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Moving forward with electronic health records

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electronic health records stimulus progressNEW YORK—Almost a year since President Obama signed the American Recovery and Reinvestment Act (ARRA), which earmarked some $19 billion to get electronic health records off the ground, most of the country’s medical and research institutions are still primarily pushing paper.

So what will it take to help medical institutions get a move on?

Researchers, health professionals and government officials gathered here today at the New York Academy of Sciences to try to hash that out. Bells, whistles and some financial carrots seemed to be the most popular ideas, but many in the field cautioned that the onslaught of information is set to create a fundamental shift in medical practice and research.

Many of the promised benefits of electronic health care records are in eliminating redundant boxes in drab workflow charts, reducing errors and cutting costs. But some of the sexier possibilities include leveraging the wealth of health info to help physicians and other health care workers make better decisions in real-time.

A new wide-ranging repository of data could help, for instance, with diagnostic decisions. As Charles Lagor, of Philips Research North America, noted at the symposium, one program being worked on there would allow radiologists, who are tasked with poring over countless images, to sync a new patient’s history with stored data on patients with similar histories to come up with a probability level for diagnoses. The algorithms in this case-based reasoning program, said Lagor, have had more than 90 percent accuracy so far. By helping care providers make more informed on-the-spot decisions, Lagor—and others working on developing new systems—hope to meet the government’s criteria for ARRA funds by proving their projects will have "meaningful use."

The deluge of e-records data, however, could sink systems and providers unprepared to deal with it. Electronic medical record systems need not just be digital versions of paper files, noted John Gomez, of Eclipsys Corporation, a health IT provider; they ought to have the smarts to organize and optimize the information. Doctors, too, will likely become responsible for taking all this additional information into account and in the future might be found liable if they neglect to do so.

Much more mobile information also means more security concerns, especially for the institutions with the electronic systems that could be held financially liable for breaches in security—accidental or intentional. A new set of rules from the Health Insurance Portability and Accountability Act (HIPAA) set in place September 2009 requires institutions to provide information to patients (if they request it) about who has seen their medical records not just in the event of an unusual breach as was previously the practice, but also anyone who accesses it for standard treatment, payment or operations—a huge increase in reporting and accountability demands, noted Soumitra Sengupta of Columbia University and New York Presbyterian Hospital.

On the up side, as with the digitization of other fields, in everything from recipes to stock trading, putting content into the ether has historically had a way of democratizing it. Health records may well follow this trend, according to many who propose that the future guardians of health records will be individuals themselves.

Records that now live shrouded in opaque manila folders and locked in hospital basements might soon be just as open to the patient seeking treatment as to the clinician providing it. "We need to eradicate that barrier" between patients and their own health data, said Gomez. He argued, however, that there is still a crucial place for health care providers in managing the onslaught of information, but they should act more as data docents. "We need to guide the patient," he said, but they will no longer accept being barred from the decision-making process.

The billion-dollar question, however, is how much will all of this cost? Despite the $19 billion set aside in ARRA, digitizing the nation’s health record systems will likely cost a heck of a lot more, said Edward Rogoff, of Baruch College in New York City. Somewhere in the order of about $200 billion over five to 10 years, he estimated. But it should pay off, right? "It does make sense in a conceptual sense," he said. But, "what’s the evidence? None." Certainly, technology and digitization has cut costs in industry after industry, yet a systems overhaul won’t automatically translate into optimal efficiency and cost saving, he cautioned. Unless there are many players in the field, it could become "more or less the equivalent of cable television," he said, where large players dominate the market and prices remain high.

With mounting challenges and costs, Rogoff, whose presentation was given against a slide with a rainbow background, strived to capture the persisting concern, asking: "Is there a pot of gold at the end of this rainbow?" Raising again the question of just what it might take to get institutions and individual practitioners to make the long and expensive journey to find out.

Image courtesy of iStockphoto/ttueni





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  1. 1. jtdwyer 7:32 pm 02/5/2010

    Sorry for swerving a bit off subject, but privacy is also a critical patient concern regarding medical records.

    Outsourced billing is a common business practice in the medical industry, which leads to many small IT businesses handling the billing for many private doctors and small medical groups. As a result, there are many small storefront offices around the country containing minimally secured PCs, each storing the personal information of thousands of individuals. These offices represent tempting targets for burglars and even smash and grab theft operations. I know of at least one major case locally where several hundred thousand patients’ information was stolen.

    The medical industry must take adequate steps to protect the privacy of patient information in all their business processes, or ultimately be liable for the consequences.

    Link to this
  2. 2. weingibz 4:09 am 02/6/2010

    Let’s see. $19 billion incentive and at least $200 billion cost, who is going to make up the difference? Physicians? Security is definitely a concern. Where is the money to ensure it going to come from? Physicians? Where are they going to get the money if fees are not allowed to rise to at least cover those costs? With this scheme, I see no restriction on the profits of medical records vendors, and IT security providers. They can gouge as much as they want risk free. I much prefer that the records be owned, which they legally are, by the patient. The physician would be the only one allowed to make entries into the objective, assessment, and planning portions of the record.

    Link to this
  3. 3. JamesDavis 7:25 am 02/6/2010

    weingibz: There for awhile you sounded like you were full of Republican crap, but your last sentence actually makes sense.

    Medical records can be stored on a computer chip data card, like a credit card, and the patient carries their records with them all the time. The doctor’s office can transpose their records to electronic form and the card can only be opened by a doctor who has the patient’s user name and password. To prevent overcharging or double charging, the patient must approve the billing with their electronic signature and if the institution, where the bill is being sent for payment, tries to copy, print, or send the bill to another institution or compter, the bill becomes encrypted and unreadable and unusable. My publishing company uses this method to prevent piracy of our electronic books and it works great and it did not cost us a billion dollars to do it. In fact, since I already pay my secretary a regular wage, the process costed me nothing.

    Since people already have a second person listed for the doctors to call in case of emergencies, that person will be the only other person who has the patients username and password.

    Link to this
  4. 4. irondoc99 10:09 am 02/6/2010

    Since we haven’t heard from a physician, you will now. EMR’s in their current incarnation STINK. They are a pain in the you know what to use, they trash your productivity, and after you read a few notes generated on a full point/click EMR, they all begin to look to the same. It works fine for demographic data and problem lists, but for real notes that mean something when you read them again, they are awful. In addition, they are ridiculously expensive and not worth the money a providers office must pay to put them in. A physician’ practice worth are their records…if you make them freely accessible to anyone, you have destroyed their intellectual property. Overall, my vote is a resounding NO and I am a doc.

    Link to this
  5. 5. JEngdahlJ 6:59 pm 02/6/2010

    Federal funding may be encouraging a move toward EHR, but there’s more to it than just installing systems. How can healthcare data pooling lead to a better system? More at http://www.healthcaretownhall.com/?p=2002

    Link to this
  6. 6. rshoff 9:39 pm 02/6/2010

    This should be well planned and take time. We need to build a trained workforce and a systems implementation infrastructure before moving forward. Otherwise, we will simply be paying India and creating jobs over there to implement a nation wide medical records system over here. As a middle aged unemployed male with implementation experience in the health care industry, I don’t see anyone knocking on my door, because the jobs will be linked to the hi-tech companies who already employ foreign workers, if not ship the work directly over seas.

    Link to this
  7. 7. medigeek 3:22 am 02/7/2010

    One of the reasons hospitals and doctors offices are slow to implement the EMR is that there are a lot of incompetent providers who are likely to get exposed. The hospitals have a vested interest in shielding these providers as they bring them business. With the current paper and charts system all the inconsistency in care remains hidden.
    Hospitals make big bucks if the tests are repeated like the CT scans, echocardiograms. They are likely to loose this business if there has been a similar test done done a few days back at the nearby hospital. Hence, the reluctance in implementation on part of the hospitals and sharing information.

    Link to this
  8. 8. medigeek 3:30 am 02/7/2010

    One of the reasons why current electronic medical notes contain a lot of redundancy is because of the current system of billing and the need to include so many conditions and information, that physicians tend to include so much of unnecessary info in the note to make sure that they meet the requirement to justify a certain degree of severity to justify payment. The documentation requirement for reimbursement has to change before we see any real change in the quality of the notes.

    Link to this
  9. 9. irondoc99 12:43 pm 02/7/2010

    Medigeek,

    While it may be "a" reason, exposition of incompetent providers will actually increase with EMR’s….you won’t be able to tell cause all of the notes will look the same. Yes, the providers of medical imaging do better when more scans are ordered, but it is not the hospitals that order the scans and it is the hospitals that are trying to implement the EMR in the first place, not the providers. Hospitals are using EMRs to take control over providers….EMR’s are ridiculously expensive and most med/small provider groups can’t afford them. If a hospital provides it, you are locked to that hospital system.
    One other point to consider is that EMR’s have yet show that they improve outcomes for patients. It is a nice theory that doesn’t reflect reality. Ultimately, EMRs in their current incarnation with point/click charting SUCK!!!! They kill your productivity and all the notes tend to regress towards the mean. I’d have to hire extra staff just to transcribe into the EMR and I have to pay for that. Thank you but NO!
    If you want a good system, then allow open sourcing so providers can amend and use what they need. If you want poor providers "exposed," then give your local licensing boards some teeth to remove or penalize crappy providers a little more easily or create such boards. I’m a doc and I’m all for that

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  10. 10. weingibz 7:01 pm 02/7/2010

    Some of the reasons that EHRs suck are that they are written by people who are not aware of the needs of the physician and different specialties have their own needs, ie, they are not user friendly. If the programmers came up with an EHR that would improve our productivity and facilitate taking care of patients we would be using them en masse a long time ago. The EHR itself should be incentive enough. There would be no need to force their use by physicians by sticks and carrots.

    Link to this
  11. 11. jtdwyer 8:09 pm 02/7/2010

    Just to state the obvious, those who have issues with the current EHR should clearly express them and submit them to a central location to facilitate development of EHR 2.0. I suggest the agency responsible for development be contacted to provide a collection site.

    Just as obviously, user feedback should have been solicited for EHR 1.0 – if it was done at all it was not done adequately.

    Link to this
  12. 12. EMRDeveloper 10:57 pm 02/7/2010

    For some reason, engineers the world over are able to develop usable systems for every other user group on the planet, but not doctors. Has anyone ever stopped to ponder why that is.

    I’ve worked on designing an EMR used in the operating room for over a decade now. A large reason that there is such poor penetration of EMRs is that the user community is such a pain in the butt to deal with. This goes beyond the typical tension between developers and end users. A large number of doctors tend to think that they know everything about everything and they aren’t used to people having to explain to them why certain things won’t/can’t work, that features must evolve over time, some of their requests taken together are mutually exclusive and on and on.

    I’ve also noticed that the doctors as a group are much more concerned about the billing/financial aspects of the system than any patient safety benefits. It is no surprise to me that the doctor on this thread feels that the individual patient’s record belongs to him and that the patient shouldn’t have access to it. I wonder how the good doctor would feel about having his accountant keep his tax return since that represents the accountant;s "intellectual property".

    Based on my years of experience, I’ve come to the conclusion that the combination of regulatory nonsense imposed by the federal gov’t and physician incalcitrance will conspire to keep the efficient utilization of health information a pipe dream for years to come.

    Link to this
  13. 13. EMRDeveloper 10:57 pm 02/7/2010

    For some reason, engineers the world over are able to develop usable systems for every other user group on the planet, but not doctors. Has anyone ever stopped to ponder why that is.

    I’ve worked on designing an EMR used in the operating room for over a decade now. A large reason that there is such poor penetration of EMRs is that the user community is such a pain in the butt to deal with. This goes beyond the typical tension between developers and end users. A large number of doctors tend to think that they know everything about everything and they aren’t used to people having to explain to them why certain things won’t/can’t work, that features must evolve over time, some of their requests taken together are mutually exclusive and on and on.

    I’ve also noticed that the doctors as a group are much more concerned about the billing/financial aspects of the system than any patient safety benefits. It is no surprise to me that the doctor on this thread feels that the individual patient’s record belongs to him and that the patient shouldn’t have access to it. I wonder how the good doctor would feel about having his accountant keep his tax return since that represents the accountant;s "intellectual property".

    Based on my years of experience, I’ve come to the conclusion that the combination of regulatory nonsense imposed by the federal gov’t and physician incalcitrance will conspire to keep the efficient utilization of health information a pipe dream for years to come.

    Link to this
  14. 14. jtdwyer 4:22 am 02/8/2010

    EMRDeveloper – When I suggested that EHR users should clearly describe their issues, I did happen to think of doctor’s notorious reputation for bad handwriting.

    Nothing personal to doctors, but as a long time sometimes developer who has more recently been subjected to the care of medical professionals, I have to agree that doctors seem to presume that they always know best, despite any evidence to the contrary. Good luck with EMR enhancement!

    Link to this
  15. 15. MercTheMad 11:18 am 02/8/2010

    19 billion for electronic records, 6 for NASA, without whom there wouldn’t even BE computers, climate research, or microwave ovens. It’s a miracle NASA has managed to accomplish ANYTHING in the last 2 decades. Politicians need to start pushing the money back into science where it belongs, where it’s been proven time and again to promote a better future for all.

    Link to this
  16. 16. Glenn Laffel, MD, PhD 1:39 pm 02/8/2010

    It would be hard to justify widespread dissemination of electronic health records if Mr. Rogoff’s $200 billion estimate is even half right. There are simply too many other less expensive ways to improve the quality of care.

    Thankfully however, newer EHR vendors like Practice Fusion, which offers a Web-based EHR for free to providers, will assure that national implementation costs will come in far, far lower than this estimate. Web-based EHRs also facilitate rapid innovation the development of intuitive user interfaces that should further spur adoption.

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

    Link to this
  17. 17. dankgray 1:56 pm 02/8/2010

    The Veterans Administration has had Electronic Health records for 25 years. That’s a total health record, Laboratory, Pharmacy, Radiology, Quality Assurance, Nursing, Inpatient Medications, accounts receivable/payeable. And it is all FOIA accessible, totally open source. Check http://www.worldvista.org.

    Link to this
  18. 18. jtdwyer 2:25 pm 02/8/2010

    Merc – Please! I happen to have had some exposure to business machines going back to 1960, my Dad was trained in computer programming and I was employed in the field in the early 1970s.

    Like all NASA programs, they did contribute a great deal of the public’s funds to the development of computers, but I can assure you that NASA would not have existed without the independent development of computers!

    Link to this
  19. 19. HealthTech 3:37 pm 02/9/2010

    I am a doctor and concurrently a developer of EMR’s and serious healthcare analytical systems. Conceptually EMRs are great, but practically still far from even early widespread adoption in mainstream practice. In large clinic settings it has some positive impact by moving around a facility with the patient, aggregating results and billing etc but this is in an environment with much non-clinical support to facilitate the EMR data acquisition. Can you imagine a patient sitting watching semi-keyboard skilled docs trying to peck-type-peek, click and hassle with multiple screens? If they dont data capture then you have to fall back on transcription and multiple redundancy. We have tried (with varying degrees of success) writing on tablet screens, OCR of structured paper records and voice recognition systems to replicate better how practices run. Sadly, none so far have improved efficiency of the operations of practice sufficiently to gain widespread acceptance. They certainly do provide great data, but that is well downstream of where the healthcare system is trying to wrest efficiencies. Only when the value saved is shared with doctors to enable them to hire the support staff and infrastructure to support the data acquisition process will EMRs begin to be adopted. But beware the double edged sword. Increased data efficiencies means initial higher total administration costs, higher throughput albeit possibly at a lower price per event, but higher total healthcare costs to the system. We have not yet been able to demonstrate a positive NPV or acceptable IRR to potential medium or small clients to justify what we develop. The majority of clinicians fall into this category of potential client.

    Link to this
  20. 20. CleffedUp 6:17 pm 02/9/2010

    #1: Research and Patient Care are apples and oranges in terms of process. Clinical trials, in particular, have their own additional layers of workflow and regulatory complexity. It’s a fallacy to combine the two in terms of technology penetration.

    #2: Many small businesses lack the wherewithal to implement and manage even relatively simple technology like websites. Small medical practices are no exception.

    #3: The rate-limiting step to widespread and effective EMR usage is not money but time. Clinical staff and faculty are rife with technophobes and curmudgeons (to put it mildly), while IT departments keep legacy systems together with bubble gum and paper clips (until just a few years ago, Medicaid was using magnetic tape on reels!). Both the old systems AND the people accustomed using and supporting these old systems need to be phased out before EMRs will become effective.

    Link to this
  21. 21. loveslawyerjokes 8:50 pm 02/11/2010

    Roe v. Wade establishes a fundamental right of privacy between a doctor and a patient. As soon as it is overturned we can begin discussing this issue as being mandatory for all americans. Please don’t forget that the ACLU successfully defended Rush Limbaugh’s right to privacy for being a drug addict.

    Link to this
  22. 22. Science Geek 1:19 pm 03/5/2010

    An important issue that has not been raised here is the incredible benefits EHRs will afford the research community. Right now it is extremely difficult to assemble population data on any disease. We are undergoing a revolution in medicine with the availability of genomic, proteomic and other technologies, but without access to high quality data from across the population the field is much more limited than any of us would care to admit. Indeed, as we begin to understand that our concepts of what defines a "disease" are rather primitive we realize that we need to assemble data in unconventional ways in order to identify trends (e.g. across several seemingly unrelated conditions that ultimately turn out to have a common cause).

    Yes, many EHR programs aren’t very good. That doesn’t mean the concept is bad. And yes, we need to deal with privacy issues, but this is actually a relatively trivial exercise in anonymization of patient data. But the gains we as a society will reap from access to such large and rich data sets cannot even be imagined at present. That is, if you want to cure diseases, give us, the scientific community, access to high quality patient data.

    Link to this
  23. 23. greggypetty 7:54 pm 02/8/2011

    I really agree with you. Privacy is the biggest concern with everything going the way of technology today. I haven’t heard of many cases of robbery, but I know that it is something people need to be cautious about. However, using an electronic health record can have huge benefits for patients and doctors though, as long as it is from a reliable and safe company (if it is web-based) and proper security steps are taken if it is just local electronic health record software.
    http://www.advancedmd.com/products-solutions/emr-ehr

    Link to this
  24. 24. greggypetty 7:54 pm 02/8/2011

    I really agree with you. Privacy is the biggest concern with everything going the way of technology today. I haven’t heard of many cases of robbery, but I know that it is something people need to be cautious about. However, using an electronic health record can have huge benefits for patients and doctors though, as long as it is from a reliable and safe company (if it is web-based) and proper security steps are taken if it is just local electronic health record software.
    http://www.advancedmd.com/products-solutions/emr-ehr

    Link to this

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