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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