expenses, and that is the loss of productivity during implementation and training. A physician can expect to see fewer patients for at least six months when deploying an electronic health record system, possibly quite a bit longer.

    This is why the point you raise concerning the Regional Health IT Extension Centers is so important. We have yet to see exactly how these centers are going to function, and it seems the funding in this area may be insufficient. Also if these centers are all located in metropolitan areas, then the far flung small rural providers could be left out in the cold.

  • http://powdermoneky.blogs.com/ John Scott

    Read this article, best damn article out there:
    “After the needless death of his father, the author, a business executive, began a personal exploration of a health-care industry that for years has delivered poor service and irregular quality at astonishingly high cost. It is a system, he argues, that is not worth preserving in anything like its current form. And the health-care reform now being contemplated will not fix it. Here’s a radical solution to an agonizing problem.”
    http://www.theatlantic.com/doc/200909/health-care

  • http://praxagora.com/andyo/ Andy Oram

    Thanks for pointing to that David Goldhill article in the Atlantic, John. It should be read and debated because it appeared in a major publication, but I actually wasn’t very impressed with it. If you can find (in the print edition or online) the responses in the following issue of the Atlantic, you will see a compelling list of criticisms. I agree with Goldhill on one thing: giving patients more information about costs is good. After that, the proposals turn into a mess. The biggest problem with Goldhill’s proposal, in my opinion, is that if you read closely you can see he’s hedged his whole approach by leaving the old system in place for “catastrophe.” Come on! My catastrophe is your routine care. We’ll never figure out this way how to assign responsibility for costs.

  • Sam Penrose

    “The people of the United States are finally pulling together around the goals of reducing health care costs (by far the highest per capita in the world) and improving outcomes (we have the worst health of any developed country).”

    There is considerable evidence that the people of the U.S. are NOT pulling together around either of those issues. Read Ezra Klein et alia. The politics are too complex for a paragraph, but to oversimplify: the constituency for HCR does not see the issues at all the way the Dems leading HCR do. The latter are (sort of) doing what you describe.

  • Mark M

    All good stuff. I recently opened an account at keas.com after reading Steve Lohr’s October 6th NYT story about Adam Bosworth. So far, I’m impressed by what Keas is doing. Just got a blood test Friday and setup a link with Quest Labs via my traditional doctor’s office to import the results. I’m his first patient to try this. He’s somewhat old fashioned, which I like, but he’s also quite open minded and optimistic about this. Looking forward to discussing the Keas report with him. :)

  • http://alecresnick.org alec resnick

    Second comes actual investment. When up-front expenditures are high and it takes years to recoup them, and especially when most sites are small, somebody has to provide incentives. Campbell said the best stimuli are actually up-front. In the case of the the American Recovery and Reinvestment Act (ARRA) stimulus, the up-front stimuli aren’t even direct cash bonuses (which make up the bulk of the stimulus, but after conversion is complete and judged to conform). Rather, the up-front stimuli are research centers that provide expertise to sites that want to digitize.

    I’m not sure exactly what that entails, but I love the idea of the government managing or incentivizing the initial seeding of expertise. Is anyone familiar with historical examples that parallel something along the following lines:

    • sponsor research and development (among a community of developers–as opposed to a traditional contract) of a platform along the lines of WordPress or Drupal (that is, where basic functionality is shared, but customizability is a high priority)

  • perhaps contract a few, compelling applications or plugins (hooking into Quickbooks, for example)
  • subsidize hooking up developers with expertise in the platform with hospitals
  • Given that the cost of digitization is so high for most hospitals, this seems like it could be a good deal. I’m not so surprised that it doesn’t seem to be on the table yet, but I was wondering if there were _any_ historical examples of something similar (even outside of the domain of software)? i.e., the government helps to bring together a community of experts, encourages them to create something of broader value, and then plays a role in making their expertise useful to many.

  • Jenny

    Some of what holds back small medical practices is the complex implementation and training requirements. (I’ve developed custom training materials for 2 hospitals.)

    Most of the systems out there are huge, it would be like the corner store trying to implement SAP… Medical records are complex, insurance claims even more so, small practices need the medical record system equivalent of QuickBooks.

  • http://www.dirkstanley.com Dirk Stanley, MD, MPH, CMIO

    All great points! As a practicing physician who also works as a Healthcare IT professional, I was initially thrilled to read about ARRA/HITECH, and the attempt to set standards, cut costs, and improve patient care. Unfortunately, in the last few months, my support for ARRA/HITECH has ended. After looking at the “small-carrot-big-stick” payment/disincentive approach, the lack of industry healthcare interchange standards, the lack of national coordination of a health record, and quite frankly, the difficulties almost all smaller practices will have in achieving Meaningful Use, I’m afraid I can’t support this anymore. As much as I had high hopes for this plan, quite frankly, it now makes me very nervous.

  • http://smallbusinessbible.org/healthproblemsrelated.html K James

    Hi,
    There are many health problems related to different professions. An employee, at the time of employment, is briefed about most of the health problems related to their employment.

  • http://healthcareitstrategy.com paul roemer

    Great conversation. From a strategic perspective, I think the very existence of the Regional Extension Centers (RECS)is but another sign that there is no workable plan for a national rollout of EHR. There is a plan, a word I use reluctantly—there may be several. Several things surrounding the rollout exist that reinforce the idea that the plan is not operational—Meaningful Use, Certification, RECs—and these things exist as a series of band-aids in the hope they will enable the plan. These band-aids have been cobbled together over time and by different parties.
    There is no EHR Czar.

    There is no roll out czar. I defy anyone to present their work plan for how this ties together and show where these add-ons are on the plan.

    Back to RECs. Similar format to Healthcare Information Exchanges (HIEs). Political in their origin and format. Carte blanche in terms of how they are built, what they will deliver, how they relate to HIEs and standards, and how the quality of their output will be measured. Five hundred and ninety-eight hope this helps million dollars. Has anyone sought out the credentials of those running the hope-this-works RECs? Does anyone doubt that they don’t have the experience to make these of any value? Where’s the national REC work plan? The individual work plans?

    Who likes the REC idea? The payors. Regionally deployed and state authorized, the payors have more than a vested interest in helping the healthcare providers in their region with their EHR efforts.

    This is another lipstick on the pig effort. By now, the pig is just about covered with lipstick. Does it make it a better pig? Of course not, it just makes it red.

  • http://www.practicefusion.com Glenn Laffel, MD, PhD

    Andy:

    Congrats on this thoughtful article and the discussion it has generated.

    One thing that was overlooked however, is that Web-based EHRs–the new kids on the EHR block– offer great hope for overcoming some of the biggest problems you raised with respect to getting these tools out to the majority of physicians who practice solo or in small groups.

    Certainly they eliminate the major barrier to date for this group…which has been cost. In fact, we offer our EHR to physicians for free. There are no fees for licensing, training, support or updates.

    Turning to the workflow design issues you raised, Web-based EHRs offer a potential breakthrough here as well. Our Web-based platform facilitates very rapid versioning of the system…we actually release new versions about twice monthly, and the releases, of course, go out to all 22,000 users instantly.

    Please note that these updates are based on direct feedback from our physicians, who are constantly suggesting ways our EHR can be tweeked to help them save time.

    There is nothing more rewarding for a physician than to see her suggestion quickly accomodated by the architects of the system she’s using, and of course these contributors know they are helping the entire community of EHR users, not just themselves.

    Thanks,
    Glenn Laffel, MD, PhD
    Sr. Vice President Clinical Affairs
    Practice Fusion
    http://www.practicefusion.com
    Free, Web-based EHR

  • http://www.linkedin.com/in/anthonyguerra Anthony Guerra

    Nice commentary. My analysis leads me to believe that healthcare will be a services provided only by mega-sized practices and hospitals in the future. With healthcare IT, and other quality initiatives, coming down the pike, the infrastructure required for compliance will be more than a one or two doc practice can handle.

    In response to Brian’s comment, I believe the RECs are a disaster in progress, and will turn out to be a HUGE waste of taxpayer money. I’ve argued as much here:

    http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&nm=&type=Blog&mod=BlogTopics&mid=67D6564029914AD3B204AD35D8F5F780&tier=7&id=34BDB9AE70BA4E7EB0BD0A0D8ACD9823

  • Ben

    An interesting article. I do have a question, though. You begin by saying that the US has the highest health costs per capita in the world and the worst health of any developed country. But do you think that the main source of these results is a lack of computer technology in healthcare? Are other nations ahead because their providers and their patients get so much more data than the providers and patients in the US?

  • http://www.dirkstanley.com Dirk Stanley, MD, MPH, CMIO

    This is, really, a great discussion.

    I can only say that no matter what we do from a technical standpoint, a lot of medicine isn’t ready from the cultural standpoint.

    Medical culture is a weird creature, that not a lot of people understand. (I’m sure Glenn above can attest to this.) Docs, historically, have been used to people “compensating for them”, for example :

    1. A doc writing a script for Percocet (1) tab PO QID PRN instead of Percocet (1) tab PO q6h PRN pain.
    2. A doc writing for “regular diet” instead of “Regular diet, dysphagia level I, nectar thickened liquids.”
    3. A doc having weeks to co-sign their verbal orders.
    4. A doc writing “Vanco 1gram IV x1 STAT” instead of “Vancomycin 1 gram in 250mL 0.9% NS run over 2 hours at a rate of 125mL/hour”
    5. A doc writing “Heparin protocol” in the pre-EMR world, versus an electronic order for “Heparin protocol” where *all of the teammembers know what to do*.
    6. A doc choosing an EMR because “It’s the best for me” versus “It’s the best thing for my patient”.

    These are the hidden implementation costs. Training docs to think along these lines is important, but nobody has a clear training plan on how to change this medical culture.

    This is why, some people look at OpenVista as the solution – IMHO, putting OpenVista into a private hospital will not produce the results it does in a VA hospital. Docs need to understand there will be compromises, and they need to buy-in to those compromises, before any migration to EMR will work.

    Technology only works if the culture supports it.
    I can tell you there are still a LOT of cynical docs out there who are quick to try a solution, and if it doesn’t work the first time, they lose faith.

    Again, I wish things were different, but as a practicing physician who sees a lot of different medical computing environments (ICU to private office), I’m really concerned about the implementation plan here.

    Finally, I agree, we do need an EMR Czar, or a “rockstar” who will talk about these things openly to help change the culture to be more supportive of technology. The problem is that to talk about it openly would mean having frank discussions that a lot of people don’t want to hear yet…

    - Dirk ;)

  • http://ahier.net Brian Ahier

    Anthony may be correct on the Regional Extension Centers and their effectiveness or lack thereof. I am very concerned at the lack of transparency on exactly what their role is going to be and how their ongoing operations are going to be funded. We are basically creating a new agency with stimulus funds that is going to need substantial additional outlays in the coming years.
    Once the RECs are in place, you will never be able to shut them down because practices will be wholly dependent on them for support. To think they could just come in and help implement the EHR and then drop the clinicians on their head is sheer fantasy. These organizations will need to be around for many years to come, and since they are private corporations spending taxpayer money, fraud and abuse will certainly be a concern. Where will the accountability be for these 70 different contracted organizations for how the funds are disbursed? This is one area of ARRA funding that we will not see much detail on recovery.gov

  • http://healthblawg.typepad.com David Harlow

    Dirk, Your point about medical culture is well-taken. Implementation of EHR systems cannot begin with the installation of the software (or the hookup to Glenn’s SaaS system). It’s a journey, beginning with a good reason to start the trip. It may be demonstrated to physicians that there are benefits to them and their patients that may be realized by making this transition, but small physician practice adoption of EHRs is not the only change that has to be made. As Andy noted in the conclusion to this post, chief among other changes to be made is reimbursement for physician services. Since, no matter what we say, humans respond mostly to monetary incentives, there needs to be a systemic rejiggering of economic incentives before any EHR implementation can be expected to work. HITECH Act incentives for EHR implementation are nice, but insufficient. Payment reforms that re-orient medical practice away from fee-for-service models and towards models that better incentivize preventive care and health maintenance (medical home, global payments, etc.) — and that can be better enabled by meaningful use of EHR systems — will be the level necessary to motivate providers to move down this path. Once the decision is made to begin the journey, there are, of course, a whole host of changes and modifications to existing practices that must be made — ranging from the way in which orders are written, to broader administrative issues like workflow in an individual physician’s office, to improved interconnections with other parts of the health care system (e.g. in order to provide case management services in a cost-effective manner to patients of a small physician practice).

    David Harlow
    The Harlow Group LLC
    http://healthblawg.typepad.com

  • http://www.dirkstanley.com Dirk Stanley, MD, MPH, CMIO

    Isn’t it frustrating :
    [This is the "baby steps first" approach] -

    1. If we just created Hotmail accounts for every patient -

    2. And every doc and nurse did all their documentation in the hotmail account -

    3. We could potentially save enough to give another 50 million people medical care, without spending another penny?

    (Obviously, we don’t do this for a lot of legal, financial, and political reasons…) But anyway…

    What a great discussion. There are some big industry people on this site – Great to hear everyone’s opinion.

  • http://praxagora.com/andyo/ Andy Oram

    Thanks for all the fascinating and well-thought-out responses.

    Several people criticized the stimulus package, which came in for some
    (less ardent) criticism in the forum I attended as well. Anthony, it
    sounds like you’re pointing to two issues in your blog.

    First, it might have been better for the bill to mandate open,
    standards-based systems and see what happens instead of requiring
    “meaningful use,” which doesn’t give much guidance.

    Second, the goal of deploying new systems is good, but seems to be
    pushed too fast. We need time to figure out what we want, time to
    train IT people, and time to train doctors and other end-users.

    In answer to Ben: my first paragraph was just reminding everybody that
    health care is a problem to solve. No, I don’t believe other countries
    achieve better results because they provide data. But I do think,
    starting where we’re starting in the US, we need better data–more
    standardized, transmitted more quickly, in a form ordinary can
    understand, and still secure–to fix our problem. I think David
    Harlow’s comment was making a similar point.

  • http://www.patagoniahealth.com Abhi

    You mentioned standards in passing. I think that is very important.
    Think back to 80s and computers. Adoption was low because there was limited things you could do with it. As Internet connected these PCs together, the growth exploded, because you could do so many things with them.

    Similarly, small practice physicians are the end-points, who are not digitized and not connected to the health Internet.
    Connect them all together (considering privacy issues) and now it is suddenly so much more powerful for both doctors and the patients. I don’t have to worry about carrying my records under my skin. This is the killer app!

    Though to achieve this there have to be communication standards. Good news, there are standards. Bad news, way too many standards. An EMR vendor has to write several interfaces (CCR, CCD, HL7, NCPDP, plain CSV, non-standard XML etc.) to get basic communication going. Health IT industry has to get it’s act together and achieve common standards.

    Abhi

  • Anonymous

    I have seen shoddy records systems shoved into production that do not work, do not adhere to any
    standards (that shift yearly) and do not exchange information with any other systems.

    I have seen systems that function more as insurance payment systems and money extractors rather than patient record systems. I have seen systems filled with garbage and errors without any method or responsibility to fix patients records.

    Plunge on into the electronic paradise and keep paying for bad systems. As an administrator of these systems I think it is too bad peoples lives depend on this stuff, I just shut my mouth and take my 20 pieces of silver, yeah, its a living.

  • http://ahier.net Brian Ahier

    I can swipe my bank card in a city on the other side of the country to buy a hot dog on a street corner safely and securely. When I go to another doctor in the next town, my medical records must faxed (just like 20 years ago). The healthcare industry needs to provide portability of health data. Consumers are going to demand it, and those that can’t keep up will be left far behind. For a glimpse of the future check out Hello Health

    http://hellohealth.com/

  • http://philippe.ameline.free.fr/index_en.php Philippe Ameline

    Andy,

    Nice article; the actual questions are asked.
    Some hindsight from France… for possible answers.

    As you pointed out, information technology doesn’t bring so much for old medical practice. New services could open the door to new paradigms of care… and self justify their use.

    Looks like the usual hen and egg problem.

    All short term money worsen it since it can only feed “usual suspects” who deliver old on the shelf softwares.

    French DMP (Dossier Médical Personnel for Personal Medical Record) is a typical failure: short term political goals led to ask big consortium to deliver several million records within 2 years… having all innovative actors starve.

    2 years later there was nothing but a new technocrat team starting from scratch to prepare the next plan to deliver several million records within 2 years (having all innovative actors know they should migrate “elseware”).

    Either pray for having less stupid technocrats (but they will, for sure, as in France, be the “Puzzle Makers” of the old paradigm well described by Thomas Khun) or think out of the box!

  • wikiderm

    The people of the United States are finally pulling together around the goals of reducing health care costs (by far the highest per capita in the world) and improving outcomes (we have the worst health of any developed country). Everyone (all those financially incentivized folks at the conference) seems to recognize the critical importance of data and communications in these efforts. So several of us at O’Reilly Media, having been involved with information technologies for some time, are tracking the issues that come up in deploying computer technology in health care–not just to streamline payments, not just to facilitate access by doctors to records, but actually to create new ways to deliver and track health care.
    I recently attended a forum on how my state, Massachusetts, is facilitating the move to Electronic Health (Uh, these are records of Disease, not Health – but Electronic MEDICAL Records seems like a reasonable saw-off) Records, a prerequisite for many things doctors, patients, and insurance companies can do to improve health. It’s notable that the chief sponsor of the event, the Massachusetts Health Data Consortium, derives a lot of its support from insurance companies. And why do insurance companies LOVE EMR? The biggest reason is that it slows down the delivery of care while not slowing down the collection of premiums. Some carefully researched papers show a 30% decrease in productivity in the first two years of implementation. BDOs (Benefits Denial Organizations) will have slower throughput, fewer admissions, fewer lab tests, all leading to fewer claims as a result of systemic strangulation – and the BDO doesn’t get blamed the way it did when HMO became a dirty word. Great idea, slow down the claims by creating waiting lists – the Canadian solution done the American way. Lots of well-deserved invective has been thrown at these companies recently, but the questions of technology can pull together the insurers, providers, and patients in a common quest. There IS NO COMMON QUEST. Patients want care. Doctors want to give care. Insurers want to make as much money as possible. They DON”T care. [AO: My original blog said that insurance companies set up MHDC, but this was incorrect.]
    My own understanding of the progress and frustrations in deploying heath care technology was enhanced by the conversations I had that day and the statistics bandied about.
    Smallness is not nimble
    Small doctors’ offices went along with other industries and services in the 1970s and 1980s by computerizing–but certain parts stayed in the 1960s. So now, the big stumbling block that doctors face—“”adapting their workflows to computerization”” (Uh, this is totally backwards, which is, DUH, why it isn’t working)–is reminiscent of the problems other industries had in the 1970s and 1980s.
    A typical scenario in those other industries was to use the waterfall development model (or something even less structured) and setting aside a requirements phase during which managers confidently told application designers, “This is our workflow.”
    OK, requirements phase over and done with. The applications were deployed, and it turned out that hundreds of little things the line staff did every day were left out of the workflow. Exactly In other words, the official workflow that the manager knew about was not rich and subtle enough to encompass reality. And nobody with boots on the ground was asked for their input. BTDT (Been there, etc)
    Doctors are more aware than those managers of how hard it is to formalize their workflows, but the mismatch between current practice and computer ideal is just as great. I can understand doctors’ reluctance to install electronic systems because in their work, more than most, when one standardizes their data ands fit their observations to the structure of the electronic record, lots can easily get lost in translation. Not only is every patient and every symptom a bit different, but every doctor is different in the manner of observing patients and recording results. And plugging everything into a fully knowledgeable database is impossible until a universally accepted medically omniscient database structure is created, capable of being modified, updated even hourly as new knowledge hits the ether. We are talking medical neural network here, really, not ‘records’.
    It would seem, therefore, that the unique individuality of the doctor–as well as the patient–would make digitization of records a problem that was independent of the size of the provider’s organization. But still, some aspects of conversion are easily when it’s done on a large scale.Oh, sure, tell that to the folks who underwrote Kaiser Thus, speakers at the conference suggested that the biggest barrier to adoption is the fragmentation of medical practices. Bushwah! It is the fragmentation of the IT industry. We need a SINGLE UNIVERSAL PROGRAM. There is no need for cross-talk BETWEEN PROGRAMS with a single program – that of course is not something the IT industry will tell you.
    According to the president of the Massachusetts eHealth Collaborative, Micky Tripathi, 80% of US medical practices consist of just one or two physicians, and small practices handle 90% of all outpatient visits. Given the difficulties of electronic record conversion and the reluctance of doctors to put in the effort, only **1%** of these practices currently use electronic health records. Want to know why?
    Suppose you are a busy family doc. You bill $300,000 and have a 50% overhead, so you take home a taxable $150,000. So you get, installed free for this calculation, a nice new EMR system. Your productivity drops by 30%. That 30% ($90,000, remember – 30% of the original $300,000) comes out of YOUR $150,000, so take home drops to $60,000. Cool, Eh?
    I suppose that small practices may improve care the way small restaurants cook more gourmet food, but the structure of medical practices clearly reduces efficiency. But electronic records hold out hope as well. TOTAL POPPYCOCK!!
    Doctors can use computer technology to accommodate their preference for small practices.
    The division of the industry into tiny segments also increases the risk of lost records (especially when they’re on paper, but even electronically). Nonsense – MGH loses stuff every day – I haven’t lost a chart in years!! Forum speakers said the patient must ultimately be the steward of his or her own records.Like in India – they take their records home – WRITTEN records. Cool, huh?
    It’s great when a new practitioner can start up an office tightly oriented around electronic health records. PCPs cannot afford to do this – that is why they wind up employed by hospitals who can then make a bundle on the labs and investigations they order. Converting an existing paper-based site is much harder. And I wonder whether EHR proponents are willing face the cost (in time as much as money) of training. The answer is in that 1% above – and the answer is “NO”.
    Issues arise when large institutions adopt electronic records, too. For instance, who gets control and the right to use the data, the employer or the doctor who actually generates the data? Legally, the doctor as creator OWNS the records, the patient has legal accss to a copy, and the hospital is merely the caretaker but also has a right to a COPY. As we’ll see, resolving questions about who benefits are critical to adoption.
    Always somebody else’s job
    Tripathi made another impressive point: doctors don’t see the benefit to them in digitizing. In fact, they see it as benefiting everybody else but them. I think this is because they don’t know of any killer app that would make the change not only desirable but indispensable. So let’s get IT to work on that killer app instead of fighting over market share.
    THIS IS A MARKET THAT WILL NOT BE SHAREABLE. But none of them wants to believe, understand or face that reality.
    This is the same reason Linux hasn’t taken over on the desktop, even though its applications and interfaces are quite easy to use and highly functional. Linux can do everything Windows does–but for the average computer user, it doesn’t do anything more than Windows does. After looking over the applications provided on a common desktop distribution such as Ubuntu, one could well ask–why bother switching?
    In short, if a system just does the same thing as the one it’s replacing–even if it does that thing more efficiently and with fewer errors–it won’t generate enough excitement to drive adoption and make adoption seem worth the pain. And of course if it does it WORSE (which IS the case), it is a tough sell, right? Only stupid docs would bother ‘investing’ in a liability. But we’ve been known as the worst investors in the world for a few decades, so why change now?
    The move to electronic records seems to have garnered support from the leadership of all the important stakeholders: the medical profession (as illustrated by the participation of the American College of Physicians and Massachusetts Medical Society today all charter members of the Electro-Medical Optimist Society of America), insurers (slow ‘em down and rip ‘em off), governments (same – great way to cut Medicare spending – slow ‘em down), and patient advocates (also all charter members of the Electro-Medical Optimist Society of America). But as I’ve mentioned, support in the medical profession hasn’t penetrated to the grassroots.
    I wonder whether doctors could be swayed by stories of promising apps–such as the one used by the Army’s mCare Telehealth initiative for Wounded Warriors suffering from Traumatic Brain Injury (TBI). (OH, you gonna give us budgets like the Armed Forces? Dreamer!) As described to me by Stuart Vaeth of Diversinet Corporation, which created the mobile platform underlying the application, doctors can use this little utility to remind soldiers to follow treatment plans. (OK, that is the medical practice equivalent of Kindergarten and you think the same system can do the medical practice equivalent of astrophysics = neural networking? Better health, fewer doctor visits, lower overhead–all in one small (but hugely expensive) app (to do Kindergarten stuff.)
    Another expert I talked to claimed that wouldn’t suffice. What doctors need is to be offered an array of useful applications that are guaranteed to work with the platforms they choose to install. This suggests that standardization is even more important than is usually thought, because it will create a platform for new applications. That leads to my next point. Standardization is not ‘important’ IT IS THE ONLY WAY _- and all that stands in the way of standardization is the IT industry itself. Not a little thing, that. Pogo was right.
    Government’s role
    Without speaking about current health care bills, I’ll focus for a moment on the medical part of the stimulus package, which suggest ways government intervention can help fix health care.
    First comes standard-setting. The most obvious role here is to promote standards that ensure the different systems adopted by different providers fit together. BACKWARDS BACKWARDS BACKWARDS BACKWARDS As reported by Ray Campbell, executive director of the Massachusetts Health Data Consortium, the Medicare/Medicaid part of the bill requires conformance to requirements that will force conversion. God is still in the (yet to be worked out) details concerning meaningful use.
    Second comes actual investment. When up-front expenditures are high AND IMPLEMENTATION MEANS TAKING A HUGE HIT and it takes years to recoup them, and especially when most sites are small, somebody has to provide incentives. YOU COULD NOT PAY ME ENOUGH TO ADOPT ANY ONE OF THE PRESENT EMR SYSTEMS – UNTIL YOU CAN DO IT WITHOUT SLOWING ME DOWN. Campbell said the best stimuli are actually up-front. In the case of the the American Recovery and Reinvestment Act (ARRA) stimulus, the up-front stimuli aren’t even direct cash bonuses (which make up the bulk of the stimulus, but after conversion is complete and judged to conform). They offer a maximum $41,000 carrot to get a GP to take a $90,000 hit for each of the first two years, if the system, maintenance, and training are provided FREE in the above example. Rather, the up-front stimuli are research centers that provide expertise to sites that want to digitize. Want to?? You gotta be dreaming in Technicolor®!
    Although I am still holding back on commenting about the current health care bills, I should reveal that I worked on grassroots efforts to pass the 2006 Massachusetts health care bill that inspired others to push for the current efforts by Obama, Pelosi, and Reid. With all its problems, the Massachusetts bill put all of us on the line in this state to work together to solve our health problems.
    So instead of fearing a takeover of health care by government (it’s strange how Americans tend to view “government” as some homogeneous monstrosity, like the mysterious obelisk in the movie 2001), the public can view legislation as a way to stand together as a country.
    The one thing of which I am convinced is that we need to replace the current adversarial model of allocating health money with a cooperative one. YES. Stop having us fight with the *%^& insurers. Are you happy that 10-20% of your “health care” dollars are used to provide road blocks to your care. Have YOU ever spent a half hour on the phone in the phone maze fighting for a patient’s right to the care he paid good money for? It is soul-destroying. Only if providers and patients get lots of data, and are willing to use it creatively, can we lower costs. EMR produces REAMS UPON REAMS of USELESS information in its present state. This is CHAFF record-keeping, and digging out the kernels of wheat takes TIME – BIG TIME TIME! 30% added onto your day TIME. Some docs take it home and do it UNPAID. On their OWN time. Their family’s TIME. Their KID’S time.
    Their DOWN time. It all adds up to BURNOUT. Not a good thing.
    It worked with the energy utilities. Until recently, they operated under a simple model where the more energy the sold, the more money they made. Regulators and utilities worked together to find new models that rewarded them more for conservation than for consumption. Health care is a more complex problem–more levers and pulleys to the system, and subjects who face a diversity of diagnoses–but with all that is at stake, we should find a way forward.
    There is another alternative – find a way backward. Come visit my office and see how it is done.

  • wikiderm

    Andy
    Send me an email address to which I can post you an attachment.
    There is so much in that blog that needed a response.
    I work in New Hampshire, private practice and teach at Dartmouth.
    Thanks
    F W Danby, MD FRCPC
    Adjunct Asst Prof of Medicine (Dermatology)

  • F W Danby

    You state “The Massachusetts Health Data Consortium, derives a lot of its support from insurance companies.” And why do insurance companies LOVE EMR? The biggest reason is that it slows down the delivery of care while not slowing down the collection of premiums. Some carefully researched papers show a 30% decrease in productivity in the first two years of implementation. BDOs (Benefits Denial Organizations) will have slower throughput, fewer admissions, fewer lab tests, all leading to fewer claims as a result of systemic strangulation – and the BDO doesn’t get blamed the way it did when HMO became a dirty word. Great idea, slow down the claims by creating waiting lists – the Canadian solution done the American way. And “the questions of technology can pull together the insurers, providers, and patients in a common quest.” There IS NO COMMON QUEST. Patients want care. Doctors want to give care. Insurers want to make as much money as possible. They DON”T care about care.
    And “the big stumbling block that doctors face”(is) adapting their workflows to computerization”” (Uh, this is totally backwards, which is, DUH, why it isn’t working)
    You note “Not only is every patient and every symptom a bit different, but every doctor is different in the manner of observing patients and recording results.” Plugging everything into a fully knowledgeable database is impossible until a universally accepted medically omniscient database structure is created, capable of being modified, updated even hourly as new knowledge hits the ether. We are talking medical neural network here, really, not ‘records’.
    And you suggest “some aspects of conversion are easy when it’s done on a large scale.” Try telling that to the folks who underwrote Kaiser’s, what. $2 billion fiasco?”
    You report that speakers at the conference suggested that “the biggest barrier to adoption is the fragmentation of medical practices.” Bushwah! It is the fragmentation of the IT industry. We need a SINGLE UNIVERSAL PROGRAM. There is no need for cross-talk BETWEEN PROGRAMS with a SINGLE program – that of course is not something the IT industry will tell you.
    Then we get to reality.1% of practices currently use electronic health records. Want to know why? Suppose you are a busy family doc. You bill $300,000 and have a 50% overhead, so you take home a taxable $150,000. So you get, installed free for this calculation, a nice new EMR system. Your productivity drops by 30%. That 30% ($90,000, remember – 30% of the original $300,000) comes out of YOUR $150,000, so take home drops to $60,000. Cool, Eh? A 60% drop in take-home, before taxes.
    Another thing “The division of the industry into tiny segments also increases the risk of lost records (especially when they’re on paper, but even electronically).” Nonsense – MGH loses stuff every day – I haven’t lost a chart in years!!
    And another “Forum speakers said the patient must ultimately be the steward of his or her own records.” Like in India – they take their records home – WRITTEN records.
    I wish it were true that “It’s great when a new practitioner can start up an office tightly oriented around electronic health records.” PCPs cannot afford to do this – that is why they wind up employed by hospitals who can then make a bundle on the labs and investigations they order.
    You observe that, “if a system just does the same thing as the one it’s replacing–even if it does that thing more efficiently and with fewer errors–it won’t generate enough excitement to drive adoption and make adoption seem worth the pain.” And of course if it does it WORSE (which IS the case), it is a tough sell, right? Only stupid docs would bother ‘investing’ in a liability. But we’ve been known as the worst investors in the world for a few decades, so why change now?
    You “wonder whether doctors could be swayed by stories of promising apps–such as the one used by the Army’s mCare Telehealth initiative for Wounded Warriors suffering from Traumatic Brain Injury (TBI).” Sounds like a great program. Are you arranging to give us budgets like the Armed Forces? Sure, “doctors can use this little utility to remind soldiers to follow treatment plans”, but that is the medical practice equivalent of Kindergarten and you think the same system can do the medical practice equivalent of astrophysics = neural networking? Better health, fewer doctor visits, lower overhead–all in one small (but hugely expensive) app (to do Kindergarten stuff.)
    I agree with the “expert (who) claimed that what doctors need is to be offered an array of useful applications that are guaranteed to work with the platforms they choose to install.” This is heading in the right direction. “This suggests that standardization is even more important than is usually thought.” Now we are getting there. Standardization is not just ‘important’ – IT IS THE ONLY WAY _- and all that stands in the way of standardization is the IT industry itself. Not a little thing, that. Pogo was right.
    Then you comment on standard-setting to “ensure the different systems adopted by different providers fit together.” This is totally backwards. We need to stop and start over.
    “Up-front expenditures are high”, I agree AND IMPLEMENTATION MEANS TAKING A HUGE HIT. YOU COULD NOT PAY ME ENOUGH TO ADOPT ANY ONE OF THE PRESENT EMR SYSTEMS – UNTIL YOU CAN DO IT WITHOUT SLOWING ME DOWN. Government offers a maximum $41,000 carrot to get a GP to take a $90,000 hit for each of the first two years, if the system, maintenance, and training are provided FREE in the above example. To the meat of the matter, you say “we need to replace the current adversarial model of allocating health money with a cooperative one. YES. Stop having us fight with the *%^& insurers. Are you happy that 10-20% of your “health care” dollars are used to provide road blocks to your care. Have YOU ever spent a half hour on the phone in the phone maze fighting for a patient’s right to the care he paid good money for? It is soul-destroying.
    And on data “Only if providers and patients get lots of data, and are willing to use it creatively, can we lower costs.” EMR produces REAMS UPON REAMS of USELESS data points in its present state. This is CHAFF record-keeping, and digging out the kernels of wheat takes TIME – BIG TIME TIME! 30% added onto your day TIME. Some docs take it home and do it UNPAID. On their OWN time. Their FAMILY’s time. Their KID’S time. Their DOWN time. Their REFLECTION time. It all adds up to BURNOUT. Not a good thing.
    You think “we should find a way forward.” There is another alternative – find a way backward. Come visit my office and see how it is done.

  • james O'Connor MD

    Andy, thanks for getting the ball rolling on this discussion of Electronic Health Records and their potential. As an Ob/Gyn in Chicago in the early 1990′s doing research in ovarian cancer, I said to my nurse, “why do we record the findings on paper and then sit at this IBM 286 (or whatever it was) and type the information in? We can build a form with this Lotus Approach thing (database) so we don’t have to stay past 6 pm putting data in. The light bulb went off: “I write the same findings again and again on paper notes about patient visits–I’ll use this same Lotus thing so I dont have to keep writing the same normal exams.” It was great: I could type the abnormalities out in free text and cookie cutter the rest.

    Then a series of events led me to some very smart doctors who built software that did so much more and was easy for me to use (I’m obviously an early adapter). I was just interested in focusing on the patient and not writing or dictating the same normal exam all the time. A pragmatist. The two doctors were from a company called MedicaLogic: Mark Leavitt MD PhD and Blackford Middleton MD PhD. They both knew the real world of the main specialty doctors of late night call and the pressure of being behind in seeing patients because some patient came in very sick and took time to get stabilized for transfer. And they knew a lot about software–something that was a mystery to me.

    Well. to make a long story short MedicaLogic liked what I did with their product, the large group I was in cut my clinic hours so I could get various specialties up on it…and then Ernst and Young offered me a full time job in 1997 with the same pay to help them with large healthcare systems wanting to use computers with patients. End result: I spend the last 10 years helping the U.S. Military with its EHR (1998-2002) which has not been a great success, mainly because the screen changes are slow. Then I was recruited to what then was called WebMD Practice Services. A Georgia Tech computer science guy named Gus and the founder of computerized billing (Mickey Singer–then CEO of that division) started in 2000 to design the next generation of EHR with three missions: 1) it had to capture charges instantly and sent it through the billing system with minimal human involvement 2) it had to be easy to use 3) it had to capture clinical data because I said that is how medicine will grow: patient data. The result: Intergy EHR now owned by Sage Software.

    Without going into boring detail I made myself on the last version which has some real cool innovation (version 5.5) go through the entire process from sale to full implementation with a willing group out in the UCLA area. Wow–it is a lot harder to get these systems working than I thought. The main problem is that the EHR software companies often have empty sandboxes for basic clinical content like note templates, procedure reports, tasks to your staff. YOU HAVE TO BUILD ALL THAT PLUS SCAN ALL THE PAPER AND CONNECT YOUR LAB SYSTEM AND HOSPITAL TO THE EHR SYSTEM. It is a hard task. What makes it very hard is that we couldn’t find a way to stop existing patients from coming over the wall. You have to keep delivering babies, or caring for flu patients even though you are in the middle of trying to go digital. As a result I spent 50% of my 2008-2009 budget on filling the sandboxes. That way the cardiologist or the orthopedic surgeon would have something they could use easier from day 1. So system configuration is key.

    But still, there is just too many screen flips and mouse clicks. So I know believe that EHRs will be truly successful (no fair just copying and pasting the same Hypertension note for every patient!) when we use large touch screens and speech recognition/Natural Language Processing so that the computer begins to help and fades out of consciousness, like the stethoscope to the cardiologist or the gyn ultrasound to the ob/gyn specialist. You can use complicated technologies by muscle memory. The oblong.com and 10GUI folks are right on track–it is not fun using 10pt font fields on a handheld tablet. But Sage has many successful practices who had doctors who filled the empty sandboxes and got better billing and better care for patients. But we as software innovators don’t hear from the 15% of the bell-shaped curve. It is the other 85%.

    Recently one of the lead oncologists invited me to the American Society of Clinical Oncologists EHR symposia. I won’t comment on how far that specialty is in adopting these systems. They had 8 vendors compete on the last day showing off their software. Four vendors were immature in the principles of graphical user design and four were pretty good. I can see progress. Then a company called Nuance had a breakthrough in 2007-20008 with its Dragon speech recognition. They let us at Sage try it out. WOW!!! It works with no training and with many different accents. The hardest two parts to capture in an EHR is the patient’s story of their current sickness (History of Present Illness) and the Assessment/Plan where the doctor documents what she or he thinks the diagnoses are and what treatment plan will be put into action. Dragon just made that easy in Sage IEHR. I forgot the computer. Up to that time you had to wear a stupid headset and it never could handle dictation well. Now with a clean Windows platform with 4 gigs and a decent EHR you just aren’t going to need to correct much…except the way we say, “uh, uh, yeah…”

    So as the National Coordinator of Health Technology Czar Dr. David Blumenthal says, usability is a major factor. And I agree totally (though I’ve been working on this for 10 years).

    But more than EHR, I think that most Americans simply don’t know what it is like to be in any of the major specialties, have your reimbursement drop while your overhead rises, and then have to use these EHR systems. If you spent a week with any of your busy doctors, especially on call, then the nation would get a better idea why it is so hard to adopt even a decent system when your job is to care for the sick.

    Jim O’Connor MD

    post note: Dr. Mark Leavitt continued on with his quest to get EHR systems that work and is the head of CCHIT, an organization that helping the federal government standardize all clinical systems so you will seldom ever have to fill in another paper form about your address and past history. Dr. Blackford Middleton moved to Boston and is working via the Partners organization on helping the current doctors and laying out the tracks to the future.

  • http://www.springmedical.com Emr vendors

    Yeah now people are realizing and reducing health care cost. Great article

  • Raja Seevan

    Benefits for Individual especially related to Healthcare

    The process involving Electronic Health Record (EHR) maintenance system for individuals, Doctors and Hospitals treating them has huge potential to serve rural population and urban poor since it improves efficiency and quality of healthcare at vastly reduced direct & indirect costs on several counts.

    Our innovative EHR system holds a great promise in revolutionizing the healthcare services delivery mechanism in our country in a short time span.

    Our EHR system (which includes Electronic Medical Record or EMR) can boost overall productivity and efficiency of healthcare services by promoting cost and time saving practices of Tele-medicine, Remote-consultancy and the like technology based services

    Timely and instant access to vital health data through and ones medical history through EHR system means reduced medical errors that can otherwise lead to expensive care. Access to patient’s images in an EHR is an effective way to avoid duplicating expensive imaging procedures and thus save wasteful expenditure.

    Any time, Any Place access through secure web-portal or 24/7 call-in service reduces time to referral or diagnosis leading to better efficiency in treatment.

    Armed with up to date medical history of self and dependant family members one can track important health parameters (like blood pressure, cholesterol, sugar etc.) regularly and take more responsibility to one’s own/dependants better healthcare especially in case of long-term and chronic illness cases.

    Data from electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management, and public health communicable disease surveillance-it also facilitates collection of data for epidemiology and clinical studies.

    Public Health authorities would also be hugely benefitted by availability of up to date accurate data in intelligent format that will lead them not only to more effective monitoring but also to bring about required changes with quick policy responses.

    We intend to take this socially oriented project to cover all especially the poor who get treated in Government and charitable hospitals-including rural ones.

    In this project of national importance we would be glad to seek ‘win-win’ model with any country.

    You can visit http://www.indiancst.in for more details and you can write to us for live demos of the product which is available as Software as a Service.

    With regards
    Raja Seevan

    email:rajaseevan@gmail.com

  • emr software

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