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Confessions of a Physician EMR Champion

Starting this month and continuing for the next year or so, I’ll be presenting a standard talk to physician audiences entitled “Confessions of a Physician EMR Champion,” subtitled “A Conversation with American Physicians About How to Save Medicine in the Age of Information.”

The broad message is that, to be successful, the adoption of health IT by physicians, nurses, and staff must extend communication and health data exchange beyond the narrow confines inside the four walls of their practice. Health IT needs to empower all providers to act as effective members of a team which includes the patient, medical home, specialists, and ancillary service providers such as pharmacists and lab technicians.

My “confession” is that for several years I led a team effort by the American Academy of Family Physicians, its state chapters, and its members, to promote adoption of electronic medical records, or EMR software systems. Between 2003 and 2007, the percentage of the AAFP’s active membership of 60,000 doctors who utilize an EMR from a commercial vendor in their practices jumped from about 10 percent to almost 50 percent. The overwhelming majority of the doctors in these practices consider this a good thing, and would never go back to paper systems. The accumulated knowledge and experience about EMRs among the AAFP’s membership is unparalleled.

But EMRs are not enough, as I’ve come to appreciate. Most EMR software systems create digital versions of paper documents, which can be accessed by physicians from almost anywhere. Certainly, the majority of EMRs help assure the accuracy of diagnostic coding and capture these better for billing Medicare or health plans, which adds revenue to many practices that have under-coded in the past. Workflow and internal communications are also often enhanced by some EMRs, especially those that permit e-Prescribing to be done electronically thereby eliminating phone calls and faxes that irritate both waiting patients and busy practice staff.

What I once thought was the end game, however, is really only the starting line. This is because most of the commercially available EMRs, including those that are “certified,” focus on what is good for the doctors and the well-being of their medical practices, but do not yet support the capabilities required to assist patients and doctors to collaborate and make better decisions. Neither do they help manage and coordinate care across a community of providers in different settings or reduce the costs of unnecessary emergency room visits, repeated lab tests, or preventable hospitalizations.

Further, they have very limited ability or commitment to capturing and transmitting the data on a population of patients that would permit improvement in quality, safety, and efficiency to proceed systematically in a community, region or state. And perhaps worst of all, many EMR vendors have resisted the call to make their software capable of exporting and importing a standard set of summary personal health data in computable format such as the Continuity of Care Record, CCR, xml standard. This means that for all practical purposes most EMRs remain “islands of data” that can’t connect even with the archipelago of data in their communities, not to mention the continents of data elsewhere.

I don’t want to blame the doctors or the vendors for this unfortunate state of affairs. Our training teaches us that the quality of medical care relies on the high professional standards of individual physicians, and holds that individual doctors ought to be accountable for excellence.

This has helped to create a health care system in which most patient visits are to small practices with four or fewer doctors. These stand-alone small businesses treasure their autonomy, and are often unwilling and unable to approach the acquisition and use of health IT unless there is an absolute focus on the narrow objectives of the professionals inside their particular small group. EMR vendors have perforce had to follow the same perceptual template, and to customize “stand alone” features and functions on the basis of what group A wants and needs, even if group B in the next county over has very different priorities for feature and function sets.

Believe me, I have a lot of respect for the tolerance and good will of EMR software developers in this domain: the fickleness and variability of their doctor customers tends to be crazy-making. Physicians, for their part, have had precious few opportunities to change their behavior, given the reluctance of health plans and Medicare to stop rewarding procedural throughput over coordination and management of disease. (See Klepper and Kibbe, Oct. 30 THCB post.)

In my Confessions talk, what I am now recommending to physicians, their office managers, and their business partners is that their health IT deployments should no longer be vendor-driven, nor should they be limited to what works best inside the individual practice. Instead, their health IT should be aligned with a business and clinical re-organization strategy that places a much higher value than heretofore on team-based care and management programs involving health data exchange. My message is that the best uses of health IT are those that support participatory medicine, reduce costs, make care more convenient, and close the “collaboration gap” between doctors and their patients in much the same way that online banking and online airline reservation systems have done. I’m encouraging patient portals, community health data exchanges, shared clinical data collection, and intelligent online tools from Health 2.0.

This is not an easy message to sell, I’ll grant you that. The idea of becoming a “virtual Kaiser” gets a lot of pushback from physicians who understand that when patients, physicians, and hospitals are all completely integrated into a single organization it makes business sense to invest in health IT that can prevent hospitalization and which can offer non-visit care such as e-consultations. They are right to protest that their painful reality is that they’re NOT organized in this integrated manner, and that becoming more efficient to the “system” through health IT purchases may actually mean money is taken out of their own practices’ pockets. They see their predicament as “lose-lose” until their cost-saving investments in health IT don’t all go towards savings to the health plans or to Medicare, and until some of those savings return to the practice as revenue that can fund the capital expense associated with health IT.

But change is on the wing, I tell them. No one — not employers, consumers, patients, nor the government — can tolerate disorganized care forever. And everyone seems to recognize that we need to find ways to enhance the organization of care so that cost savings can be achieved and health care dollars are not wasted.

It won’t be easy. But the idea of health IT deployment for its own sake is going out of fashion. In a future blog post, I’ll provide examples of the way health IT can be deployed in medical practices to enhance the capabilities of the Connected Medical Home, and how this just might turn into a “win-win” for doctors and their patients, provided  policies under the new Obama administration encourage new payment mechanisms to reward quality, continuity, and efficiency. I confess that I should have seen this earlier!

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.

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103 replies »

  1. I’ve read it from other site. Follow up, is it better to have the developers bring it to you for you to know how to use it easier because others just buy one and then complain.
    -nj

  2. Great blog. Dr. Kibbe is going in the right direction. I wish him success. The current buzzword in medicine is evidence based medicine. We should apply the same to our use of computers etc in medicine. I don’t believe that I have seen a single article demonstrate with real world data that computers and EMR’s are saving lives. Let’s get the data before we spend a few billion dollars and find we have to do it all over again.

  3. Very interesting post. Using a completely integrated solution which combines EMR and practice management would seem to be the best way for a new practice to start so that there are no “islands of data.”

  4. Can anybody show me objective, reproducible, evidence that an EMR actually SAVES money? – remember, I’m not talking about making more information more available – I means evidence that would persuade a hard nosed accountant that it was a good FINANCIAL decision. pLEASE REPLY VIA EMAIL – CVALLEN@POL.NET – CV ALLEN M.D.

  5. MEDICAL RECORD AWARENESS: REQUESTING AND EXAMINING YOUR MEDICAL RECORD IS THE FIRST STEP IN COMMUNICATING WITH YOUR PHYSICIAN!
    Teacher inspired by her students to raise awareness about medical record errors. Teacher/Entrepreneur Eunita Winkey and founder of ATWINDS Foundation, Inc. (A Teacher’s Work Is Never Done Services) will host and moderate a Health Care Community Discussion conference call on Medical Record Awareness. She is a victim and survivor of medical record errors. She believes that in order to save lives and decrease medical cost, electronic medical records should be mandatory just as electronic credit records. What do you think is more important medical records or credit records? Do you know what’s in your medical records? To join the Health Care Community Discussion visit http://www.atwindsfoundation.org for the conference call schedule and rules.
    This is my story what’s yours!
    At some point in our lives, each one of us will visit a physician and put our lives in the physician’s hands. However, the stakes are high in the medical profession because misdiagnosed illnesses or incorrect medical information could cause grave consequences. Health care professionals should be held at the highest possible standards since medical errors can seriously affect the decisions that are made regarding our health, possibly resulting in irreversible health results or even death. Errors made by healthcare professionals are often swept under the rug, even when serious damages are the result. As an educator, it is my responsibility to educate and be an advocate for our communities by sharing my medical record story. If I had been educated on the importance of requesting my medical records during my treatments, I would not have experienced such a tragic outcome of a total hysterectomy and suffered the emotional and physical stress I have had to endure since my hysterectomy. In 1998 at the age of 39, I was beginning a new life with a second marriage. My husband and I did not have children and anxiously anticipated starting a family. However, that anticipation was shattered in the wink of an eye by a life-altering experience with an in vitro fertilization (IVF) physician and obstetrics-gynecologist (Ob/Gyn). The treating IVF physician visited me during my consultation at the Ob/Gyn’s office. I felt very special when the physician traveled to see me for an appointment, and I was also relieved by the referral to the IVF medical center. However, I later learned that it was unethical for the Ob/Gyn to refer me to his IVF physician-friend. Always be cautious when accepting a referral from another physician. Conduct your own research by using the Internet or get referrals from family members or friends. Out of 15 doctor visits, my name was misspelled 10 times, e.g., my first and last name were completely misspelled—not just a simple typo. Treatments and other information were also incorrectly recorded in the Ob/Gyn’s notes, e.g., treatments that I requested were never noted. In addition, the hospital that performed my surgery had another person’s name listed on my record, instead of mine. My medical records also revealed that the Ob/Gyn had held a conference with me prior to my hysterectomy concerning the complications and side effects of the surgery, but that was untrue since there had been no such discussion with him or anyone else. A review of the Ob/Gyn’s records left me speechless, and it did not dawn on me until later that the IVF physician’s notes were also false. On my husband’s semen profile, the andrologist documented that his semen analysis was completed at 10:00 a.m. on May 10, 1998. However, our first appointment was not until May 11, 1998, which is the date my husband’s semen sample was taken. My husband and I are still wondering what happened to his semen sample since that information was not documented in the medical record. In 1997 at age 38, I started trying to conceive a child by taking Clomid fertility drugs. However, in 1999, the IVF physician signed a report stating that I was 49 years old, which was 10 years older than my correct age of 39. No date of birth was listed on the report to bring attention to the error. In addition, the IVF physician stated that I had previously taken two cycles of Clomid treatments in 1987. This was a false statement since I did not begin taking Clomid treatments until 1997. My chances of becoming a mother at 39 would have obviously been greater than at age 49. Unfortunately, I did not learn of this error until 3 years later. When the IVF physician reported that the first fertility treatment had failed, I requested a second fertility treatment but was immediately turned down due to my age, which was incorrectly recorded. The failed fertility treatment was not noted in my medical records. However, the Ob/Gyn records indicated that the IVF physician had recommended a total hysterectomy, but the recommendation was made 3 months before I began the IVF treatments. As a result of the 10-year error in my age and other false statements noted in my medical records, I was given a total hysterectomy (removal of my uterus, cervix, both ovaries, and fallopian tubes) that left me scarred for life. I immediately became very depressed and was prescribed Paxil for my depression. Following the surgery, my body was immediately thrown into full-blown menopause without any prior discussion regarding these devastating side effects. For the first 2 years, I only slept about 2 hours each night due to the severe hot flashes and night sweats that kept me awake. For the past 6 years, some areas of my body are numb and there is no feeling, even when I pinch myself. In addition, the nerves in my body are damaged due to the absence of my female organs and, at times, my life seems very foggy. Some of the other side effects experienced by myself and other women who have had this surgery are loss of sexual desire and arousal sensation, joint and muscle pain, painful intercourse, displacement of bladder (which may cause incontinence or other bladder problems), bowel problems, nerve damage, high blood pressure, varied body odor, loss of short-term memory, personality changes, and irritability. Hysterectomy side effects are life long, and no treatment or drugs can replace ovarian or uterine hormones. My life and marriage have been under great stress since my hysterectomy. According to the Centers for Disease Control and Prevention (CDC], “Hysterectomy is the second most common surgical procedure among women of reproductive age and will affect more than a quarter of all U.S. women by the time they reach the age of 60.” The CDC also reported that approximately 600,000 women undergo a hysterectomy in the United States each year at an estimated annual cost of over $5 billion. Fifty-five percent of the hysterectomies performed are on women between the ages of 35 and 49. Women between the ages of 40 and 45 are at the highest risk of undergoing hysterectomy, while women ages 15 to 24 have the lowest risk. The American College of Obstetrics and Gynecology is currently entrenched in a controversy stemming from the recent rise in the number of women under age 35 who are undergoing hysterectomies. Many of these women are reporting a variety of problems including early menopause, decreased sexual function, and other medical and psychological problems. There are other alternatives to hysterectomy, depending on the nature of the problem and the age of the patient. Even though many physicians elect surgery, this should only be used a last resort. The three most common conditions associated with hysterectomy are fibroid tumors, endometriosis, and uterine prolapse. Cervical displasia and menstrual disturbances are the most common reasons for hysterectomy in women under age 30. Women ages 30 to 34 most often undergo hysterectomy due to endometriosis, while the most common reason for hysterectomy among women ages 35 to 54 is fibroid tumors. In women ages 55 and older, uterine prolapse and cancer are the most common reasons for hysterectomy. If a woman suffers from fibroids or myomas, the physician should consider the size of the lesion and determine whether or not it is causing problems for the patient. Many times, doctors opt to “watch” the fibroid for changes and evaluate the patient annually instead of performing surgery. If the fibroid is one of the 5% that cause intrauterine bleeding and severe menstrual pain, there are also ways to treat it aggressively without resorting to hysterectomy. These include D&C or endometrial oblation, where the lining of the uterus is literally scraped, or uterine artery embolization, where the blood flow into the fibroid is severed in order to stop its growth. Another option to consider in the case of fibroids is the use of the drug Luperon, which stunts the growth of the lesion. Fibroids are highly sensitive to estrogen and progesterone, and they are literally “fed” by these hormones. During the onset of menopause, however, the hormone levels drop sharply and, in most cases, the
    fibroids will stop growing. Following a review of my medical records by a hysterectomy expert, it was determined that I did not have a severe case of endometriosis or large fibroids as was documented in my medical records, thus, my hysterectomy surgery was totally unnecessary. Although the cost of the IVF treatment was $16,000 for one 6-week cycle, my medical insurance provided me with a 6-month referral, which would have covered two more cycle treatments. However, due to the serious medical record errors, the IVF physician refused to give me the opportunity to try and procreate. Citizen must request copies of your medical records from all health care providers every 6 months or annually because you have a legal right to all of your medical information. Once you receive your medical records, be sure to examine them for accuracy and question any medical inaccuracy.
    10 Ways To Make Sure Your Medical Records Are Accurate Make sure you request all medical records from doctors, make several copies of all medical records and read each line of your medical records carefully.
    · Make sure you examine all of your medical records with the aid of a medical dictionary, drug or pill book. As you read your medical report highlight what you do not understand.
    · Make sure that all names, ages, date of births, social security and patient identification numbers are correct and listed.
    · Make sure that all names, ages, date of births, social security and patient identification numbers are correct and listed.
    · Make sure that all names, ages, date of births, social security and patient identification numbers are correct and listed. Make sure all dates and time of services are noted and correct.
    · Make sure you compare all reports for accuracy from your doctor office, hospital, lab, and pathology.
    · Make sure all doctors and other healthcare staff signatures are on your reports.
    · Make sure that all conversations between you and your doctor are accurate to the best of your knowledge.
    · Make sure all treatment options, medications, and side effects are noted.
    · Make sure you research all medical terms, illness, and treatments using the Internet or medical manuals.
    · Make sure you have other non-bias experts examine your medical records.

  6. MEDICAL RECORD AWARENESS: REQUESTING AND EXAMINING YOUR MEDICAL RECORD IS THE FIRST STEP IN COMMUNICATING WITH YOUR PHYSICIAN!
    Teacher inspired by her students to raise awareness about medical record errors. Teacher/Entrepreneur Eunita Winkey and founder of ATWINDS Foundation, Inc. (A Teacher’s Work Is Never Done Services) will host and moderate a Health Care Community Discussion conference call on Medical Record Awareness. She is a victim and survivor of medical record errors. She believes that in order to save lives and decrease medical cost, electronic medical records should be mandatory just as electronic credit records. What do you think is more important medical records or credit records? Do you know what’s in your medical records? To join the Health Care Community Discussion visit http://www.atwindsfoundation.org for the conference call schedule and rules.
    This is my story what’s yours!
    At some point in our lives, each one of us will visit a physician and put our lives in the physician’s hands. However, the stakes are high in the medical profession because misdiagnosed illnesses or incorrect medical information could cause grave consequences. Health care professionals should be held at the highest possible standards since medical errors can seriously affect the decisions that are made regarding our health, possibly resulting in irreversible health results or even death. Errors made by healthcare professionals are often swept under the rug, even when serious damages are the result. As an educator, it is my responsibility to educate and be an advocate for our communities by sharing my medical record story. If I had been educated on the importance of requesting my medical records during my treatments, I would not have experienced such a tragic outcome of a total hysterectomy and suffered the emotional and physical stress I have had to endure since my hysterectomy. In 1998 at the age of 39, I was beginning a new life with a second marriage. My husband and I did not have children and anxiously anticipated starting a family. However, that anticipation was shattered in the wink of an eye by a life-altering experience with an in vitro fertilization (IVF) physician and obstetrics-gynecologist (Ob/Gyn). The treating IVF physician visited me during my consultation at the Ob/Gyn’s office. I felt very special when the physician traveled to see me for an appointment, and I was also relieved by the referral to the IVF medical center. However, I later learned that it was unethical for the Ob/Gyn to refer me to his IVF physician-friend. Always be cautious when accepting a referral from another physician. Conduct your own research by using the Internet or get referrals from family members or friends. Out of 15 doctor visits, my name was misspelled 10 times, e.g., my first and last name were completely misspelled—not just a simple typo. Treatments and other information were also incorrectly recorded in the Ob/Gyn’s notes, e.g., treatments that I requested were never noted. In addition, the hospital that performed my surgery had another person’s name listed on my record, instead of mine. My medical records also revealed that the Ob/Gyn had held a conference with me prior to my hysterectomy concerning the complications and side effects of the surgery, but that was untrue since there had been no such discussion with him or anyone else. A review of the Ob/Gyn’s records left me speechless, and it did not dawn on me until later that the IVF physician’s notes were also false. On my husband’s semen profile, the andrologist documented that his semen analysis was completed at 10:00 a.m. on May 10, 1998. However, our first appointment was not until May 11, 1998, which is the date my husband’s semen sample was taken. My husband and I are still wondering what happened to his semen sample since that information was not documented in the medical record. In 1997 at age 38, I started trying to conceive a child by taking Clomid fertility drugs. However, in 1999, the IVF physician signed a report stating that I was 49 years old, which was 10 years older than my correct age of 39. No date of birth was listed on the report to bring attention to the error. In addition, the IVF physician stated that I had previously taken two cycles of Clomid treatments in 1987. This was a false statement since I did not begin taking Clomid treatments until 1997. My chances of becoming a mother at 39 would have obviously been greater than at age 49. Unfortunately, I did not learn of this error until 3 years later. When the IVF physician reported that the first fertility treatment had failed, I requested a second fertility treatment but was immediately turned down due to my age, which was incorrectly recorded. The failed fertility treatment was not noted in my medical records. However, the Ob/Gyn records indicated that the IVF physician had recommended a total hysterectomy, but the recommendation was made 3 months before I began the IVF treatments. As a result of the 10-year error in my age and other false statements noted in my medical records, I was given a total hysterectomy (removal of my uterus, cervix, both ovaries, and fallopian tubes) that left me scarred for life. I immediately became very depressed and was prescribed Paxil for my depression. Following the surgery, my body was immediately thrown into full-blown menopause without any prior discussion regarding these devastating side effects. For the first 2 years, I only slept about 2 hours each night due to the severe hot flashes and night sweats that kept me awake. For the past 6 years, some areas of my body are numb and there is no feeling, even when I pinch myself. In addition, the nerves in my body are damaged due to the absence of my female organs and, at times, my life seems very foggy. Some of the other side effects experienced by myself and other women who have had this surgery are loss of sexual desire and arousal sensation, joint and muscle pain, painful intercourse, displacement of bladder (which may cause incontinence or other bladder problems), bowel problems, nerve damage, high blood pressure, varied body odor, loss of short-term memory, personality changes, and irritability. Hysterectomy side effects are life long, and no treatment or drugs can replace ovarian or uterine hormones. My life and marriage have been under great stress since my hysterectomy. According to the Centers for Disease Control and Prevention (CDC], “Hysterectomy is the second most common surgical procedure among women of reproductive age and will affect more than a quarter of all U.S. women by the time they reach the age of 60.” The CDC also reported that approximately 600,000 women undergo a hysterectomy in the United States each year at an estimated annual cost of over $5 billion. Fifty-five percent of the hysterectomies performed are on women between the ages of 35 and 49. Women between the ages of 40 and 45 are at the highest risk of undergoing hysterectomy, while women ages 15 to 24 have the lowest risk. The American College of Obstetrics and Gynecology is currently entrenched in a controversy stemming from the recent rise in the number of women under age 35 who are undergoing hysterectomies. Many of these women are reporting a variety of problems including early menopause, decreased sexual function, and other medical and psychological problems. There are other alternatives to hysterectomy, depending on the nature of the problem and the age of the patient. Even though many physicians elect surgery, this should only be used a last resort. The three most common conditions associated with hysterectomy are fibroid tumors, endometriosis, and uterine prolapse. Cervical displasia and menstrual disturbances are the most common reasons for hysterectomy in women under age 30. Women ages 30 to 34 most often undergo hysterectomy due to endometriosis, while the most common reason for hysterectomy among women ages 35 to 54 is fibroid tumors. In women ages 55 and older, uterine prolapse and cancer are the most common reasons for hysterectomy. If a woman suffers from fibroids or myomas, the physician should consider the size of the lesion and determine whether or not it is causing problems for the patient. Many times, doctors opt to “watch” the fibroid for changes and evaluate the patient annually instead of performing surgery. If the fibroid is one of the 5% that cause intrauterine bleeding and severe menstrual pain, there are also ways to treat it aggressively without resorting to hysterectomy. These include D&C or endometrial oblation, where the lining of the uterus is literally scraped, or uterine artery embolization, where the blood flow into the fibroid is severed in order to stop its growth. Another option to consider in the case of fibroids is the use of the drug Luperon, which stunts the growth of the lesion. Fibroids are highly sensitive to estrogen and progesterone, and they are literally “fed” by these hormones. During the onset of menopause, however, the hormone levels drop sharply and, in most cases, the
    fibroids will stop growing. Following a review of my medical records by a hysterectomy expert, it was determined that I did not have a severe case of endometriosis or large fibroids as was documented in my medical records, thus, my hysterectomy surgery was totally unnecessary. Although the cost of the IVF treatment was $16,000 for one 6-week cycle, my medical insurance provided me with a 6-month referral, which would have covered two more cycle treatments. However, due to the serious medical record errors, the IVF physician refused to give me the opportunity to try and procreate. Citizen must request copies of your medical records from all health care providers every 6 months or annually because you have a legal right to all of your medical information. Once you receive your medical records, be sure to examine them for accuracy and question any medical inaccuracy.
    10 Ways To Make Sure Your Medical Records Are Accurate Make sure you request all medical records from doctors, make several copies of all medical records and read each line of your medical records carefully.
    · Make sure you examine all of your medical records with the aid of a medical dictionary, drug or pill book. As you read your medical report highlight what you do not understand.
    · Make sure that all names, ages, date of births, social security and patient identification numbers are correct and listed.
    · Make sure that all names, ages, date of births, social security and patient identification numbers are correct and listed.
    · Make sure that all names, ages, date of births, social security and patient identification numbers are correct and listed. Make sure all dates and time of services are noted and correct.
    · Make sure you compare all reports for accuracy from your doctor office, hospital, lab, and pathology.
    · Make sure all doctors and other healthcare staff signatures are on your reports.
    · Make sure that all conversations between you and your doctor are accurate to the best of your knowledge.
    · Make sure all treatment options, medications, and side effects are noted.
    · Make sure you research all medical terms, illness, and treatments using the Internet or medical manuals.
    · Make sure you have other non-bias experts examine your medical records.

  7. David, It is encouraging that your perspective on the role of electronic medical records in the context of small physician practices is based on widespread innovation in the American Academy of Family Physicians. This experience and your comments emphasize the importance of changing the model of health care to create a new team model including the patient. Let’s ask that Obama and Daschle set up guideposts and standards that encourage effective change in health delivery, going far beyond new software systems that record information only to support traditional behavior.

  8. Dr. Kibbe, I’m an admitted babe in the woods here with tons to learn but I have to tell you that your use of the phrase “better health care” seems vague and somewhat hackneyed, akin to the idea of “improving health”. (Noble but not highly quantifiable.)
    My Family Medicine husband has, off the cuff, these main problems:
    1) a reimbursement system tilted towards the doc who can see plenty of patients rapidly;
    2) a generally older, high complexity patient base with multiple problems (which he likes and does well with) that generally do not fit into a rapid visit format;
    3) A documentation framework that isn’t serving him. He uses a mix of dictation and paper templates that leaves him constantly behind. (An experiement in EMR about 5 years ago initiated by a partner was totally disastrous and not time saving.) He needs a documentation system that is responsive to his individual style and recognizes the unpredictable nature of family medicine visits. And that does not typically involve him keyboarding in anything except perhaps unique documentation of the points of discussion and recommendations and referrals.
    4) Ideally this system would gin out some kind of summary sheet of the visit, concerns and recommendations when a referral was needed that would integrate some PMH, current meds and problems, and perhaps HPI of the reason for this visit. This would promote timely information exchange with a referred specialist.
    5) It would facilitate billing and maximizing his billing
    6) It would allow him to input data into a PDA/Treo for charging hospital visits and it would be real time and go directly to his billing department.
    7) It would output information to the patient that would summarize the visit and reiterate patient recommendations and medication instructions.
    8) I guess it would electronically transmmit prescriptions.
    But it doesn’t seem like systems are organic and they don’t seem to really answer the core problem: A quick and easy to use documentatios system that reflects the unique nature of Family Medicine visits and their range from the acute sinusitis to the follow-up of the multi-system impaired elederly patient. I personally think that this is the core thing that wears my husband out. And I think that if this nut were cracked, other issues would soon follow.
    So, I realize my basic newbie-ness here. What do you mean succintly when you say “improve patient care”. There may be some summary document you’ve already published that says this…
    I’ve been reading Dr. Bean’s comments and others and while I realize that data is a much more trendy phrase, most doctors (aside from lab data) don’t deal so much in data as they do information. When you integrate knowledge about a person, their family, their community, their wishes, their disease state and it’s particular point of progression and their goals for their health, you really don’t come away with that many data points. Often with elderly patients that my husband sees, he’s dealing with, say a person who is on a research based medicine protocol designed to maximize cardiac function BUT the crux issue for the patient is they cannot afford OR tolerate OR feel as well as they want to on that regimen. If your outcome measurse is blood pressure or CRP or cardiac ejection fraction, the patient may “worsen” based on med changes but the patient may subjectively feel better and be willing to make the trade-off.
    Just a mish-mash of thoughts. This is a fascinating blog.

  9. Got a quick update here: Implantable RFID chips are already in use at some major hospitals. They are harmless, and just make sure the patient and his data set are in the right place at the right time so nobody gets lost and nobody loses the wrong kidney.
    Imagine a chip that can be a permanent implant which contains all the patient’s records and which is updated with all lab, diagnostic testing, and visits with a doctor at the time they occur. It is almost here, and it will be the greatest thing for doctors. They wouldn’t need to chart anymore because it would all be stored in the patient. Nobody would waste hours of staff time faxing, e-mailing, and calling for old records.
    Every decision and note would be permanently etched in the memory chip. (Every mistake too, so lawyers will be happy).
    Patients could upload claims from a computer terminal to the government or to big insurance companies or their employers, or whoever else has access to this data.
    It could also surreptitiously record the patient’s travel habits, purchasing habits, and lifestyle habits. ( But hey, who would do such a thing?)

  10. Thanks to David, Ted, Cyril and all. I think of this as The Great Kibbe Debate, the gift that keeps on giving, at least to the non-specialist 🙂
    Every time I tune in, I learn more.
    And thanks, Ted and I are in contact. And David, I would like to hear how you altered your TN talk, if at all, after this blog, and if anything on this post helped you reach that audience more effectively.
    Or, if the political and economic news just obviated half of these issues.

  11. Many of the issues discussed in this blog are addressed in our Healthcare IT Public Policy White Paper which can be found in the News section at http://www.amcisnetwork.com . The white paper is written from the vantage point of innovative EMR companies that want to improve physician adoption in a cost-effective manner with minimal interference in the private market. I hope that you have a chance to review it and see how the recommendations in the white paper could benefit our nations healthcare system.

  12. Thanks, Ted. And thanks, Christine. I’m certainly not an expert on the health IT systems at Kaiser, either those primarily for physician and staff use, or those offered to patients as a PHR. But I hope that Christine will take up the kind offer from Ted, and meet with him to discuss how to improve it. This is extraordinarily generous as an offer, and I know Ted to be a sincere person in all respects.
    Part 2 of Confessions tomorrow. DCK

  13. Christine,
    Great comment about transparency. I hope you will keep expecting it from your health care system – all stakeholders. I will, too.
    On that note, I want to also say that the comment about Kaiser Permanente’s electronic health record is not reflective of my experience at all, and I’ve known the KP HealthConnect team since it was formed, in 2003.
    I have a little bit of extra experience recently because I’ve actually been reviewing all of the data about this project in the work I am doing right now, and it’s very clear that patient/member experience is front and center in the way the system is designed, and the way its value is measured.
    As I mentioned previously, I am beginning to post information about Kaiser Permanente and the KP HealthConnect project on my blog. A presentation I gave covering the patient-access side of things is here.
    Maybe there are other questions, concerns, or thoughts that people have about the Kaiser Permanente HealthConnect project, so here’s my offer:
    Feel free to send any question to me via the contact form on my blog:
    http://www.tedeytan.com/contact
    …and I will either get you the information you are looking for or connect you to a KP expert who will.
    If you are in or near a region with a Kaiser Permanente medical office, I will work to connect you with an expert locally, as well.
    The goal is not to show perfection – we want to be accountable to improve the things that need to be improved, and that happens best when everyone has accurate information.
    I’m actually spending some focused time with the team this week, and will be happy to deliver the feedback/questions, so send away.
    With respect,
    Ted
    (Ted Eytan, MD, The Permanente Federation)

  14. Then (to clarify my own thinking), the question is not whether all stakeholders’ interests are represented in your discussion, but the difference between their relative financial power and the actual weight one gives their specific interests in finding an IT solution.
    Kaiser chose an IT system, it appears, where the primary focus was billing and coding, excluding the patients, their customers, almost entirely. You can’t pay lip service to patients and then “forget” their existence while expecting a viable outcome.
    Again, patient access to records creates transparency. This is the first step in identifying error, demanding accountability, rectifying deceptive or inefficient practices, and correcting an unhealthy balance of power.

  15. But David, de facto you’ve already segmented out distinct players in this debate — physicians and tech companies — and mainly forgotten two others, patients and insurance companies.
    If the US healthcare system were a medival kingdom, that would be like leaving serfs and the Privy Council out of a debate on economic transformation. Some of the latter, you might note, are already quite “servantlike” in their position — I don’t think its the patients who need lessons in humility, nor nurses, come to think of it — while others are so powerful they can afford invisibility.
    Given way this debate has unfolded, if you leave insurance companies out of the equation, meaning you demand no accountability, I would guess this leaves them laughing all the way to the bank.

  16. Christine: There are a lot of problems with the current health plan system in the US. Too many plans, too many benefits programs, too much paper work, too little reward for efficiency and quality….etc. But it’s probably not helpful to single out one component of this dysfunctional set of systems to place most of the blame upon. Patients, doctors, hospitals, health plans, the feds, the device companies, etc. etc. all need to change and move from the death spiral-cum-speculative bubble-cum-hardcore denial scenario that we’re all in, and which Esther Dyson has called a “calcified hairball.”
    I, too, hope that the Obama administration is listening, and that they’re going to be able to shock “the system” back into some reasonable behaviors on the part of all of us. We need a healthy citizenry to face the challenges of the future on this planet. We are all citizens. We are all brothers and sisters, mothers and fathers. We ought to care deeply that health is made available to all within the limits of our resources. We ought to care that people die in dignity and peace when their time has come. We ought to care that our health care professionals — doctors, nurses, health plan CEOs, pharma executives, and device company managers — are not primarily concerned in making deals and getting rich, but are truly servants. Regards, DCK

  17. David,
    To make a system work, what kind of political reform do you envision for insurance companies? It seems from the above, that the sticking point (or one) for physicians is that insurance companies are inflexible. Why should taxpayers subsidize innovation while insurance companies extract the same high (and mysterious) level of profit from physicians and patients?
    Perhaps the real IT revolution is for the patient-physician nexus to rebel against the headlock that insurance companies have on everyone. As currently envisioned, the insurance-physician nexus is doing a patient lock-out. This frustrates and angers physicians, who can only innovate within very narrow parameters, and increases physician-patient hostility.
    Note we hear from everyone on this site BUT insurance companies. Even though members of this tribe must read THCB, apparently none of their reps are jumping forward to defend practices. They don’t seem to be screaming from frustration or complaining about prices or profits.
    I hope someone from the Obama administration is listening.

  18. Christine: The VA’s system is of great interest to me. I did some consulting for the VA on its design way back when, and it’s a great system. The problem is that it’s incredibly difficult to replicate in other communities where the health care practices, hospitals, and pharmacies are not owned by a single entity. It is the epitome of a centralized, massively supported health IT architecture. Kaiser has a similar situation and infrastructure, whether one likes it or not.
    And, in both the Kaiser and VA there is alignment around payer, provider, and patient interests…or at least there is much greater alignment than in most community settings, where data are isolated and fragmented, almost impossible to aggregate as is done in the VA and Kaiser, and where this fragmentation leads to more care that someone has to pay for. Hence, a vicious cycle that encourages waste and duplication, and not prevention or coordination. And problems of neglect for the patient.
    It will be incumbent on the Obama administration to encourage more Kaiser-like and VA-like behaviors in the community-based and independent health care system, perhaps by paying differentially higher amounts to quality health care organizations that can share information, coordinate care, and provide a better and more continuous patient experience. Participatory medicine is going to grow and expand if this happens, because so many people — doctors and consumers alike — are ready for the change. Regards, DCK

  19. So, to sum up for the uninitiated:
    Richard has a patient-centered system (PHR) that works for the patient-physician relationship, and allows for patient control-privacy, but doesn’t profit the physician except through greater efficiency, better patient care and interoperability but doesn’t interest the physician-insurance nexus;
    Kaiser spent a zillion dollar on a system that is efficient in terms of coding, billing and intra- and perhaps inter-institution communication, but they FORGOT (or deliberately excluded) the patient;
    Integrating IT for mid-sized practices which allows for efficient staff use, billing, and physician use but mostly forgets the patient is an experimental hair ball and does not allow for interoperability (meaning ease of referrals, which don’t profit those practices);
    The VA, which tracks the patient for life and is the model for the possibilities for a successful single payer system, has IT which works with regard to billing, coding, interoperability and serves the patient’s interest, but is not of much interest to Dr. Kibbe’s project . . .
    What’s wrong with this picture?
    (and yes, I agree with XRay, that HIPPA is used mainly against the patient; sorta ham handed like No Child Left Behind)

  20. R. Ferreira is correct. The patient must assume some responsibility for his/her own health. When patients call the office for a prescription refill, 90% of the time, they cannot tell you what medication they are on, or what their dosage is. Only a programmable medical chip could manage this information efficiently, and the technology is mature. Mr. Ferreira, please post this link again!
    HIPAA was supposed to protect the patient from abuse/ commercialization of their healthcare information. Instead it has resulted in a fearful kneejerk reaction where summer camps have parents filling out HIPAA forms, and hospitals denying critical information to primary care physicians calling about the patients they admitted!
    At the same time, I personally have received marketing materials from a competitor pharmaceutical company for a condition which I really do not want publicized!
    None of the protection which is promised. Additional penalties and work for everyone involved. That is the typical result of “There Ought to be a Law.”

  21. The problem with many existing systems are:
    1. They work only in a Local Area Network (LAN) or Wide Area Network (WAN). This means they work within that particular provider’s system but cannot be accessed by anyone else.
    2. They are designed to sustain a specialty need (a hospital environment or a subspecialty of medical practice).
    3. They are designed by vendors to store data and are not aimed at the creation of a usable record depending instead on what is input.
    What is needed is simply an electronic record that is owned and controlled by the patient and secondarily by the physician. All physicians can input their data and it is accessible to the patient and all other physicians with proper permission by the patient to view the information. It is NOT (emphasized) accessible by any other institution (government or private.
    The EMR is owned by the patient and not by any hospital, clinic group, physician, software vendor, other enterprise, be it governmental or private. The processes to accomplish this and the methodologies to assure privacy and control exist.

  22. David
    A basic primer w/ issues statement would be good to tie different audiences into the discussion. For many people, the IT angle is the least interesting or the most intimidating
    Btw. I just asked my daughter’s ortho surgeon who was best in terms of HIT and she said the VA hands down. Kaiser is good for everyone BUT the patient.

  23. Christine and others: In my Part 2 Confessions blog post, I’m going to articulate 5 capabilities that I think are most important for health IT to provide or enhance in the framework of participatory medicine. I call the health IT that provides or enhances these capabilities “empowering health IT.” While I think that knowing health IT terms is important, I think it’s more important to understand and agree on the tasks and capabilities we’re trying to accomplish or create via some kind of health IT product, service, or application. If we start there, perhaps we’ll have fewer acronyms, or, at least they’ll be more meaningful. 😉 But I’m glad to do a basic primer of IT terms, too, if that will help someone. Regards, DCK

  24. Great discussion! Amazing what one can learn when all sides of a discussion are represented. — except insurance. One senses if the macro problem was solved — the stranglehold insurance has on physicians and patients– the microproblems of tech innovation might disappear.
    Insurance has two customers/serfs: physicians and patients. As consumer / participants, neither group is well served . That says something pretty bad about the last eight years of
    “free market”/corporate activity in the US.
    Two ideas: challenge/invitation to Dr Kibbe to create a primer of basic IT terms, most of which appear here, for posting on thcb and e-patients.net. This is a win-win in that it serves a novice physician audience (present company excepted except me) and it provides patients a portal to enter into the conversation.
    Thanks to Malcolm and Ferreira for presenting solutions which work…one upshot of the systems you describe is that of demands reasonable levels of patient literacy. Which is a good thing and accords with the emphasis of the oncoming administration. Literacy.

  25. I sit here each day and read through the comments on this blog and note the number of instances where local area responses are provided (Kaiser and Mayo)and also comments relating to costs (billions of dollars) to implement such a system. Yet in my comment I provided an existing product with full capability and there is no comment back.
    The need is now and it would not take ten years to implement nor cost billions of dollars. Insurers have seen the product as have physicians and both want it. It is a universal application of existing technologies without any programming to learn. It is simply point and touch and then read. The information and data is all there and is up-to-date.
    Why does there seem to be no interest in such a product?

  26. This is a great discussion. It truly highlights that health care reform will not occur by fixing one thing — but that there are several steps that need to be taken in tandem for true, patient-centered reform to occur.
    I work with the Mayo Clinic Health Policy Center — for the past two years, we’ve gathered more than 2,000 stakeholders including patients and patient advocates, health care providers, large and small employers, and representatives from insurance, medical industry and pharma, the government and academia. When these people have gathered, face-to-face, at dozens of events, they have discussed and agreed on four principles (and specific steps to take) to achieve reform: coordinated care, creating value (reducing error, improving patient outcomes, increasing patient satisfaction, focusing on wellness), payment reform, and insurance for all.
    Health IT (EMR and PHR) and interoperability is a key component but, as stated earlier, providers also need to learn to collaborate and work together and the payment/reimbursement system must be redesigned to reward that behavior. We need to move away from a fee-for-service model and think about (and pay for) health care that keeps people as well as possible over time. That includes management of chronic illnesses so catastrophic events are prevented, a focus on improving access to and rewarding primary care and preventive care, and making sure that providers are rewarded for delivering good outcomes more efficiently over time.
    In April, we will be gathering patients, health care educators at all levels, government groups, and related societies and boards for a Medical Education Reform symposium. The goal is to look at how we educated and train all our health care professionals — and what needs to change to produce a work force that can deliver the kind of health care reform that is needed. I encourage you to check it out on our Web site. And keep the conversation going!

  27. American Medicine is anything but Free Market. Unlike a visit to your auto mechanic, where you pay a skilled laborer for services rendered, you do not pay your doctor.
    Your insurance pays your doctor. Your employer pays your insurer ( out of what could be your bigger paycheck). Your employer tries to find the most affordable insurance. Your insurance company makes a profit (and awards tens of millions to its CEO) by taking in your premium and by not paying out claims. Since you must use a doctor contracted by your insurer you are limited to whom you can see, and “taking your business elsewhere” is meaningless. Since your doctor isn’t paid by you, it isn’t his concern whether you waited an hour or two, or whether you are improving. He has to see 40+ people just as important as you to cover costs or he will be fired for not meeting productivity standards.
    The patient experiences this disconnect as bad care, but thinks, “Thank God I had insurance, or it would have ruined me.” The reality is, you pay a $20 copay, the doctor gets $30 from the insurance company. The insurance company sends you an “EOB” which tells you how much money you saved based on an exaggerated “customary charge,” which is a made up figure used to extort you into buying insurance.
    Sadly, the only people who must pay this “customary charge” are the uninsured. The insurance company has the doctor sign a contract which states that if any patient receives care for less than the customary amount, that same discount must be offered to all patients on that insurance plan. BANG! The end of cash discounts. BANG! The end of charity care.
    The latest payer development is to base “usual and customary charges” on Medicare rates. Even five years ago, an office seeing 25 patients a day would lose $10 per person at Medicare rates.
    What this adds up to is a system only one group is happy with. Patients are run through like cattle. Doctors are doing assembly line work at an impossible pace, producing ‘payment codes’ for a wage that is less than that of a mechanic, and constantly fearing that everything they have will be taken from them by a lawsuit. The only winners are the insurance companies. If you think they will not find a way to win with Obama in charge, then you greatly underestimate their power and longevity.

  28. Amen Sister!
    With only a few modifications to the CHIP, a hair-thin electrode leading to the hypothalamus could be used to induce AGONIZING PAIN whenever the Physician even considers his own needs.
    Just so you know, the average length of visit with a patient is now under 6 minutes. You see, physicians spend 80% of patient visit time documenting and coding, reviewing other physician’s reports, and ordering referrals and other paperwork; there are no martini lunches. Often there are no lunches at all!
    Effective January there won’t even be free pens in the waiting room (sorry all you sticky-fingered sick people, but doctors are so easily swayed by free pens that they keep prescribing the newest and most effective medicine instead of the cheapest, oldest, and ineffective medication your insurance wants to use, so the pens are gone!).
    In short, any Doctor who thinks he should be paid a middle-management wage in exchange for a high risk, demanding, unforgiving, thankless job, and who thinks the 8 extra years of training, the 120 hour weeks of labor, the 90+ hour shifts, and the hundreds of thousands in debt racked up, somehow entitle him to charge a fee that is as much as that of a HAIRDRESSER or god forbid, a PLUMBER, had best re-think his career path. During residency you will make about $1.25/ hour. During your career, after expenses, you will make about $45/hour.
    For comparison, United Autoworkers average $73/hour.
    Previous poster, just out of curiosity, who do you consider the hyper rich?

  29. To X-Ray
    And this would be an even more fun project if we implanted the same chip in the physician population and the hyper-rich.
    Wow! Then we’d see some ril health care solutions. No more martini lunches. No more scapegoating members of one population by a population with sufficient wealth to hide its own addictions and poor health habits.

  30. Until patients can be brought into the communication loop in a way that can be utilized by the undertrained medical staff that represent New Medicine in America, no amount of digitization will help.
    UNLESS!!!: A programmable chip similar to the RFID tag could be IMPLANTED in the patient and UPDATED each time that patient receives medical care, a prescription, a lab, or a scan.
    FURTHERMORE, it would not be difficult to program this same device to communicate with grocery store scanners where information such as diet, cigarette, or alcohol consumption could be UPLOADED. Indeed, it is a short step to communicating with the patient’s vehicle where road speed and driving habits could be integrated therein.
    With only a few tweaks, payers of healthcare would have the data they would need to deny coverage based on real data, poor life decisions, and risky behaviorS, rather than for made up reasons like, “Not Medically Necessary.”
    I’m sure we would all be willing to accept the implant of such a chip. It is for the Greater Good!

  31. Malcolm, I think you’re onto something. Slowly but surely, more physicians and medical practices are moving their health IT budgets away from EMRs and towards web portals and data transfer systems that are, as you say, affordable and pragmatic. I do believe some of this motion is the result of patient and consumer input to the practices, and awareness by the physicians that they have a web savvy and services hungry patient population. They’re looking out for themselves first, but they’re listening to their kids, their friends and neighbors, and their patients, and they’re hearing this message: don’t make me wait, and don’t keep me ignorant! Please communicate.
    Coordination of care is based on communications about care. It’s the opposite of working in isolation. It requires a high signal to noise ratio, but open channels at all times. Things happen that aren’t expected.
    I agree with you, Malcolm, that this is happening in a grass roots and community by community fashion, not as a result of huge top down programs from the government. Regards, and thank you for your comment. DCK

  32. The contradiction in the above arguments is that software engineers and physicians generate IT systems for medicine, but the only genuine measure of success is patient satisfaction.
    Designers and engineers create cars. If customers don’t like them, however, the business goes under.
    Given the above, would one wish to consult patients first or last, as an afterthought, to create a successful IT system for medicine?
    How did things get so backwards in medicine?
    In our free market medical system, patients seem less like consumers and more like pawns.

  33. Dr. Kibbe,
    Your post addresses a fundamental but often overlooked challenge. EHRs, when well implemented, have done much to provide timely access to data, reduce errors, and in some instances improve quality. But EHRs and other technology advances have yet to facilitate one of healthcare’s most crucial needs: collaboration.
    As widely reported, the incoming Obama administration has plans to fund healthcare IT to the tune of $10 billion annually, under the mission of improving efficiency. Despite the best of intent, most of the dollars invested in HIT under the existing administration has yet to facilitate the kinds of grassroots collaboration necessary between small and large practices throughout America. Further federal investment in healthcare IT must be spent on pragmatic solutions that are affordable, easy to use by a doctor, and provide real results in increased mobility to the data residing in average family practices – data that is vital to the health of U.S. medicine.
    I’m not asking for grand new technology schemes or describing another smoke and mirrors utopia of healthcare revolution. On the contrary: not only does this technology already exist, it’s working today in clinics around the country. Physicians are already taking simple steps, like integrating secure email and other everyday technology into their existing workflows, to widely share information, practice medicine resourcefully and without technology limitations. With this, physicians are:
    – Transferring referrals and consultation reports electronically between practices so they move faster than the patient;
    – Supporting eCurbsiding between providers;
    – Communicating with patients electronically to avoid unnecessary office visits and provide more coordinated care ;
    – Notifying patients of necessary and recommended treatments by secure email, and reminding them when appointments are due;
    – Eliminating the patient clipboard and paper-based billing.
    Physicians that embrace these pragmatic standards can collaborate and coordinate care with colleagues, whether or not they’re in the same building, the same neighborhood, or the same health system. Taking a more practical approach to our technology, we can realistically get physicians back to their roots – providing quality patient care.
    Malcolm Costello
    SVP Marketing and Strategic Relations
    Kryptiq Corporation

  34. The Plane Ad
    Hooray! Hooray! for Ted.
    Hooray for David if he can elaborate on the concept of alignment and offer a single product/experience, a prototype where alignment works to the satisfaction of mid-sized medical practice like J Bean’s. Then we have a common reference point other than ideological (i.e., IT is common sense).
    On the plane home from NY, I glanced at a US Airways magazine ad by Magic Johnson. Johnson said the key to business success was satisfying the CUSTOMER, not the owner. When HE chose from his array of sports products, he didn’t make money because consumers didn’t share his taste. When he paid attention to what consumers wanted, everyone won.
    Still, the great IT system and dedicated doctors doesn’t explain why Kaiser tends to kill its sarcoma patients absent ACOR or e-community emergency intervention. (see “In the Spin . . . ” e-patient.net). One suspects there are other factors at work within the Kaiser billing/profit structure — like foot dragging on referrals and refusal to accept “niche” expertise within a reasonable window of action.
    The thing about lawsuits, by most standards endorsed by the AMA, in California, for instance, the patient has to be more than dead to prevail on a lawsuit. The fact that patients prevailed on sarcoma lawsuits against Kaiser (and I will double check the information, Ted) is pretty scary.
    Sarcoma is the prototype of rare cancer. Tracking a sarcoma case is like injecting dye into a patient: it demonstrates beyond a shadow of a doubt where the blockages are.

  35. Respoding to Ted Eytan: Yes, the term “virtual Kaiser” is first and foremost a reference to the patient experience, or the replication of the best of the Kaiser experiences, but outside Kaiser. I think it is more than that, too. Kaiser (or Kaiser-like) organizations unite payer, provider, and patient perspectives pretty darn well. We often speak of this as “alignment.” And they’re huge, have lots of health IT, and are generally managed professionally. The term “virtual Kaiser” begs the question: can we create this alignment in communities or regions where there is not single ownership, and currently not this alignment yet? How would we do that? Certainly, the kind of health IT I’m describing in these Confessions posts are part of that answer. Hope this is helpful. DCK

  36. David/Christine/all,
    I just caught this thread and I appreciate (of course) the interest in a great patient experience and the reference to the patient-centric tone of my blog post, above.
    I’d add the information that my enthusiasm comes from being a Permanente physician for the past 13 years and seeing/being part of a system that’s driven by its structure to do right by its members/patients.
    With that in mind, can I ask you to look at one more blog post of mine? It’s about my trip to the medical centers of Kaiser Permanente’s Georgia Region:
    http://www.tedeytan.com/tag/georgia
    Before anyone suggests failure of a system, go to where care is being provided and see for yourself. It’s remarkable to see what the care experience has become with a mature, functioning, electronic health record and personal health record.
    I know you mention a “Virtual Kaiser,” David, and from that I take that the goal is not to replicate the business model, the goal is to replicate a great patient experience. It’s why we’re all here,
    Ted

  37. Before making my comment I want to identify myself as a retired physician with 20 years of private and group clinical practice and 20 years of management and executive experience in a large multispecialty group as well as a major healthcare insurer experience. I have worked with an organization for several years to develop a tool for physicians that creates an electronic medical record. The product has been developed and it works but has not come to the marketplace for reasons beyond this commentary.
    The product I describe is handheld and was designed to function in the same manner as physicians currently function. Through the use of technology incorporating a smart card, a specific electronic tool with Bluetooth, cellular, infrared, remote server(s) and existing biometric technology, the physician can do all of the following.
    1. In compliance with HIPPA only an authorized physician can review the individual patient’s complete medical history (or as much as has been provided and converted to electronic digital data), all results from laboratory testing, radiological and imaging diagnostics, past medical history, vaccinations and medications.
    2. The physician can then record his/her observations by direct dictation to the system which is transmitted electronically for transcription into the system through the server.
    3. The physician can electronically submit the claim to the patient’s insurer with all procedures converted to a proper CPT code and all diagnosis listed by their correct ICD-9 code.
    4. The physician can also electronically create and submit a prescription to the patient’s pharmacy provider and never issue a prescription for which the individual has a known allergy.
    5. All data is compiled and stored in an infinity file at the server level and is updated continually.
    All of this is possible and it does not cost thousands of dollars at the individual physician level for implementation. It is not a tool designed by or for researchers, academicians but for a tool to help create a quality process of record keeping at the individual patient level. Other companies are developing tools to meet very specific specialty needs, researcher focused aids, academic and other special interests. These interest should be ancillary to the EMR and physicians should return to a concept of treating patients and not systems.
    By the way, there is no programming to learn, no computer language to learn. All that is required is the ability to look at an icon and select a specific area of interest on the touch sensitive screen.
    The technology exists and physicians who have seen the prototypes have been anxious to have one for use in their practice. By the way, the system can be used worldwide and can be applied in the field (ambulance, police, fire), the emergency room, the hospital and anywhere where there is WiFi, GSM or cellular connectivity.

  38. Response to Barbara Lavery’s comment: First, thank you so much for taking the time to recount your experience. It would be funny if it weren’t a tale of discomfort and confusion. And none of it has to be like that! We’ve designed it that way, as absurd as that sounds. Un-designing it, and then re-designing it, is going to be difficult…but it’s possible.
    I’d also suggest that you find another group of providers, if you can. This one sounds quite disorganized and ineffective, to say the least. Regards, DCK

  39. I sat next to a geneticist on a plane to NY two days ago. We discussed these various issues of communication among groups with disparate interests, the powers of the Internet, the role of imagination in research — what his field, and required/creative collaborations will look like in five years — as well as what it took to simplify these advances and vision for political debate and funding.
    I’m not sure what the solution is, but I do know that there are key people with specific skills who are positioned to facilitate discussion. After the conversation on the plane, I am interested in hearing more about how pathologists as a group arrived at current technological solutions. I know that techno advances in this field are such that scientists in a lab at one university may share slides/diagnostic issues with teams in other countries in real time. I am curious about how they got to this point. I have yet to hear a pathologist talk about cost:benefit ratio or be bitter or angry about technological innovation.
    From the above discussions, the EMR transition sounds very rocky for GPs and mid-sized medical practices, and a disaster for Kaiser on a large scale.
    So where’s the daylight? What works? Where’s the glitch with mid-sized practices? Existing systems of reimbursement from insurance companies?
    Perhaps that is where the change needs to be addressed first.

  40. Recently, I have had more doctor visits, tests and prescription drugs than in my entire 41 years. I put it down to people being like cars – once you fiddle with one part something else gets broken 🙂

    Anyway, as a way to keep myself entertained while waiting in doctor’s offices, hanging out in the ER, and waiting in line at Walgreens, I decided to start tracking my “Patient as a Consumer” experience in this blog. Starting with the ER here’s the story so far:

    The ER – The ER is a scary place! Nobody seemed to really know anything and the switch from frantic activity (saving the life of the lady next to me) to drug-induced bliss (me on morphine) to the completely bizarre (nurse yelling at old man with severe Parkinson’s to keep his arm still) was like being in several parallel universes at the same time. After ten hours of tests and waiting and morphine dreams, I was sent home with some pain killers…

    My “Patient as Consumer” ER experience – glad they saved the lady, sad for the man, wish I’d stayed home…

    Bills – I’ve never seen so many bills! I have counted nine multi-page bills so far mostly full of codes that I cannot decipher for tests for which I have yet to receive documented results. I have insurance so mostly I am covered but for the amounts I do have to pay I tried to use my HSA credit card – it didn’t work. HSA bank said there was nothing wrong with it – docs office said there was – same thing at Walgreens. So I paid with my non-HSA credit card meaning I replaced my tax-free money put aside for healthcare costs with my regular money.

    My “Patient as Consumer” bill paying experience – confusing, overwhelming, and unresolved…

    Diagnosis – I’ve been told “everything is fine” and “you’re perfectly healthy” so that’s great but there were also some details of what I was tested for, why, and subsequent precautions I should take, that I’d like to have – also every doctor – there have been four – have interpreted test results differently and then ordered more tests to test their interpretation – mostly resulting in more bills (see above) Scariest part is that I do have one small issue that I should “monitor” and “if it becomes a problem, just go in the ER and they’ll take it out…” seriously I am quoting here…

    My “Patient as Consumer” diagnosis experience – vague and open to interpretation…

    Medical record – Every doctor of the four I visited asked me to verbally tell them what my problem was even though all of them with the exception of the ER doc (!) had access to my medical records and are all part of the same practice network. My suggestion that they look it up fell on deaf ears even though two of them had laptops in their laps while they were talking to me. Had it been a business meeting I think I might have fired them…

    My “Patient as Consumer”personal consultation experience – disconnected, repetitive, circular…

    Electronic Medical Records! – My doctor’s practice has actually implemented an electronic medical record system. There are signs all over the office thanking patients for their patience while this was completed. I have been a very patient patient and I was excited to think I would actually be able to have up-to-date records available electronically from my doctor.

    I get the feeling that someone has forgotten to tell the doctors! As I told you above none of the four doctors I have repeated my symptoms to appear to have consulted earlier test results or my medical record before or during our little chats.

    I finally thought I’d just ask for the EMR myself and bring it with me on my laptop to my next doctor visit. So I called and asked – “Hi I would like to access a copy of my electronic medical record please?” “Can you hold please?” 3 minutes later, “Oh.. Hi I would like to access a copy of my electronic medical record please?” “Sorry what do you need?” “I would like access to my electronic medical record” “Your doctor will have to request that…” “Ok, my doctor is there, can you ask her?” “The doctor is not in the office today, can you hold please…” and so on, and so on…

    I am still without my EMR, a diagnosis, and haven’t ever had any calls back from doctors to discuss test results even though they all said they would. I can’t imagine how I would feel if I was really sick…

    My “Patient as Consumer” overall experience – I was patient, my money was consumed, and I now understand how very, very far we have to go before patients, health and care are truly at the center of the healthcare system.

  41. Tim: Thanks for your comment. But I’m a little confused by your statement about the “paradigm used by HL7 (and specifically the CCR.” The CCR standard is very much not an HL7 standard, nor is it patterned or modeled after anything that HL7 has done. Please see http://www.ccrstandard.com for more information about the CCR standard, and then let’s talk. By the way, how are you liking your time in Brazil? Regards, DCK

  42. WOW!
    Dr. Kibbe has certainly started a firestorm of comments that should be consolidated into some kind of permanent document. There are so many great comments and replies here that I believe they are essential to moving forward.
    A key point that was missed in many of these comments is that interoperability between applications is essential. We MUST drive to the point of a common information model. The messaging paradigm used in HL7 (and specifically the CCR) does not contain the full semantic context needed for real computability and interoperability. The CCR is okay for legacy systems that need to transfer summary information.
    However, the CCR is NOT a true information model for healthcare. It is just another “patch” in our 45+ year legacy of expensive health informatics incompetence in the US.
    Adoption of a well engineered, well governed information model such as is embodied in the openEHR specifications http://www.openehr.org are more akin to TCP/IP and HTTP for healthcare. These approaches are the tested and proven solutions to real interoperability and systemic cost saving in healthcare information technology.

  43. This is a fascinating set of comments that hit on so many topics.
    I’ll pick up on just one point, raised by Christine Gray and not much responded to by others, and that’s the question of what kinds of culture or mindset lead to collaboration and teamwork.
    She asked about our state, which has Mary Selecky as Secretary of Health. Washington has a female governor, both U.S. senators are female, the member of Congress for my district is female, the Senate majority leader in the state legislature is female (and represents the district that includes both my neighborhood and my campus), and at one point (not sure whether it’s still true after the recent elections) we had the highest percentage of women in the state legislature of any of the states.
    At one point on my campus, nearly every bench scientist was a woman. We’ve hired a few more men since then 😀 but we definitely have strong female leaders and thinkers. As one example, Signature Genomics was founded by a Washington State University graduate and WSU Spokane research scientist, chromosome biologist Lisa Shaffer. Inc. Magazine recently named her one of the top female CEOs of private companies in the nation, and Signature Genomics is #114 on their list of the 5,000 fastest-growing private companies in the U.S. She founded the company, which makes cytogenetic diagnostic microarrays, with a (male) research partner–another form of collaboration.
    We recently had a health IT workshop here, facilitated by experts from Vanderbilt. They told us that the collaborative opportunities in health IT that we have in Spokane are genuinely unique (an overused word, but true in this case).
    It’s an exciting time to be here as we build a new campus from the ground up (the oldest building opened in 1996) and a new culture. We have the advantage of not having to remove existing silos.
    Yes, our faculty hires are coming out of the traditional mold, but we are recruiting for entrepreneurial thinkers who are fine researchers and oriented toward becoming part of a team. Speaking as a person who is sometimes a patient, but always responsible for her health behaviors, I hope our new culture includes the individual person at the heart of all of this as a member of the team. I believe it will.
    If any of you are on Twitter, I’d be interested in following, and/or reading blogs you recommend. I’m building my understanding of health IT as rapidly as I can, as we’ll be going to the legislature with a funding request looking to expand our research agenda and establish a master’s degree.
    Campus Twitter account (which I manage): @WSUSpokane
    Personal: @BarbChamberlain

  44. Responding to Jane Jacob, one of the reasons I am addressing the physician audience with this set of messages is that I assume consumers/patients/citizens will begin to demand better communications and the right to access their own health information.
    It’s a slow process of awareness that having access to your health information could be beneficial to you. It’s work to get it and organize, because the health care professionals generally don’t yet support this level of patient participation in their own care.
    But it’s coming, and there is a growing community of physicians and other health professionals who are supportive. Perhaps not yet a critical mass, but getting there.
    Look for the term Participatory Medicine as, perhaps, the flagpole around which this group of health care professionals rallies. Regards, DCK

  45. Jane,
    Thanks very much for your comments, and the specifics. Patients need to know this.
    Although it might be a dominant physician perspective, I don’t think people can imagine solutions when they think only of the bottom line. That divides communities against each other.
    They have to think of a positive, do-able endpoint, which you described very succinctly. I think David does this with his audiences; I am just late to the game.
    Patients can’t “hear” the conversation if it is about profit. I know it’s relevant, but I don’t think you can build to that endpoint without some notion of teamwork, which Barb Chamberlain described very well with regard to a dominant culture of information sharing in Washington state.
    Also, I don’t think the physician audience can underestimate the sense of disenfranchisement that patients experience toward the health care system, particularly if they’ve been burned by a bad diagnosis. Just by PHRASING outcome from the patient standpoint, Jane got buy-in and dropped my patient-anxiety level.

  46. Responding to Christine Gray: Absolutely, the patient MUST be at the center of not only Health IT but all of health care reform. Through my work with the Mayo Clinic Health Policy Center, I’ve met many patients who tell horrific stories of trying to keep track and gather up their records from all of the providers they have seen — and with chronic and complex medical problems, this can become a full-time job that the patient should not have to do.
    Two of the specific recommendations that came out of the Health It forum we held were:
    — Individuals have the right to access their health and medical information. Individuals should have flexible choices about the use of that information (i.e. allow all requests or be selective about use).
    — Providers and other stakeholders should maintain and have access to the information, with appropriate protection for patient privacy.
    As has been pointed out previously, EMR and personal health records can be interoperable. Patients should have access to and control over everything that pertains to their health — accessibility and privacy can go hand in hand — when the hand belongs to the patient.
    No system will be perfect, but the more coordination and sharing of information we can achieve the better care we will be able to provide.

  47. Double oops!
    That would be Susannah FOX who posted an excellent piece on effective use of PHRs on e-patients.net. 🙂
    Sorry, I must have been foaming at the mouth. L Bean’s post on the possibility of killing the patient and the word “error” just triggered something in my mind.
    The Fox piece raises the question: What does the system look like if patients are driving innovation?
    And still, the question: Who has legal liability for errors? Who is MOST motivated to keep the record straight?
    Correction to an electronic error can be immediate, whereas a lost record or referral on paper creates a potential cascade of errors, with potentially ugly results (for the patient).
    See “In the Spin . . . ” on e-patients.net.
    See also the emergence of Sarcoma Hitperson in the same piece. There’s a point where the tragedy just turns to farce.
    I am beginning to think e-patients should look more toward Hollywood for solutions. I don’t even believe this stuff when I read it in print. I just recall the horror, and the crushing responsibility of making an “informed” decision for a cancer surgery for a child in such shaky institutional settings, where every doctor is either saying, “Trust me. I’m an expert,” or “My colleague so-and-so is the best” but they keep losing records, they don’t talk to each other, and you can’t verify their credentials.
    Worse yet: Now I have a grudge against Quizno’s sandwich shop 🙂 I want to kick in their FedEx box.

  48. Thanks for chiming in, Dave. I wish I had the technological expertise to bridge both worlds. Many people still don’t understand how ACOR lists work. No one is asking permission, or checking profitability. We are working as fast as we can, pooling resources and working with existing technology to save the lives of our loved ones.
    Susannah York just posted an excellent piece on PHR’s that work on e-patients.net
    I don’t understand why PHR’s can apparently work so well, and how this relates to the tangle of issues concerning EMRs.
    I have come to conclude that the EMR interoperability problem is primarily political in nature. Innovation lags because no one can guarantee the flow of profits. Monster health insurance companies, like their cousins on Wall Street, have gone virtually unchecked for the last eight years. It truly boggles the mind to contemplate what it will take to unravel the mess.
    I really appreciate J Bean’s post
    //The idea that a change in software might cause you to make a mistake and kill somebody is a pretty big impediment to “social will”. These are real costs and considerations for making thes kinds of changes. In the case of EMR, it’s not clear to me that the benefits outweigh the considerable costs.//
    The question I have re: PHR’s is who is legally liable should there be an error? Surely they must have some sort of confirmation check off system built in.
    I would like to be more Pollyanna in perspective, but surely the glitches in a new EMR system pale in comparison to the strong of manual record-idiot errors that occurred in my daughter’s case.
    I watched a clerk in Nuclear Medicine at Idiot Hospital #1 MANGLE the information on her in-take form. I wanted to grab the woman by the throat, throw her out of the chair and type it in myself. When we transferred from IH#1 to the more competent (we hoped) Hospital #2, we couldn’t set up an appointment because the the tumor board couldn’t meet because no one could find the ____ing film at IH#1. They were not in Medical Records; that was a different department.
    The film was finally sprung loose after H#2 threatened a lawsuit. (There was the very real possiblity that IH#1 delayed transmission of records so their legal teams could go over the information to defend against a possible lawsuit. Naturally, the head of Patient Relations just had to be the wife of the chief oncologist. For the unwary, Patient Relations units are housed in the Legal Department.)
    Meanwhile, my daughter had a half-excised tumor which disseminated through the blood sitting in her arm, killing her. Or not. “Don’t worry, mom” said the very excellent (cosmetic) surgeon at IH#1 whose colleague in oncology had somehow failed to include a copy of the path report from a nationally known expert — the one with the REALLY bad news — in my daughter’s records: There was no rush to do the re-excision surgery. That would be the same day that the NCI POB and MSKCC teams checked in, screaming, “Why is that tumor still in there?!”
    Oh, and did I tell you the one about the clerk from the county hospital where the “whoops!” procedure was performed misreading the FedEx schedule at Quizno’s sandwich shop? Day after agonizing day we waited for the slides to arrive at IH#1 so the experts there could confirm the diagnosis. Everyone scrambled, assuming the slides were lost in the mail. Nah, they were just sitting in the FedEx box at Quizno’s during the long holiday weekend. I could have WALKED there with the slides by the time they figured that one out.
    I really don’t see how the glitches in a new EMR system could be worse than this.
    Really.
    btw The office that did excellent work coordinating records was that of my daughter’s PCP, her pediatrician.

  49. I see this through a variety of different lenses. On the one hand I’m a patient empowerment geek, active member of the e-patient scholars working group, having gotten there via the route of a patient who used “e” in a wicked fun cancer adventure last year. Unlike Christine’s family, I wasn’t screwed by the system, but I got to see plenty of what doesn’t work well, even though my hospital (Beth Israel Deaconess) is a pioneer in EMR.
    I’ve been frustrated by referral delays and idiotically ancient billing systems. But I also had my life saved by leading-edge oncologists in my field, superb nursing staff, and by a physically and mentally brilliant surgeon who did astounding things with my innards (a laparoscopic nephrectomy under nasty circumstances where success meant life or death). I owe my life to all those people.
    In my day job I’m a technology business guy who’s observed process transformation before. I’ve seen how inefficiencies make an old system vulnerable, ripe for replacement. But I’ve learned to keep an eye out for the telltale influences, the fulcrums if you will, that provide the leverage that cause the boulder to tip in a new direction, or not.
    Last spring I learned of PCPCC and its emphasis on the medical home, and the Dartmouth data they cite about the difference in cost and outcomes when medical home is a reality. It’s stupid that this country isn’t leveraging a model that so clearly works! Stupid! So I really WANT primary care practices to succeed. (Disclosure: I’m now a patient advisor to PCPCC.)
    And this is why I’m very interested in what David’s pointing to: I want this system to work better. I’m the first to admit that I only started studying this field in 2008, but I think he’s exactly right when he says

    Health IT needs to empower all providers to act as effective members of a team which includes the patient, medical home, specialists, and ancillary service providers such as pharmacists and lab technicians.

    The tagline on the e-patients web site says “Because health professionals can’t do it alone.” Nor should they; nor need they. Enormous amounts of value (real, life-altering medical value!) are being generated by and between patients, completely outside the fortress walls of the traditional medical establishment. (It was members of my ACOR peer community who told me I was at the right hospital to get the best care.) No less a visionary than Clay Shirky expressed this at the Connected Health Symposium last month, saying about ACOR, “They don’t need our help, and they don’t need our permission.” Anyone who plans for the future without realizing this will miss the boat.
    btw, I feel for Dr. J. Bean’s practice. Too often in different industries I’ve seen well-meaning people get honked into buying a new system that just seems to be what everyone’s buying. Without thinking it through before purchase, that’s what can happen. Vendors who do that are unconscionable, imo.
    And that leads back to part of David’s original point: merely computerizing bits of the old process isn’t going to accomplish a thing. The driving value, the “tipping point” value proposition, will come from doing completely new things with the data that weren’t even imaginable before it got online. (That requires cultural change, too.) We must accomplish this.
    Finally, to return to my self-interested patient lens: I want you guys to make better use of our data – and your own internal data. C’mon, get with it! Get modern! This isn’t rocket science, and it certainly isn’t a life-saving laparoscopic nephrectomy. This is a business problem, not a medical miracle.
    David’s right when he urges people to think things through, to a new world, rather than dressing the old pig in new clothes. That method is frustrating for everyone, including the pig and the people with the new clothes.

  50. This is a great discussion. I hope in the last few comments, vis a vis putting primary care in charge of IT, that all discussants assume that the IT system, in addition to being accessible to the patient, will also be interoperable with whatever hospitals the patient may attend, or outpatient surgery facilities, outpatient radiology facilities, freestanding laboratories, etc., etc. Every point of contact of the patient with the healthcare system needs to be connected together – and this becomes very complex. Also keep in mind that people move – so what will happen if Christine and her daughter move from California to the east coast?
    This is why I believe nothing short of national leadership, be it government-sponsored or not, is crucial. Otherwise we will continue with this patchwork of IT systems where some can access the patient’s data and some cannot.

  51. I agree with Dr. King’s suggestions to have PCPs coordinate patients’ electronic health records. I don’t quite understand the ins and outs of how insurance companies rip off physician practices, but I’m sure they are good at it 🙂
    My question: Given that the implicit assumption here is that physicians will innovate if the systems work and profits can be guaranteed, what is to stop physicians from using the increased efficiency to add more patients to their practices, thereby increasing their own profits but not substantially improving patient care? What is to guarantee that insurance companies will pass savings on to their customers given how insurance companies operate?

  52. I commend you on your pursuit of the EMR integration. You are absolutely correct on all accounts. The fundamental problem that we all face as physicians, regardless of admission, is that it does drain us financially to institute IT.
    Many of you may work for a large group and are thus not as sensitive to the IT cost(although I doubt this is the case since the larger you are the more expensive your IT system will have to be and thus the more it will cost). The fundamental problems as I see it are many; 1. there are far two many hands in the medical money pot as someone already alluded too. We happen to have chosen a profession were there is only so much money to go around and we are all vying for it from the business side of medicine. Unlike most other industries medical professionals are capped on revenue generation. We all get paid the same no matter what our office looks like, how much or how little IT we integrate, or how many staff members we employ to be more efficient. Thus, every dollar spent on Efficiency decreases net profits (which are already too low, at least in primary care). 2. Patients and health care insurance industries appreciate the IT on the front end but not on the back end (a patient loves a high tech office and efficient procedures as long as he does not have to directly pay the bill, insurance companies love to have you in the system but refuse to pay you one dollar more than the doctor down the street with a 1950’s office design, an the top knotch Orthopedic surgeosn get paid the same money for the same procedure as your good local general Orthopedic surgeon, it just does not matter) 3. Due to the above there is no time in the day and no extra money for an office to institute more man/women power to keep yet another system updated for the benefit of the community (the me factor), and I don’t blame them either.
    Solutions for such a dilema then must start with basics. Dr Greens comments and thus overall message was perfect. We have to conrol cost. By doing so we eliminate the Insurance companies taking the patients premius, building $1 billion dollar cash vaults that are earning tons of interest, paying multi-million dollar CEO salaries, paying $25,000 plus to hundreds of psuedo-board members that sit on these Board of Director position for the Insurance companies, and put this money back into the hands of the professionals providing the health care.
    The next step to integrate EMR is to realize that one person or entity will need to be the administrator of this system whose primary purpose is to make it work for the benefit off all. The most appropriate person for this task is the Primary Care Physician. Let the surgeons, Cardiologist, Neurologist etc do their job. Let the primary care team truly manage a patients health. This would mean a transformation in the way in which we view priamry care but a much needed transition if we are going to make change. We must remember (as President Elect Obama has shown) that change comes from the ground up. Not the top down. We need a health care system that pays primary care to manage the health of patients instead of paying us to run around with our heads cut off. How is a doctor suppose to manage diabetes, htn, cholesterol, and obesity in a 15 minute vist? I will blog about this on my own site in more detail but I like the EMR push by Dr Kibbe. I appreciate Dr Oates who commneted and has spent years developing a wonderful EMR program which I have used since 2001 (soapware) and Dr Greens comments on Universal health care system.
    Dr Kibbe, if you could image putting the responsibility on the primary care specialty to mange health care and IT then we have a chance. Someone must be responsible for making sure that any changes in a patients health care program (medicitions surgeries etc) is being looked at from a holistic approach to benefit the patient. Lets change what Primary care means and start managing peoples health care. I will post more on this issue on my own site. Sorry for taking up so much space. http://medicalhealthcarecrsis.typepad.com/webblog/

  53. My practice chose a big name EMR because it saved us $1-2M or at least $15K per doc. As it is, it cost us over $25K not including the loss of business due to the change over. Presumably no one is going to be sued for malpractice due to system breakdown during the change period. I also haven’t figured personal cost due to the increased work load into the total costs.
    If, somehow, we were able to force our specialists to use RelayHealth, what would stop Talbert or Harriman-Jones or any of the other big groups from demanding different communication tools? Do the private practice and small group guys have to buy servers and hire IT departments? In France the government provides a communication structure to docs. Individual docs have to buy a couple of PCs and download a little software. Would that not be a more reasonable solution? Define standards and let the HIT vendors compete to build and maintain a federally supported set of tools. It works in the defense industry.
    The change in work flow is the main reason that docs are uncomfortable with the change to EMR — not cost. When I was a systems/software engineer, I built military training systems which were complex software based tools for coordinating the activities of large groups of people. Military trainers had the same “insufficient social will” about making a similar transition. The idea that a change in software might cause you to make a mistake and kill somebody is a pretty big impediment to “social will”. These are real costs and considerations for making thes kinds of changes. In the case of EMR, it’s not clear to me that the benefits outweigh the considerable costs.

  54. Responding to J Bean: There are a number of classic elements in your wonderful post that are worth repeating –
    – your practice chose an EMR because they had a legacy relationship with the same company’s billing system…
    – the medical director is a “wanna-be techie”…
    – workflows change, and it’s “actually a pretty big systems engineering issue” (which no one appears to have realized prior to the implementation…)
    – you “seem to be stuck with ‘Fax-Net'” because colleagues to whom you refer can’t or won’t agree upon one system for secure email and health data exchange with you… (RelayHealth would work fine, as would several others, if people would agree to use it together and put pressure on RH to improve it.)…
    – only a minority of patients are ready to take advantage of the “internaut” services you’d like to provide, which gives anyone who wants it a convenient excuse for holding back on innovation…
    Thanks for your comments. They should put you in charge of their next efforts to utilize health IT in the practice.
    Regards, DCK

  55. Responding to Jane Jacobs, YES! — this is all about making better health and health care decisions for people/patients/citizens. Perhaps there is a formula here: collaboration and integration = coordination and continuity = quality improvement and cost savings. Of course, this is too simple. But it does focus on the objectives that health IT ought to attempt to meet. Regards, DCK

  56. “In August, the Mayo Clinic Health Policy Center gathered 30 leaders in Health IT in Chicago — represented were health care providers, information technology experts, privacy advocates, academia and employers. They achieved consensus on a series of recommendations about ownership and privacy; interoperability, infrastructure and standards; and adoption.”
    This is a great post, but my question, again, is Where’s the patient in this? “Academia”? “Privacy?”
    I thought patients were legal owners to their records, so where did they stand in this dialogue? You discuss privacy, but not accessibility.
    With physicians and technology companies as the two primary (if not only?) “stakeholders” in the debate as currently constructed, how can the results possibly purport to support patient interests?
    One footnote: Due to the difficulties of my daughter’s case, pathology slides were sent to multiple institutions for evaluation, meaning the original block was depleted. Each lab/institution, as is customary, kept them as part of their path research “library,” which is fine if it helps educate people. They are, however, the legal property of the patient, which no one (except the certified case manager) bothered to inform us.
    One distinguished physician at the aforementioned institution, eager to review the slides for his latest monograph, stained the last two w/out permission when it was unclear if we needed reserve materials for future medical testing re: chemo. sensitivity.
    HIPPA in practice has been subverted by medical institutions to block patient access to records (see “In the Spin” on e-patients.net).
    I appreciate J Bean’s comments re: the frustrations of medical practices adapting to existing programs. Again, is the technology currently available, or not? Technology companies, for sure, are focused on profit, as are physicians.
    The patient seems like an inconvenient footnote to these discussions.
    I hear of car companies going under and patients dying of poor medical practice in the current economy, but I have yet to hear of doctors going under. The bar seems to be set pretty low for their “frustrations” as compared to the rest of the populace. In contrast, as evinced in some of this discussion, the bar for expectation of reimbursement for time expended on innovation and adaptation (risk for profit) seems to be pretty high as opposed to other professions, say engineering or teaching or restaurant work.
    I have to laugh. Yesterday I was instructed to wait in a waiting room for information on a follow-up appointment on a fairly frightening (for the patient) subject. After 30 minutes or so, I knocked on the door just to see if the wait was indefinite. Oh, sorry. Someone forgot to inform me they didn’t need me to stay.
    Get it, folks! They just FORGOT the patient. If a real business did that, they’d go under. I don’t think “consumer” is quite the right word here. And certainty you have to wonder who coined the word “patient” in this business.
    “I don’t know what line of work you are in Christine, but if you were asked to spend an extra 15 hours per week doing the same job that you do now with no additional improvement in any aspect (and less money!) you’d probably find that you had “insufficient social will” too.
    //
    The line of work I was in when I encountered pediatric oncology was the “mom business.” Try losing your job and almost your home and oh yes perhaps your child’s life in a continuing stream of uncertainty and medical ineptitude fueled by Sarah Palin-style arrogance and then we can discuss frustration, inefficiency and who is most strongly motivated toward change. These experiences are documented on thcb and on e-patients.net re: the Gina Kolata articles in the NY Times.
    As a cultural anthropologist, I am curious about the social and class dynamics at work here. Also, as per Dr. Kibbe’s enterprise, I am trying to see if, as an outsider, I can offer any daylight into advancing the agenda since IT, as I have noted above, is a critical first step in creating an educated, “activated” patient.
    The flow of information as currently structured is guaranteed to keep the patient ignorant, thereby preserving the doxic or taken-for-granted imbalance in power that characterizes the American medical system. Ergo the disconnects in the present dialogue. (Even as they complain about the new medicine, my South Asian doctor friends would do almost anything to insure that their children enter the profession, and it is not out of altruistic motives.)
    That is why e-medicine communities have leaped ahead. The folks on the ACOR (ACOR.org) lists are trying to keep their loved ones alive. They lost sight of the bottom line a long time ago.

  57. “Why would an 80+ provider group with an existing IT department make this kind of expensive error?”
    I’m relatively new to the practice and the purchase decision had been made when I started. However, there were several mistakes made. I think the people making the decision did not have as much sophistication about the issue as they needed, but the big driver was cost. We’re an all primary care group and not as rich as other multi-specialty groups. This particular package was less expensive for us (at a mere $1.5M plus $500K for data conversion) because we already owned and used the coordinated billing package. We already had a paperless office and our IT department has built a P4P tool that we have sold to other groups. Unfortunately people were overly confident and no one saw the need to hire an outside consultant for the selection and implementation of an EMR, but the package we did buy is a big name EMR, so we aren’t the only group to have purchased this clunker. We have certainly heard from other groups anecdotally that it can take as much as a year to regain your old level of productivity after implementing an EMR and that many people/groups don’t ever get back to the old levels.
    Following my husband about on career moves, I’ve worked for three different groups now and this is the first one that took the plunge on an EMR rather than wobbling uncertainly at the edge of the cliff. EMR implementation is starting to loom as a P4P issue and our management (i.e. medical director) is kind of a wanna-be techie, so they jumped. Our management and, I suspect, many of the people who criticize “doctors with insufficient social will” don’t understand that substituting an EMR for a different record keeping system is not quite as simple as installing a new word processor on your home computer. Not only do you have a new computer package to learn, but with the EMR, the work flows throughout the office require a complex reworking and relearning. It’s actually a pretty big systems engineering issue.
    I don’t know that there is a tool that would make it possible for our specialists to communicate with us more effectively. We mostly work with private and small group specialists. They’d have to have access to compatible communication software. Although we are big enough to benefit from an EMR, our specialists aren’t, and we aren’t big enough to force them into an EMR. For now, we seem to be stuck with “Fax-net”. We have experimented with Relay Health for patient communication, but that hasn’t been particularly popular with either the patients or the providers. It’s clunky and didn’t interface with our old data sources (who wants to e-mail their patients’ results, if they have to re-type the damn values themselves?). We’re still trying to decide whether to stick with Relay Health or switch to a different package for the patient interface tools. My patients who tried to use Relay Health were equally unenthusiastic and found it kind of frustrating. Our patient population — at least in our office — is older and blue-collar and computer access is not as universal as we netizens (the French say “internauts”) may believe.

  58. EMR is absolutely necessary…..see below how a national health insurance single payer based EMR can improve health care for all Americans.
    The Call to Action/Health Care Reform 2009 proposal released 11/13/08
    (http://www.finance.senate.gov/) by Senator Max Baucus is a disaster.
    The Baucus plan is an expansion and continuation of the status-quo
    mixture of a government subsidized ineffective private health
    maintenance insurance industry operating parallel to and within Medicare
    Insurance.
    7 Specific Reasons Why the Baucus Health Reform 2009 Plan Fails…..
    1) The Baucus plan fails to enroll all Americans in a single payer
    National Health Insurance such as the most efficient health insurance
    plan (Medicare) which is already contracted with most doctors,
    hospitals and clinics in the Country. Medicare has the lowest operating
    expenses and the best morbidity (sickness rates) and mortality (death
    rates) compared to all other insurance companies. The Baucus plan will
    therefore divert $700 Billion to $1 Trillion per year away from
    patients, hospitals, doctors, clinics, nurses, pharmaceuticals,
    therapist and researchers into the overhead pockets of health private
    insurance company administrators and executives.
    2) The Baucus plan fails to technologically upgrade, integrate and
    centralize medical billing and records systems in order to optimize
    examination of clinical outcomes, pharmaceutical efficacies and monitor
    fraud and abuse. In addition, by failing to centralize and
    technologically upgrade billing and records systems within a single
    National Health Insurance plan, America will be unable to instantly
    monitor disease outbreaks and instantly respond to natural and man made
    disasters or bio-nuclear terrorism..
    3) The Baucus plan fails to control drug costs by failing to allow a
    single efficient national health insurance company such as Medicare to
    bid on pharmaceuticals. In addition, the Baucus plan by failing to put
    all Americans on a National Health Insurance Plan such as Medicare does
    little to shrink the ‘risk pool’ of insured, thereby failing to decrease
    insurance premium expenses for all Americans.
    4) The Baucus plan fails to provide funding for scientific, clinical and
    epidemiological research and development by allowing private private
    insurance companies to divert funds from medical research and
    development to instead support their massive and profitable
    administrative and executive bureaucratic overheads.
    5) The Baucus plan fails to provide physicians with the same legal
    protection from malpractice lawsuits which have been established for
    commercial health insurance corporations during the last 3 decades.
    6) The Baucus plan fails to explain where to find the 1.5 million new
    health care workers which will be needed once 100 million new Americans
    obtain health care insurance. Health care workers can be found easily by
    shutting down the wasteful and inefficient private health insurance
    companies, putting all Americans on National Health Insurance such as
    Medicare. The 1.5 million former private insurance company bureaucrats
    can then be remployed to actually deliver health care in hospitals,
    clinics, nursing homes, assisted living facilities, pharmacies and home
    health services such as Alzheimer family assistance.
    7) The Baucus Plan fails to address this problem of disenfranchised
    physicians. Many physicians in this country have left the practice of
    medicine, or downsized their practices due to private insurance company
    abuses, malpractice threats and direct pharmaceutical marketing. A
    recent national poll of physicians based on the AMA database
    demonstrated that 60% of physicians support a single payer National
    Health Insurance such as Medicare. A continuation and technological
    upgrading of our most fair Medicare Health Insurance for all based on
    the concepts outlined above, would undoubtedly motivate those
    disenfranchised physicians to return to the profession and bright
    younger physicians to invigorate the field.
    The Baucus plan is wasteful, inefficient, fragmented, creates a new
    redundant bureaucracy and will continue to provide no potential future
    health improvements for America. Only an efficient National Health
    Insurance carrier such as a technologically upgraded Medicare Insurance
    company will be able to provide low cost health insurance and pharmaceuticals
    for all Americans while maintaining the quality of private physician practices and Hospitals.
    H. Green, MD, FACP, FAAD, FACMS

  59. Good morning —
    I would like to support Dr. Kibbe’s point; let’s not lose sight of the main objective here — to provide better care to patients. And I don’t think anyone would disagree that coordination and access to information leads to better quality care (more efficient, less errors). The challenge is always in the details and it’s hard to get to the details without everyone agreeing on the goals and objectives.
    In August, the Mayo Clinic Health Policy Center gathered 30 leaders in Health IT in Chicago — represented were health care providers, information technology experts, privacy advocates, academia and employers. They achieved consensus on a series of recommendations about ownership and privacy; interoperability, infrastructure and standards; and adoption. A summary of their work can be seen at our Web site http://www.mayoclinic.org/healthpolicycenter/healthit.html.
    Health IT isn’t THE solution; it’s one important part of a series of steps that need to be taken by government, providers, employers/payers and patients.

  60. “It’s been a freaking disaster,” Dr. J Bean writes. This is an oft repeated story. The question I have to ask is “Why would an 80+ provider group with an existing IT department make this kind of expensive error?”
    What if your group had started our with a much simpler goal in mind, namely “let’s find a way to improve interactions with outside providers, with our patients and their care givers, and with other sources of important clinical information.”
    Where might that have taken you? I’m asking very seriously.
    Regards, DCK

  61. This is a fascinating discussion in that there are two paradigms at work: the business/profit paradigm (which tends to forget the patient entirely), and the cultural. Apparently the technology is (?) available for inter-connectivity, but there is insufficient social will or profit for physician-providers to implement it.
    Unfortunately, you’re wrong about that. The technology for interconnectivity at present is still vaporware — i.e. it’s a good idea that’s still in the fantasy stage. The EMR products available commercially are very unsatisfactory. They seem to be mostly oriented towards capturing charges and offer little in the way of improved patient care. The multi-million dollar package that my group purchased is so poorly engineered that it requires any additional 25% user time to perform the same amount of work that we did with our old system. I don’t know what line of work you are in Christine, but if you were asked to spend an extra 15 hours per week doing the same job that you do now with no additional improvement in any aspect (and less money!) you’d probably find that you had “insufficient social will” too. We are still stumbling through rebuilding the workflows that allow the providers and the support staff to interact and we have absolutely no way to improve interactions with outside providers. (And what about HIPAA anyway?)
    We are an 80+ provider group with an existing IT department, many servers, and fully wired exam rooms and offices. We didn’t have to upgrade hardware or support staff, we just had to buy a software package. It’s been a freaking disaster. It’s not surprising that smaller groups see “insufficient profit” in implementing EMRs.

  62. To Louis D. Wright, MD: I would look forward very much to a discussion about how genomic information may/will be a “game changer” in terms of diagnosis and treatment of illnesses and risks of conditions. My sense is this is a moment not unlike the x-ray and radiograph; or cultures and antibiotic testing. We may have the power to look directly into the risk profile of individuals, obviating some of our other clinical data collection. So far as I know, there is really no forum for the discussion of how this will impact health IT acquisition and use in primary care, for example. Please contact me to discuss and feel free to blog here at THCB on the topic. Regards, DCK

  63. The obsession over genomic medicine and making sure other types of data is incorporated into EMRs seeing to be putting the cart in front of the horse. Amazed at how much activity/time is spent on areas that are largely secondary/tertiary data issues. Not downplaying the emerging importance of genomic data but isn’t it kind of crazy to obsess about your bathroom faucet fixtures when you toilet and shower either work in a sporadic or antiquated fashion?

  64. David: Today there is a significant driver emerging, Personalized Health Care. As defined, PHC will require a vast interoperable patient and societal database. The imbedded drivers are the patient historic data and Molecular/Genomic medicine. This present session of Congress has left more than twenty PHC bills in the hopper; most are expected to be re-introduced in the next Congress. The underlying consideration is that genomics will take the trial and error out of both diagnostic and therapeutic medicine leading to more specific patient management and, ultimately, lower cost. I recently participated in a “National Summit on Personalized Health Care” facilitated by HHS Secretary Leavitt and Jon Huntsman , Governor of Utah. Yes, the large disciplined integrated systems like Kaiser, Geisenger, Partners and others demonstrated they ‘get it’ and are off and running. Sadly, if you take all these integrated systems, including DOD and VA, you cover 20% of the US population. Our challenge is in community settings where most care is given. It will happen because the science is so compelling. The challenge all of us in leadership positions have is in creating a rational approach to resolving the Information Science issues. I would be happy to discuss what we, in The College of American Pathologists, are developing as an initiative for pathologists. We need to extend our discussions to others in primary care and oncology, and I welcome such informal discussions.
    Louis D. Wright MD, FCAP
    Chair, Personalized Health Care Committee,
    College of American Pathologists

  65. This is a fascinating discussion in that there are two paradigms at work: the business/profit paradigm (which tends to forget the patient entirely), and the cultural. Apparently the technology is (?) available for inter-connectivity, but there is insufficient social will or profit for physician-providers to implement it.
    Barb’s comment is of particular interest in that it details what works — a culture of teamwork and collaboration — on a medium scale.
    I am curious about the gender dynamics at work in her organization — A female secretary of health who encourages collaboration? — and also why commentators did not pick up on this.
    In my experience with children’s hospitals, those with few (if any) women in positions of authority (or even on the oncology staff) were most wedded to authoritarian/hierarchical styles of communication and practice, meaning they had no workable protocols for sharing reports and test results with patients.
    Certainly their version of “informed consent” would not pass muster with the present audience.
    Coincidentally, these physician-teams were the most resistant to second opinions, the least Internet-adept, the most deaf to Patient’s Rights. Certainly they had never heard of participatory medicine. (One pediatric oncologist did, however, invite me to turn my energies to fund raising for a new wing for his hospital, response to a request that his team consider expanding their website and Internet capabilities, which he considered a waste of time.)
    In contrast, I found women, including top “niche” experts, more collegial, less wedded to their titles, more quick to share information, and more willing to clarify the ambiguities and conundrums in my daughter’s case. Plus they didn’t confuse me with the Junior League.
    (And yes, there are several memorable outliers in the pack.)
    David points out that physicians are a mixed crew, which is quite true. For perhaps obvious reasons, I found pathologists as a group to be the most open, the most willing to commit on paper, the most Internet-adept.
    Information is power. At its core, debates about IT are about who is motivated to share, and who is not.
    The “takeaway” from any business or consumer transaction is something in writing: a receipt, a warranty, operating instructions.
    It dumbfounds me that the “takeaway” from a meeting with a physician, even on something as damning as a cancer diagnosis, is nothing. Memory of a heartbreaking conversation, heard while in shock.
    And yes, it’s frustrating and limiting that these IT systems are as yet not interoperable. What this audience seems to forget: Even an “information silo” offers patients what they need. That first piece of paper.

  66. I’d like to address both Matthew Holt’s and Dr. J Bean’s comments. Matthew, the approach that I’m recommending physicians and practices take is actually LESS expensive and disorienting than the “traditional” route with an established EMR implementation, the dark side of which is perfectly described by J Bean in his or her comment. I’m really not urging physicians to break the bank or ruin their marriages. On the contrary, I’m suggesting that they focus on capabilities and design qualities in the health IT they acquire, not so much for a future that hasn’t arrived, but a reality that is already here. The consumer/patient demands for improved communications and real help from their doctors that can be deliverd via software….these are powerful forces in that new reality. If I’m standing in front of the tank, can I do so on my beloved Goldwing? May make for a quicker escape! 😉 Regards, DCK

  67. Matt,
    I think you’ve bought in to the provider spin a tad too much with the phrase “economic suicide.” In most cases, it is not suicide at all, simply greater-discipline in decisions about equipment purchases, practice patterns, etc. Yes, it means lower revenue. But we need to think about that more like we do in other industries: as efficiency gain rather than suicide.
    You’re certainly right to be skeptical that exhortations will get us very far. Ultimately, reform is going to have to be legislated. Right now, there are tiny carrots being dangled in front of physicians and medical organizations that are used to all the carrot cake they can eat. The more you eat, the bigger your stomach gets, and the more you crave more food.
    To carry this extended metaphor to the breaking point: what is needed is bariatric surgery on the health care sector. Only Congress and CMS can provide it.

  68. Deron,
    I think you’re getting tripped up in terminology. Both EMR and PHR data can be made interoperable. EMR data can be shared through a RHIO or other health information exchange. Ideally, this creates a seamless integration where the data from other systems (hospital and ambulatory EMRs, PBMs, labs, etc.) appears inside the EMR viewer portal that the physician normally uses.
    Providers don’t have to be affiliated to share data in this way, other than by participating in the same RHIO, or in RHIOs that share data with one another in the promised NHIN.
    Maybe Google Health or HealthVault can serve as a supplementary NHIN, where the PHR becomes the central record. But I think that is far from certain at this point. A fascinating possibility, but far from certain.

  69. When David first sent in this post I wrote back to him saying “Kibbe stops bike, gets off in front of tank, stares it down.”
    It’s of course an open question as to whether encouraging providers to prepare for a future–even if it’s the “right” thing to do–that isn’t here yet and may not be here for a long time is actually good advice. I’ve had my run-ins on these very pages with Porter/Teisberg/McKinsey & others for encouraging hospitals to live in the future before it gets here–with consequent damage to their bottom lines.
    And with the comments about David’s piece over on http://www.emrupdate.com/forums/p/17317/91162.aspx#91162 it does appear that some of the tank drivers are happy to shoot rather than capitulate.
    On the other hand physicians are running into a cash-based, consumer-facing world much sooner than hospitals. Hospitals serve predominantly sick patients who are older, less computer savvy, and less “consumer-like” than those showing up at a typical family practice. So if we can nudge just a few doctors to help their “consumer” patients across the spectrum of their lives–rather than just automate the fraction of their patients health experience that is the current office visit–then it might be the camels nose under the tent. And in that case David’s appeal might be not too far ahead of the market. But it is a huge request of already stretched primary care doctors.
    I’m not sure if David’s correct or if he’s asking doctors to commit economic suicide. But I sure hope he’s right.

  70. In terms of HIT, I think PHRs will do a much better job of promoting coordinated care than EMRs will. The trick is making sure that EMRs can integrate with PHRs to avoid double entry. EMR is a tool for efficiency within a practice, not coordination among practices. PHRs on the other hand can be used to track a patient’s entire care from all providers involved, regardless of whether those providers are affiliated.

  71. I agree both with Dr. Kibbe and Dr. Rowley. The EMR that we have recently implemented in our practice replaces a system of scanned images. Disappointingly, it offers no improvement in patient care and at the same time represents a real step back in terms of communication within our clinic and, of course, absolutely no improvement in communication with specialists outside of our group. This is a large, well-known EMR package and it provides awkward tools for physician to physician interaction. Since we are a very large group with an existing IT department we’ve been able to tack our own modifications so that we can communicate among ourselves. The communication tool provided with the system is not only clumsy, but it also doesn’t save messages in the patient records!
    Another stunning systems engineering oversight in this very well-known EMR is that there is no way to redirect messages and incoming lab data to a covering physician when someone is out sick or on vacation. We installed the system in August and our current solution involves vacationing or sick docs scanning their “Provider Approval Queues” while out of the office. On top of that the user interface is so poor that we are all spending 2-3 hours more per day getting our work done.
    The cost of the system was enormous. The cost of the transition from the old system to the new system also large. The personal cost of the additional time spent every day at work is overwhelming to us. It might all be worth it, if it provided better patient care — but it just doesn’t. I was a systems and software engineer for 10 years before going to medical school. I was initially enthusiastic about EMRs, now, not so much.

  72. Where can I go to better understand what kinds of features and functionality the new Kaiser Health IT system enables? I’ve heard a lot about it in general, but I haven’t seen any specifics anywhere. Thank you in advance!

  73. David, my friend, you are so right, “most EMRs remain ‘islands of data’ that can’t connect even with the archipelago of data in their communities, not to mention the continents of data elsewhere.” You are also right to not blame the doctors or the vendors.
    The blame goes the proprietary software system business model because it fails to support health care. The model is by nature proprietary and that stifles collaboration on many levels. They are expensive, not interoperable, and complex. It is main reason why that in 2008, only ~15% of health organizations have fully adopted EHR’s.
    The open source model and health care model are both by their natures collaborative. Bringing the two together is an idea whose time has come. It is the disruptive innovation needed to truly transform health care.
    It’s terrible when organizations’ IT systems cannot communicate within its own walls, let alone across the street or country. That’s not doing right for our patients. We need to move ahead and communicate and collaborate within organizations and across the health care community.

  74. Robert Rowley, MD wrote above “Coordinated care is very difficult to achieve absent a local, accountable physician organization – a clinic, a robust IPA, a large group. However, in many parts of the country such organizations are few. Can technology bridge this gap?”
    The answer is “by itself, health IT can’t bridge this gap.” In my opinion. I believe that new business arrangements and organizations capable of collaborating in taking on risk, and sharing in the savings, are going to be required. However, the use of health IT will be very empowering to these new business models for the delivery of safe, effective, and more affordable health care.
    Thanks for your comments. DCK

  75. Fascinating topic. I’m far from an expert–I work in communications for Washington State University Spokane, where we have several faculty doing research based in health informatics.
    Spokane has Inland Northwest Health Services, http://www.inhs.org, which has over 1,000 participating docs, the two competing hospital systems, and other providers such as imaging and pathology labs. We have a culture of participation as a community that may give us an advantage in developing a “team care” approach. That’s what our campus health science programs are working on so the next generation of health care professionals understands and can apply the power of knowledge derived from HIT. It will certainly take a culture change.
    One more piece to tie into this that Mary Selecky, Sec. of Health for Washington, has encouraged us to pursue as we expand our health sciences work is tying individual patient data to population-based public health records and ultimately animal disease surveillance systems. WSU has expertise in animal health and infectious disease, and we’re working to link our research programs in animal and human health to bridge yet another of the gaps in the system.
    @BarbChamberlain

  76. The points made here are indeed very good ones. As an EMR enthusiast myself, I have seen the “first generation” of expensive, locally-housed EMRs as merely being an electronic replacement of traditional paper charts – the data (though e-accessible) is still confined to a physician’s practice much like the e-equivalent of a paper chart rack. And these systems have typically been so expensive as to be out of reach to smaller and solo practices, where EMR adoption has been so lacking.
    The value of next-generation e-health really is in the potential to connect data from disparate sources and achieve “one patient, one chart.” This requires moving to SaaS-based, hosted next-generation EMRs (which I like to call “EMR 2.0”), in my opinion (see Practice Fusion’s Free EMR for an example). Everyone taking care of a given patient should be able to see and share clinical data as appropriate, without having to clip-and-fax between offices, like happens now in a paper environment, and even happens in an “EMR 1.0” environment.
    In addition, wellness and disease-management prompting – both as a display for the physician and also for the patient in an EMR-filled patient-centered PHR – is only really achievable in an interconnected system. This sort of data-mining and presentation of automated reports that are clinically useful is the “next stage” of e-health.
    Coordinated care is very difficult to achieve absent a local, accountable physician organization – a clinic, a robust IPA, a large group. However, in many parts of the country such organizations are few. Can technology bridge this gap? If there is widespread adoption of hosted, shared “EMR 2.0” solutions with robust data reporting, participation of patients in their consolidated health records… maybe. This is an interesting time for health care.

  77. Okay, I get it. I have been thinking about why your medical audience is so resistant to your message.
    Doctors don’t change because they don’t have to change.
    You have used logic, economic and otherwise, comparison and example, compassion (I hope) and politics in your presentation, none of which is able to dent the culture of fatigue and importance that is built into the U.S. medical system (see Do Doctors Read? http://e-patients.net/archives/2008/11/do-doctors-read.html#more-674). However difficult their lives — and they are difficult — physicians’ prestige and income is sufficient that they cannot be the prime movers for change.
    They are franchised individuals, patients, not.

  78. bev MD wrote:

    “Gilles; My apologies for not mentioning the most important stakeholder; patients.”

    Rather than apologize, why not reformulate, to wit: people are people first, then – maybe – patients.
    Heck, most patients don’t think first of themselves as patients most of the time, even in the MD’s office.
    I urge all to consider this variation in MIS (Most Important Stakeholder), if for no other reason imagining more effectively the necessary economics of any practical health reform initiative.

  79. Bev,
    I spent a few years trying to raise awareness for best practices for sarcomas, to encourage rationalization of referral routes for suspicious lumps and bumps so that patient with the 100th diagnostic possibility didn’t have to die. Nada. Logic didn’t work. Cross-cultural comparison (it’s been done successfully elsewhere) didn’t work. Compassion (lots of kids getting diagnosed way too late) didn’t work. Appeals to non-profits didn’t work (too unprofitable). Political appeals didn’t work (not a big enough popn. to get an earmark).
    What did work were the ACOR lists, which had up-to-date information and great research capabilities. Publicity, positive and negative. And market competition. Again, the bottom line for “activated” educated patients was quick and easy access to test results and medical reports. I hope this factors somewhere into David’s work and the macro issues therein.

  80. Gilles;
    My apologies for not mentioning the most important stakeholder; patients. However, I took it for granted that we all assume that patients WANT this to happen (remember, I am a patient too), but have no power to make it happen. Thus my restriction of the term to the foot-draggers.
    But perhaps you have hit on something – patients can be empowered through influencing their elected representatives, as we have so recently experienced.

  81. Many thanks for these great comments. I will be thinking about them over the next few days, and will respond in my next post on this topic. By the way, my next “Confessions” talk to physicians will be Thursday, in Knoxville, TN. Their comments and feedback are also very important to me. Kind regards, DCK

  82. Great post, David.
    My only comment is that I hope your talk brings out much more clearly why being interconnected is absolutely critical in order to get the value out of HIT. I know it wasn’t really the point of your post here to explain this.
    One of the biggest “aha!” moments in my work in HIT came when I realized that EMRs and similar tools in isolation had almost no net impact on the cost or quality of care, but, as part of an interconnected system geared towards efficiency and supporting best practices, they open up the world in improving quality while decreasing cost.
    Now when I look for clinical HIT opportunities on behalf of the managed care company I work for, I only look for opportunities to promote interoperable and systematically interconnected HIT. Simply giving a provider a subsidy to get an EMR is worthless both from a health plan point of view and from a public policy point of view.
    Looking forward to reading more of your work on this topic.

  83. Bev M.D. wrote about all the stakeholders: physicians, vendors and hospitals. It’s hard to explain in simpler terms the essence of the problem.
    There is no medicine without patients and their bodies. Don’t you think it is time to give the role they have always deserved? At a minimum everybody should think of them as one of the primary stakeholders?

  84. BevMD – I think it would be a hasty generalization to state that none of the stakeholders want it to happen. I think some do, but they haven’t been shown what coordinated care looks like and how it can be achieved. Deep down, I think we all know what reform needs to look like, we are just so fragmented right now that it’s hard to conceive.

  85. In the information age today, we have many on-top health institutions that are realizing the time and money saved by using such products as http://try.nefsis.com The product saves endless paperwork, and allows file sharing and information sharing instantaneously, with meetings allowed anywhere at anytime. In the current age of medicine, this is the sort of help we need to advance the information while being productive in our respective fields.

  86. My take is that the needed “comprehensive-ness” (is that a word?) has not occurred because none of the stakeholders want it to occur – physicians don’t understand its value and only see the $$ drain, vendors shortsightedly don’t want interoperability because of competitive reasons, and hospitals want to lock in patients to their own proprietary systems involving only their patients and doctors. There will have to be leadership and incentives on a national scale to gain any traction.
    And ps Christine – interesting comment about Kaiser killing sarcoma patients. As a retired pathologist who was interested in bone and soft tissue sarcomas, I am not surprised. The tertiary institution-centered expertise (and therefore added expense) needed to deal with these rare tumors does not fit well with Kaiser’s business model, nor does my personal experience interacting with them as a pathologist. I do not see them as the panacea for health care that many do.

  87. David is of course right about all of this. There is no rational reason, at this point, that all EMRs are not interoperable through a standard like the Continuity of Care Record, or easily integrated with practice management systems. And the cost of these applications must come WAY down, as they have begun to do with tools like eClinicalWorks, Soapware and Amazing Charts.
    The costliness of the Kaiser example is hardly representative, or applicable to the needs or experience of most physicians. Kaiser’s experiment with EPIC has been, well, epic, and has sought to incorporate a range of complex functionalities that are far beyond the scope of most physicians’ needs or wants at this time.
    As many have pointed out, what’s needed at this time is for the use of EMRs (and other electronic tools) to provide physicians with value that they can’t get without them. There are ways to do that: aggregation of clinical record information across users to identify performance against external benchmarks, providing a stronger and more quantitative framework to understand and negotiate for payer compensation, offering a platform across practices and specialties that offers a more straightforward approach to collaboration. But so far, most vendors have not thought this broadly.
    David is urging us to move beyond the current flailing model by identifying the deeper utilities that can significantly enhance the EMR value proposition in a market-based health system. To me, that hits the nail on the head.

  88. What I am really reading in this column is that health IT is not a panacea for the organizational and payment issues in American healthcare and that these issues must be tackled first for which health IT can be an enabler but not a true change agent. Is that a fair assessment?

  89. After daily experiences of the past couple of years, we could write a book describing the combat and self defense techniques required for those wanting to move physicians from where they are to a true, integrated data management philosophy. As we have attempted to move the SOAPware medical record software and user base from a simple tool to one that has the infrastructure to manage information exchange, it has often been brutal. If/when there are real incentives for physicians (rather than token ones) it will happen. Kaiser has shown the way regarding the value and business case for an integration of information within an island. Have they done anything to cross the waters?

  90. I have read a little about this at the http://www.calchroniccare.org/ website – I guess my question to those in the field is how much of this is related to payment reform? I have read about Medicare projects for high risk beneficiaries and there is also pay for performance projects but will a bigger ‘nudge’ come from payers starting to give a flat rate per month or more incentives for clinics to take on initiatives for this type of care?

  91. Very happy to see you mention Participatory Medicine. There can be no real, meaningful and successful reform of the healthcare system if you do not center it squarely on the patients. The work of Patty Brennan on PHR’s speaks loudly about this fact. To quote their report:
    “Patients testing PHR tools under Project HealthDesign grants are giving researchers important feedback on what kind of ODLs (Observation of Daily Living) they wish to provide and what information they prefer to keep to themselves. The difference in its conception – gathering information that is important to individuals, but not necessarily collected in a clinical setting – may be the single most important defining feature of next-generation PHRs.”

  92. To refine the point: Is it possible to built the Toyota Motor principle “Seeing the impact of what you do” into the discussion to help motivate your audiences toward change?
    The present economic climate is one of fear. The Kaiser example is not encouraging. (Kaiser has a reputation in the sarcoma community for killing patients through misdiagnosis and mismanagement. Probably less so now that the e-community has raised awareness and actively advises patients how to navigate their system.)
    Contrast this with the tone and content of Ted Eytan’s recent piece http://www.tedeytan.com/2008/11/07/2212.
    I’m not sure how this came about, but UCSF has integrated decent Internet communication into its Pediatric Specialties Department — the part of the “elephant” with which I have experience. This saves everyone time and money, and, for their patients — children — unnecessary fear. That alone is worth its weight in gold to consumers. In my experience, management “walks the walk,” particularly at Mt. Zion Hospital. They invite patient feedback and then incorporate that feedback into their institutional practice. This makes their STAFF happy.
    The first patient request is for efficient communication, meaning easy (and private) access to records and test results. Which means Internet communication. No phone tag. That is the first step for e-patients — getting accurate information to begin the education process. Once test results are in hand or can be shared with e-communities, the decoding process begins, which saves the medical staff time and brings the physician-patient exchange to a higher level, or to more middle ground.
    I’m not sure how this relates to your broader mission, but I hope it helps.
    Best to you.
    Christine Gray

  93. Interesting post. Given the communication divide among the various audiences involved, the trick is to devise an incremental approach that includes some immediate benefit for each entity as well as some means of generating input guaranteeing that no one’s interest gets hijacked by any other entity.
    Is there any case study or small scale example of this working out?

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