This was my editorial at FierceHealthcare on Friday
This week I heard a very bitter physician complaining that using an electronic
medical record got between him and caring for his patients, and imposed
secretarial tasks on him. Then on Tuesday we got perhaps the most negative news
yet about a problematic CPOE installation at Childrens’ Hospital in Pittsburgh,
where after its introduction patient mortality increased. There was also news
about an emergency department in Arizona pulling the plug on its EMR.
Whatever the real reasons behind the data, it’s clear that simply installing
an EMR or CPOE system did not have the desired impact on patient safety. My
cursory assessment is that electronic records are vital in improving the
healthcare delivered to patients, particularly those with chronic illnesses,
over the continuum of care. But it’s clear that when they’re introduced to ICUs
or ED, where speed is the key and care processes are not well defined, things
may not be so successful. A real examination of the process absent the
technology, and a massive commitment from vendors to improve the human-computer
interface, is quickly needed before the movement toward CPOE and EMR is stopped
by these kinds of stories. After all, it’s easy for a hospitals or physician
groups to decide instead to do nothing.
Well, some people were reading. Kelly Clark a physician from Boston, recently relocated to
Louisville, wasn’t too impressed. She wrote to me:
Any time you want to hear a physician complain about using
CPOE/EMR, simply ask any clinician who makes their living actually treating
patients and billing insurance for their services. “Speed is key
and care processes are not well defined” as the default condition for the
current practice of medicine – it is in no way limited to the ICUs and ERs.
A large amount of information on digital access is useful to care
coordinators who are salaried to manage a fairly small caseload of patients with
chronic conditions. The time constraints placed by the market on
the physician-patient encounter do not allow for the thoughtful assessment of
large quantities of historical data by a practicing physician. Physicians are happy with their CPOE/EMR system in the salaried and
subsidized world of the VA. Outside of that arena, the
administration and the 1-3 physician champions of EMR in each health care system
will be the primary sources of effusive positive regard for EMRs, but those of
us in the trenches are typically not quoted and not happy. Having
been forced to use these CPOE/EMR systems and seeing them severely limit the
efficiency and safety of medical care, as well as increasing error rates, I am
among the practicing physicians who can wax eloquent about their problems.
the way medicine is practiced and huge investment in improving human-computer
interface systems in order for the EMRs to work well and realize any savings of
dollars or lives. However, I believe you are incorrect in
predicting that the stories you quote may result in stopping the movement toward
EMRs because it is “easier for hospitals and physician groups to do
nothing”. This is not true. The move toward EMRs is
not being led by physicians or hospitals, so our input is amazingly
irrelevant. The movement is largely based on a fallacy that
improved technology will lead to decreased cost, with a side bar of improved
quality of health care. It is led by business interests and
followed by the government – ie, the payors. Improved technology will be a huge
boon for consulting firms, administrators, and other types of technician and
advisors. It will absolutely not decrease costs. Only improved rationing of health care resources will do that. However, since no one wants to deal with the true issue, our current
resources have been diverted to The Holy Grail of Techno-Salvation. The interests behind this are well-entrenched and will not be stopped by
a few facts that contradict their ideology. This is evident with
the push to P4P, when there are almost no “performance” scales that are relevant
to medical care for real patients with real co-morbid
medical/social/psychological issues that impact their health and health
care.
Medicare continues to be a main player on their field, and the push toward
electronics by Medicare cannot be ignored by hospitals. As
economies of scale push toward large Kaiser-like systems and physicians move to
stable jobs being employed by large entities, EMRs will make more sense. In the meantime, the move toward these large systems of care, including
the fits and starts of competing EMRs, will lead to more wasted health care
dollars and worse medical care, as well as complaints by bitter physicians who
are being devolved from being professionals toward being marginalized purveyors
of a technical commodity.
I actually agree with much of what Kelly says especially about the lack of conversation about rationaing, although I’m not so sure that payors are leading the way towards EMRs, or that anyone is. I suspect that underlying the lack of appreciation of the EMR is the realization that it in fact only really makes sense for bigger organizations. What Kelly may be underestimating is the ability of the AMA and others to delay the imposition of IT, such as the rejection of the mandating of electronic prescribing in the House-Senate conference of Medicare Part D. But this debate and this process is by no means settled.
Categories: Uncategorized
A major US survey has shown lately that majority of doctors think implementing electronic medical records is necessry at this time.
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Really good article. I have been following your blog for several months. You have good knowledge on medical billing software. It was also helpful to me to update my site.Please continue the good work. Thank you.
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Hi.. It is been a very big discussion on EMR or CPOE system..Really they do provide the desired impact on patient safety.the move toward these large systems of care, including the fits and starts of competing EMRs..Its really very much helpful to physicians and professionals toward being marginalized purveyors of a technical commodity..I really enjoyed your valuable information on your blog..
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I think that there are two views points to be considered when strongly advocating the use of EMR in practices. For a Doctor it needs to easy to use and save time so that more time can be spend on the patient. Currently we have many vendors with different types of EMR that are so hard to use that it simply puts them off. I think healthcare technology companies need to develop product after regular interaction with doctors to ensure that they provide just what is required. At binaryspectrum we have developed our healthcare solutions after spending countless number of hours with doctors to ensure that its work flow is kept simple and intuitive. This is then followed up with a period of Beta testing in real time environment before it is offered as a product in the market.
Is it just me, or did anyone else notice the time and date stamps so close together on the July 20th postings. Hmmmm…
Kelly Clark:
You hit the nail on the head. I could not agree more about your comments about the EMR and who is likely behind the push. I’d been trying to figure it out myself this past year in our hospital.
I see these companies pushing EMR’s no different than the pharmaceutical industry.
Eric Harrington
I have used Soapware for many years and as such have grown with it. I have found it a very cost effective and efficient way to streamline my office and facility operations. More importantly I have been a meical school faculty member for 22 years and a regional medical director for a major insurer for 7 years. I have found Soapware to be an excellent teaching-and compliance tool in our clinical teaching site. I am responsible for the development and implementation of evidence based guidelines. This is an invaluable tool in that sense. As such it is also a risk management tool that increases patient safety. I presently encourage all students to strongly consider the implementation of an EHR at the outset of clinical practice- and at that stage Soapware is without doubt the most affordable and flexible-allowing progressive growth and implementation
mmd.net EHR is the best product as part of usability and legal compliance concerns.
we would recomment all small and medium size healthcare providers to contact us for schedualng a Web Demo as to have better feel of versatility of the mmd.net EHR.
I agree with the positive comments made above regarding the use of Soapware (DOCS, Inc). The program is simple, user friendly and is designed to be used by physicians, not by institutions. It is also designed to be affordable. Other systems are extremely expensive, require extensive training, and require costly annual fees. Within weeks of our purchase, my partners (neither of whom are very computer savvy) and I were all using the EMR system. We have had no issues with customer support. To the contrary, we have found the support to be excellent and the training opportunities perfect for our needs.
Any criticism of SOAPware must be taken with a large dose of salt. (way more than a grain!) And if the detractor doesn’t have the heart to sign his/her name, that in itself eliminates any credibility as far as I am concened. My name is below. I will be more than happy to talk to anyone who wants to know about SOAPware.
I have used SOAPware for 4 years and I have looked at numerous other EMR’s as well. I am owner/operator of a primary care clinic. Without SOAPware I would have a LOT more work managing my documentation. It is cost effective far beyond any other system I examined when starting my clinic in 2002. Support is top quality, far better than from any other software maker I have EVER dealt with. I cannot recommend SOAPware highly enough to my colleagues.
Stephen Shortridge, PA-C
Clinic Director
Rainbow Medical Clinic
Big Lake, AK
Simply put, SOAPWARE by DOCS, Inc. is the most widely used EMR in the marketplace. And it’s that for a reason: it works !
I researched countless EMR programs when our office moved to EMR.
We chose SOAPWARE. That was many years ago and we haven’t had any cause to look back.
Quite a few doctors have visited our office to observe SOAPWARE in action during their search for an EMR and have made the decision to choose SOAPWARE for their practice too.
Disagree totally with SCREAMING MIKE:
I have been using SoapWare for two years & love it more each day. Labs go directly into chart, can make your own templates the way you like them!!!
Support is fantastic. Every call returned within an hour and the problem is alway fixed… cold. The tech takes control of the computer remotely. I go back to seeing patients.
Using MS SQL database allows you to scan in everything, including all those bits of loose paper that fly around, without worry. SoapWare has never crashed in the 2 years. MS SQL automatically backs up the database and checks for internal consistancy.
It takes a bit of time to get SoapWare to do what you want it to do, the way you want to do. However the concepts are easy to learn, very powerful and very, very flexible. You do not have to hire a group of programmers at $150/hr to make changes like some other EMRs.
The GUI is a little dated but so what!! my dated GUI gets me into my new beemer and off to the links lickedy split.
Soapware rocks!! During the 10 years that I have used SW, a number of surgery residents who rotate through the office have seen and appreciated its functionality and easy adaptability and have later started using it in their own practices. The developers are easily accessible and incorporate suggestions for improvements. I have seen it grow since Version 2, which was good. It just continues to get better.
I have used SOAPware since 2004. The tech support is excellent. And it only costs $300 a year!! I am looking forward to the new version. My staff loves it, it really has saved us a lot of time and effort in our office (I am sure any EMR can do this, but at a much higher cost!)
A brief comment regarding the earlier post on SOAPware by a gentleman by the name of “mike”.
I have been using SOAPware (by DOC’s, Inc.) since 1998 and I have no idea where “mike” is coming from. The program works well, the notes generated hold up in court as well as with the various insurance and managed care companies, and the support has always been quick, helpful and thorough. SOAPware has been a sound and reliable EMR and is routinely being improved as the EMR world evolves. Again, the EMR world is evolving and none of us are quite sure where it is going. SOAPware is a great effort by the people at DOC’s, Inc., it is, and has been all these years, an indispensable part of my practice. Oh, by the way mike, I started practice in the 1970’s and there was nothing like this. If “mike” was unhappy why not simply ask DOC’s, Inc. for his investment back (DOC’s has a guarantee). I have simply not seen a more reliable and consistent EMR program for the money. I’ll stay with SOAPware.
Dr. Holland
I have used SOAPWare for 3 years and totally disagree. I found it to be fully customizable giving me the means to mold it to my style of practice. I also like the expandable codes which allows protocols to be developed and a few letters and a space bar spits out a comprehensive treatment. You then just check off what you did and clear everything else. I have never had any problems with support and have never had any real problems with any of the program.
I am also a happy Soapware user. I have been using it in a paperless outpatient environment for 3 years. It is relatively easy to use and I have had excellent support on the few times that I have had issues. I think that it is an excellent value. The basic module costs $300. You can add additional modules as needed. Soapware does what I need at a price that I can afford.
I started out in solo practice about 2 years ago. I got estimates from several vendors, including GE, EMDs, eClinical Works, PMSI, etc. They were well over 15,000! Then I found SOAPware; it was written by a family doctor, and served my purposes just fine; I installed on my laptop, didn’t have to buy a server, and added modules gradually as my practice expanded. I agree it’s not the most high-tech product like some of the others, but it’s very economical. The company is coming up with a killer product – Soapware Liger, and if you look at the functionality it is a big improvement over even the more expensive products. Also, I am able to do e-prescribing, and export charts, and Soapware has dedicated themselves to being a truly “open” record. I use Soapware in conjunction with Medisoft for billing. As for the documentation, the macros actually save time and create a nice note that doesn’t look like it was generated by a computer. If you want, you can buy dragon dictate and dictate your note directly in the computer if you don’t type fast.
I think even $4000 for a complete package is very reasonable compared to $15,000+ for the other guys – and I know Soapware will be around, they have excellent customer service, and the ongoing annual fees are minimal for what you get. Any problems I have had have been resolved by customer service.
Please feel free to contact me for any specifics on Soapware, and I am happy with it overall and pleased with the new version that is going to be coming out.
I have used Soapware for over 2 years – my experience has been the opposite of Mike’s. It is a very stable system – one of the cheapest that you can buy and my experience with their tech support has been excellent. Compared to other emr’s that I have tried data entry and functionality has been if anything better
we JUST BOUGHT AND INSTALED A PROGRAM CALLED soapware – WHAT A JOKE – STAY AWAY – HORRENDOUS SUPPORT – ARCHAIC PROGRAMMING – SAVE YOUR MONEY – LOOKS LIKE IT WAS WRTTTEN IN THE 1970’S
Why can a little $295 and a $1,000 EMR vendor produce a demo link of their EMR in action when the expensive ones are not?
Customers want:
Give us dynamic demo’s of the EMR in action of the common office functions.
How to book a patient.
How to create a note for new patient (and old patient).
How to write a Rx.
How to functionality of document managment.
etc, etc…….
Customers SAY: Inspire us with your goods ! Fill in the gap between screen shots and the tailored “demo sessions” that one signs up with the sales dept.
Regards,
EMRWorld.NET
It is amazing to see the divergent thought processes of practicing doctors, the programmers, health care administrators . It is easy to talk about quality but hard to define it objectively. Perhaps the only measure of efficacy of what we do is “how well is the patient feeling, in spite of our treatment!”. This is an area that has been well leveragerd by people who administer “miracle Cures” or practice the “Feel-good medicine” and make a lot of money by writing books and being on national TV ( Example: among the super Quacks Kevin Trudeau, and among the formally qualified Dr Deepak Chopra).
Talk about CPOE/ EMR to a neurosurgeon operating on the base of the brain or a pediatric heart surgeon fixing multiple congenital anaomalies in a newborn heart, you will hear a different tirade. Medicine should never cease to be an art. Practice of good Medicine is borne out of years of really hard work, tuning the mind, body and heart to the care of sick people, learning by mistakes. Computers are just an adjunct to make our work processes easier. EMR’s as they are being currently touted do NOT meet the needs of practicing physicians and should be soundly rejected, subjected to rigourous testing and usability analysis before forcing it on doctors.
Allan, why do you consider it “EVIL” to include keywords somewhere in a billing software? It just helps me to retreive my patient lists for clinical studies much more easily than the billing codes would. The ICD-9Cm and the CPT codes are not yet detailed enough to describe the nuances of all diseases we see, particularly emerging diseases.
This blog has the flavor of the old “nature/nurue” question, or the “cure for cancer” quest of the 1970’s and 1980s. Now we accept that all cancers are not the same and there isn’t a universally applicable “cure,” and we all accept that most diseases require a genetic predisposition and certain environmental influences to become pathologic. Yet we argue about which group is primarily responsible to push IT/EMR forward. Of course, all groups are responsible.
The use of technology to improve that very human and non technical interaction between the physician and patient will require the utmost effort from all parties; physicians, payors, govt, patients, IT vendors, etc.
To David:
‘As noted above, successful computerization of any process depends heavily on self-knowledge. If you can’t or don’t want to analyze your procedures, to a level well beyond normal human awareness, then your project is doomed to be Broken As Designed’
The “techies” have their own cultural resistance to improvement of EMRs in a primary care setting that I find most amazing. I’ve been part of two EMR implementations, one at my own (considerable) financial cost. I have analyzed my own mental and physical processes for the tasks invlolved in providing care. I’ve tried unsuccesfully to communicate the nuances of these tasks to the development staff and they simply can’t seem to hear me saying “it’s too many clicks/ it takes too long/ it’s oversimplified and doesn’t work.” When I ask an EMR vendor salesperson how many click/minutes it takes to update a medication using their product they NEVER know the answer. If I ask if there are any industry standards for a basic set of functions and the industry target in time/clicks for each of the those functions I get a blank stare. I really don’t think the IT development folks have enough self knowledge; does your process development include a primary focus on speed and efficiency for the user? Do you have an industry standard for measuring the efficiency of use of your product?
There simply isn’t a vernacular for EMR efficiency. We don’t speak in those terms, there aren’t any standards for evaluating the efficiency of a EMR based on “number of clicks” or “average total hours of physician training required to meet an established basic proficiency standard.” I can’t imagine how we can develop technology solutions for implementation into a complex decision making envirionment like the delivery of primary care medicine without some standards in terms of what the basic tasks are and setting standards for time for performance of those tasks and the training time required to master those tasks.
I do agree that the efforts of the acadamies have been abysmal. The AAFP has an ambitious project, and yet they haven’t proposed any basic standards or models to measure the efficiency of use or efficiency of implementation of the the 400+ EMR’s available in the market.
For now I’ll remain a physician on the sideline waiting to see meaningful head to head comparisons of EMRs. Never again will I squander what could be part of my children’s college education on a poorly conceived, poorly “field tested” product.
I think we need to take care that such claims as “increased quality” of healthcare provision are based on reality. Often, the evidence that is spoken of in “evidence-based” development of “best practice” type approaches is only short-term. For example, published evidence on the value of benzodiazepines in anxiety disorders is 1) only a few months in duration, and 2) based upon exclusion of patients with substance use disorders. Since at least 1/4 of patients with anxiety disorders also have substance use disorders, a recommendation for use of benzos as first-line treatment for anxiety disorders is foolish as we know most docs don’t spot substance use disorders, and many patients are prone to hiding their symptoms quite well. Such a recommendation, though often made, leads to long term problems for a significant percentage. Those of us in the field recognize that even those without substance use difficulties, if left on benzos for an extended period of time, often have significant side effects that are worse than the original disease. This is only anecdotal, however. Until state-of-the-art research is conducted over several years (better yet, a decade), using drugs that may be off patent, and requiring a non-exclusionary process of admission to the study, development of best practice guidelines is without significant merit in this and many similar situations. MDs recognize this, which is why we often look at “best practices” with disdain. But it is difficult if not impossible to convince the public of these issues, let alone the academics who so often are simply producing the research that they can get funded (e.g. pharmco-funded and hence biased studies). Tom Leith has a good point in that data generated by EMRs will be of potential value to academics looking to develop best practice guidelines. As an academic myself, I have a soft spot there as well. But GIGO applies – what may well be a best practice for Doctor #1 might not be for Doctor #2, who has a different patient population, a different level of rapport, and different personal strengths and skills. Since the practice of medicine always comes down to the 1:1 relationship between patient and physician, I suspect it would be unlikely and indeed inappropriate that any group of best practices beyond the obvious would be applicable to all physicians. If I’m paying for healthcare from the best doctor available, I want that doctor to be able to do whatever he thinks of as best. I don’t want to be forced into accepting mediocrity just because it’s the best practice as judged by a review of data coming from, by definition, the average doctor. Some patients may, of course, choose to see the average doctor, or may not have much of a choice, just as some may choose to eat chicken with skin fried in oil instead of steamed fish. But that’s another issue entirely.
I’m not a medical type at all — I’m a techie, in fact a computer programmer, and I can *completely* understand why doctors don’t like EMR systems as they exist now. The First Rule of Computer Science is (still) GIGO: Garbage In, Garbage Out. The important point here is, that’s not just about data and results! It applies equally well to system design, which is where Dijkstra’s comment comes in.
As noted above, successful computerization of any process depends heavily on self-knowledge. If you can’t or don’t want to analyze your procedures, to a level well beyond normal human awareness, then your project is doomed to be Broken As Designed. Medical practice in general has rarely been analyzed to the “operational” level needed for system design, and the natural variations in practice are poisonous to (usually premature) attempts to generalize such a design. (And don’t get me started on user-interface issues!) It doesn’t help that the “computer knowledge” and the “medical knowledge” are usually provided by different groups of people, or that both groups are vulnerable to “political” interference by other stakeholders, especially the folks paying for system development….
It’s an unfortunate fact of life that the costs of a major software development are unpredictable, and prone to overrunning the initial budget. Admittedly, some of the overruns come from political failures, such as failing to get the users on-board beforehand, or trying to treat a bespoke design project like an off-the-shelf product spec. (“Here’s what we want, don’t bother us until you’ve got it done.”) Regardless, if you try to limit the budget by fiat, you get “Space Shuttle syndrome”, where every “cost-cutting” measure adds another liability or risk to the product.
And then of course, you’ve got “dusty deck” issues (i.e., the existing paper records, and/or existing computer systems), hardware spec and procurement issues, infrastructure issues (Exactly where are you putting all the new machinery? How will you get the network cables installed in ‘clean rooms” such as the ICU?), support issues, authority issues (“the computer says you can’t do that”), et many al.
The biggest complaint I have about the EMR system is the wait time for new meds to be put into the system. It makes the patient’s wait longer to receive medications, especially pain meds. It does prevent medical errors when passing meds if used correctly. (ie: not accidently giving someone in A bed B bed’s meds, or allergy alerts)
The doctors I work with don’t want to have to type in their own orders and they continue to ask the nursing staff to act as secretaries even though they have access to the computers themselves. With the handwriting being so bad, it’s a wonder more patients aren’t hurt or killed. Computer order entry will also cut down on the amount of calls to offices in order to clarify orders as well as cutting down redundant orders..
“any QI process that relies only upon patients as its key actors powering the engine of change is, I’m sorry, not a very serious reform attempt. ”
First- I never said ‘only’, I said “best, first step”.
Second- if patients refuse to take the minimum of responsibility for their own healthcare, you or I or anyone else can dream and plan and even try to implement change– it will not work.
Allan–your point was (and is) rock solid, and I couldn’t agree more with the “who pushes who” chain you outline in terms of quality and cost containment.
And you were completely right to leave out the human cost to the consumer, because it’s really not a part of the causality chain at this point. It’s that fact, and not your analysis that I was railing against and I apologize for my poor writing suggesting that you were not aware or were indifferent to this human cost. Quite obviously, you are not.
John C, I would like to share your optimism but I do not feel that employers will maintain this commitment for a long time. They’ve bought the “improve quality and costs will be contained” argument on faith, but they want to see an ROI, and they won’t have much patience for it. This is reasonable–again, they didn’t go into the car business to reform the health care system, they went into it to sell cars. If this approach doesn’t control the cost of building cars, they have a responsibility to their shareholders to find a solution that does. And find it quickly.
Eric, the problem with expecting that people will have this record is that, well, they’re supposed to have it now and bring it to every appointment and they by and large don’t. http://www.ahrq.gov/consumer/quicktips/doctalk.htm.
I think it would be great if people did this! But sick people tend to be really irresponsible and confused. Should we try to engage them and improve their behavior as part of a QI process? Sure. But any QI process that relies only upon patients as its key actors powering the engine of change is, I’m sorry, not a very serious reform attempt.
The topic of EMR/CPOE has generated some fine discussion about quality and cost. I have come across many examples of implementation of quality programs at local hospitals that have had positive impacts on the bottom line and patient health. One thing I’ve notice about them all is that it takes a lot of work and effort to implement new ideas and processes correctly. Dr. Benjamin Brewer’s discussion of his improvements in his solo practice in Illinois in the Wall Street Journal are one good example where he has increased patient health while increasing income by approximately 35%. The website IHI.org has many other positive examples. One common tool to all of these seems to be local implementation of quality tools that fit the local situation with local champions of the change.
Theora- using profanity demeans your argument and is not nearly as interesting as ‘conflating’!
Kelly- thanks for the kudos: ‘brilliant insight’
Theora- what is the problem with expecting that when you or I or anyone else comes into a doctor’s office, urgent care, emergency department, that he or she has a simple record of current medications and dosages and significant medical conditions? I cannot understand your resistance to this idea. It is simple, cheap, and would be very effective- and it does not require legislation, regulation, or interoperability.
That is the best, first step.
I agree with Allan point that payers and purchasers incentives are often not aligned. Payers are essentially contract administrators. As with any private market, payers are responsive to customer demands. The problem lies in the ability for customers to demonstrably measure results (what will this do for me).
How long has HEDIS been around? The push for payers to have quality certification (NCQA) has produced what tangible benefit for consumers (employERs and employEEs)? I believe the Leapfrog Group goals will result in the same outcome, a lot academic hype but not much in the way of tangible results.
Remember most large employERs self-insure the majority of the employee’s benefits (nearly 80% for firms with more than 1k ee’s). Therefore, in many instances the payer and purchaser are one in the same (GM, Ford, etc). It is these purchasers that are primarily pushing for efficiencies. They have good reason to believe efficiencies will produce tangible results (we’re talking $$$) because of their own experience. Most other industries have made great strides in efficiency and increased production capacity through the implementation of technology. So they figure (and I believe they’re right) that the efficient use of technology should produce the same results in the health care system. I sat in on national conference call a few years ago were GM was beginning to take this approach with its health care vendors. As they saw, we were part of their supply chain. And in their manufacturing thinking, they wanted to apply lessons learned from improving the mfg supply chain to the health care supply chain. Pitney Bowes started to do the same thing.
What happened? As Pitney Bowes’ CMO found, the health care system is not as unified as the manufacturing sector. The various stakeholders (hospitals, physicians, specialty physicians, outpatient centers, etc) all have very strong self-interests. Plus, they don’t need to hitch their future to a handful of purchasers like the mfg sector.
Because the health care delivery system, despite consolidation and vertical integration, is still highly fractured. Most physicians are essentially mom-and-pop-type operations with very little interest or capital to invest in major IT improvements. Event though they will benefit in the long run. That is why I believe the only party who can truly push technology is govt, but they must also provide the incentives (or subsidy) for the transition (and I’m a conservative).
Allan writes:
> purchaser and payer incentives are fundamentally _not_
> aligned, unless the purchaser takes a very, very
> active role in telling the payer exactly how they
> must structure the health plan
Well, I think this is exactly what is happening: puchasers are getting very involved — look at the Leapfrog group. The member companies are the purchasers, and they’re telling the ASO contractors what to pay for, what to demand from providers, and what quality data to collect. This is far from universal right now, but it is happening. And what is “shift[ing of] more health care costs to employees” BUT a restructuring of how the health plan works? Medicare/Medicaid absolutely will get into the act, as Theora reminds us. In fact, they already are. When insurers take risk, they’re both the purchaser and the payer (within limits).
I think purchaser and payer interests are converging, and they will force change, including the technology adoption to make the reporting work. The government will be important (and has been already on the financing side with the mandatory transaction sets that came with HIPAA) but I bet the private sector moves faster. Oh, and don’t forget the Mother of All Data Warehouses being built by the Iowa Foundation for its QIO contract for Illinois and Iowa with CMS: OK it uses billing data as a proxy for clinical data, but it is a huge (government) move.
So, I think purchasers & payers will be driving the adoption of EHR and quality initiatives.
Dr. Murali has a great approach: start with electronic document management and transcription. This will help him understand what he needs from an EMR, and get him and his staff in the habit of integrating IT into his practice. After using this for awhile, he will be in a great position to either build on what he has, or he’ll have a great “requirements document” for a replacement system. But he should never include keywords in his billing software’s miscallaneous column. This is evil. The billing software should not have a miscallaneous column in the first place. When he has a need for some clinical vocabulary, he should specify his needs to his software vendor so the syntax and semantics of the data will be understood. I encourage him to consider a truly robust backup process, with offsite storage.
Finally, it is not magic we rely on to sling these messages around the net, but causality, whose existence can’t be proved empirically. Causality is the first of the metaphysical truths.
t
The currently availabe EMRs are terrible. Absolute waste of time. Each practice needs to know its work flow and design the IT it needs. There is no one size fits all when it comes to EMR. Look at it this way. If you want quick, secure, rapid, reliable access to your records in the wayyour paper records look and feel, buy a good quality high speed scanner and start scanning your records using Adobe PDF. Use intelligent managable databases to track meds/allergies and write prescri