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Fact or Fiction: Electronic health records save money

Note by Brian Klepper: Today the actuarial consulting firm Milliman is convening a town hall meeting in Seattle focused generally on health care reform, but specifically on Electronic Health Records (EHRs). The larger Seattle metropolitan area is a hotbed of health care innovation, with Virginia Mason Health System, Costco, Starbucks, Boeing, Premera and other forward-thinking firms. The conference will have representatives from CMS, Microsoft, the VA, Group Health Cooperative, and Milliman, and is open to the public. Should be an interesting session.

To kick it off, here’s a little piece on EHRs by Jeremy Engdahl-Johnson, Managing Editor at Milliman.

Earnestbwsmall
Of all the initiatives endorsed by outgoing Secretary of Health Mike
Leavitt, few are likely to be met with as much agreement by his likely
successor, Tom Daschle, as the need for wider adoption of electronic
health records (EHR). While there is general agreement on the need for
this technology investment—both presidential campaigns included EHR in
their health platforms—the cost ramifications are still up for debate.
Will electronic health records reduce costs? There are compelling
reasons to answer both “yes” and “no.”

“Yes, electronic records decrease costs”

Our system of care is fractured, and EHR is one way to tie it together. Doing this is more than just a convenience. It could save money. Why? For one, the cost of some conditions are compounded by the presence of other conditions, creating expensive co-morbidities that are not treated well in a fractured system.

On a monthly basis, asthma costs $390 per member per month, but in the company of depression it costs $940. This co-morbidity is not always diagnosed (only 16% of the time even though it is expected 45% of the time among asthma patients), and while the cost of treating the diagnosed comorbidity is high, the cost of the undiagnosed comorbidity is higher. When physicians use electronic records, they are more likely to provide effective treatment because they can coordinate care with other physicians and also with nurses, therapists, technicians, and other organizations, cutting across care silos for the good of the patient.

Furthermore, patients with chronic conditions have more to gain from a personal health record. Their treatment plan is often self-administered and reliant on the correct information. If they can facilitate the kinds of questions and discussions needed to properly care for their condition without office visits, they can reduce the cost of their care. That’s why the medical home model, of which EHR is a cornerstone, is receiving more and more attention.

But it’s not just about chronic conditions. Despite the common assumption, the cost trends for nonchronic care are actually rising faster than those for chronic care. All patients have something to gain by tapping into the growing body of medical science. Evidence-based guidelines—the best of which have some 15,000 scientific references and can chart better paths of care—can bring that science to the bedside and to the home health environment.

Why is this science important? Much has been said about healthcare consumerism, and the suggestion that being more responsible for your health will create an economic incentive for staying healthier, a seemingly important carrot in a country with a 35% (and rising) obesity rate. Does the consumer-driven theory work? Maybe. Like them or hate them, consumer-driven health plans are shown to save 4.8%. This is in spite of the relative scarcity of good consumer health information … which is where dispensing medical science comes in. Most people don’t even know what health consumer information looks like.

We’re only beginning to see health care equivalents of Consumer Reports. Many people know more about the different brands of canned goods available to them than they do about their different health care choices. Sources like WebMD have begun to change this, and health surveillance tools like Google Flu Trends are promising if unproven. Regardless of whether the consumer-driven model wins out, it seems likely that an information-driven approach can help improve care and perhaps reduce costs.

Throw in the most frequently cited virtue of EHR—a reduction in unnecessary administration—and you have a compelling case for the cost benefits of this technology.

“No, electronic records increase costs”

But there is cause for skepticism. From the small family business to the biggest multinational organization, technology deployments routinely cost more than anticipated. Going overscope and overbudget is almost a rite of passage. And now is seemingly a bad time for that kind of investment, when the country can scarcely pay off debts already incurred. Who picks up the tab for EHR during a recession?

Then comes the question of effecting change. Efforts to legislate IT have encountered mixed results. HIPAA implementations cost more and took longer than expected. They had the benefit of happening during a robust economy that was already investing heavily in technology. Today is different, and we’ve seen more resistance to legislated IT investments. Just look at ICD-10: The mainstream press poses questions about cost and doctor groups suggest this is one investment that can wait. The mandated 2011 conversion deadline is an interesting trial balloon for nationwide EHR requirements.

The final verdict?

We can’t know for sure whether electronic records will increase or decrease costs. As a purely cost-based argument, the debate can go on indefinitely. Ultimately, the quality argument may win out for a reason independent of cost—because it is deemed the right thing to do. The idea that healthcare has grown too complicated, becoming “too much airplane for one man to fly,” is often invoked as justification for surgeons’ checklists and better use of tools built on evidence-based medicine. It’s not that our doctors aren’t good; it’s that there are too many details and too many scientific improvements to keep track of.

The quality imperative—now emboldened by an administration that claims to be intent on change—may clear the way for other changes, generating the will to make a pervasive electronic health environment a reality.

Find out more at www.healthcaretownhall.com.

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24 replies »

  1. It has occurred to me that the institution of centralized EHR data that effects the outcome of caring for a patient is not the purvue of the physician. Neither is it the purvue of the hospital. There is a point in time where the curves of available time and record review time cross, beyond which the compensation for the effort is not included in the reimbursement for the encounter. If the doc has to capitalize the system with his/her time, it will fail to achieve the objective for the covered population. While it may work for a single patient, it will not work in real time for a population.
    The entities with the incentive and the clout to centralize data and make it available to providers are the insurers themselves. They can benefit from reduced duplication of effort. They can have all the data submitted with claims and make it available to future providers of care of the patient. They can make more money by making the data available for the care of their customer, the insured. The insurers are the only players with the incentive to do this. The doc will not make more money from EHR. He will see fewer patients because he will have a mountain of data to review; it will take too long. In fact, the doc will not even be in the exam room, having chosen to enter a different field or hire extenders to see patients. That of course is the future of primary care…extenders. Cheaper to produce and pay. Patients rarely can tell a difference.
    So far all EHR efforts are directed and meeting documentation requirements for compliance and payment. None have been created for patient care. Our ED nurses spend scads of time documenting for hospital risk management, which benefits the patient and the doctor exactly ZIP! And our average length of stay since the switch was turned on has gone up by 100 minutes.
    Productivity needs to be a denominator in any system to assure the real costs are included in the equation.

  2. It has occurred to me that the institution of centralized EHR data that effects the outcome of caring for a patient is not the purvue of the physician. Neither is it the purvue of the hospital. There is a point in time where the curves of available time and record review time cross, beyond which the compensation for the effort is not included in the reimbursement for the encounter. If the doc has to capitalize the system with his/her time, it will fail to achieve the objective for the covered population. While it may work for a single patient, it will not work in real time for a population.
    The entities with the incentive and the clout to centralize data and make it available to providers are the insurers themselves. They can benefit from reduced duplication of effort. They can have all the data submitted with claims and make it available to future providers of care of the patient. They can make more money by making the data available for the care of their customer, the insured. The insurers are the only players with the incentive to do this. The doc will not make more money from EHR. He will see fewer patients because he will have a mountain of data to review; it will take too long. In fact, the doc will not even be in the exam room, having chosen to enter a different field or hire extenders to see patients. That of course is the future of primary care…extenders. Cheaper to produce and pay. Patients rarely can tell a difference.
    So far all EHR efforts are directed and meeting documentation requirements for compliance and payment. None have been created for patient care. Our ED nurses spend scads of time documenting for hospital risk management, which benefits the patient and the doctor exactly ZIP! And our average length of stay since the switch was turned on has gone up by 100 minutes.
    Productivity needs to be a denominator in any system to assure the real costs are included in the equation.

  3. The cost in upgraded technology is surely less than the cost to our patient population if we continue to sit on our hands. Medical records are vitals to the care of a patient. Technology really boosted Medical science resulting in Food Supplements etc. Many people know that they are eating poorly which is probably contributing to their poor health. This is why we need a food supplement like Proleva! Visit http://www.proleva.com Proleva also contains superfruits such as acai, mangosteen, goji and noni which are known for their remedial properties.

  4. In Oregon when a number of hospitals were asked to join into a regional network they quickly discovered that they were being asked to pay for a system that would eliminate duplicate tests (ie profits) so opted out of it.
    //
    If I understand her argument correctly, Sherry Reynolds has hit the nail on the head. Profitable for whom? Costly for whom? In what terms? Again, it helps (me) to distinguish between profit and utility.
    Medical practices and technology and software companies engage in a negotiation over profit and loss.
    Saving their own lives may not be profitable for patients — quite the contrary — but it is certaily “utile,” as the French might say.
    What a business perspective fails to account for in these IT debates and in debates about healthcare innovation in general, for patients, particularly those who’ve had a bad medical outcome through some sort of systemic negligence, this is not an INTELLECTUAL debate, it is PRAGMATIC.
    Sort of like fighting a war with the Vietnamese (or the Afghans) on their own turf. Native armies will go to any lengths to defend their territory and culture, while military engagement on the part of an outsider eventually boils down to profit and loss.

  5. I agree with others that there’s some confusion in this conversation. EHR software in docs’ offices un-linked to a wider “interoperable” (yes, I hate that word, too) national electronic information system is just another management tool for docs to track patient care – hopefully much better than in all those silly color-coded paper files. As such, EHRs are an upfront expense that takes years to recoup in efficiency gains. The clinical benefits usually flow pretty soon, but may be small at first.
    Even unlinked EHRs will absolutely yield clinical gains (e.g. – better preventive care reminders) and financial savings, but over many years and perhaps at the margins. The real transformative power of EHRs will occur when we as country finally nail down the standards, make the necessary investment in a secure, encrypted national electronic health info system, and, over time, mandate its use for the transfer of patient information and de-identified data.
    I would go so far as to say…(link to the BLOG on http://www.prescriptionforchange.org for rest of post)

  6. One of the challenges I rarely hear discussed is the disconnect between who makes the investment in Health Information Technology (typically the hospitals, providers) and where the cost savings accrue.
    The VA, Kaiser and Group Health were early adopters because they are both the provider and the insurer so any ROI accrues back to their own system. The VA has some of the highest quality care in the US and some of the most cost effective care but at least on the West Coast neither Kaiser nor GHC are able to provider lower cost care then those without an EMR (clinical)
    None of these three systems really even track costs (yes charge codes are captured but patients aren’t usually billed the same as in private insurance program).
    In Oregon when a number of hospitals were asked to join into a regional network they quickly discovered that they were being asked to pay for a system that would eliminate duplicate tests (ie profits) so opted out of it.
    In Bellingham, Washington (single hospital town) they actually had a PHR that was designed by patients with chronic conditions (shared care plan) and linked that with nurse case managers through a RWJ grant but they were able to save so much money per patient per year ($3000) that the local specialists opted out of the program and the only way they were able to get the program running again was with a 1/2 million state grant to entice patients to sign up.
    So even if there was a strong cost savings (quality is the real driver) you need to link who makes the investment with how gets the savings if you really want to implement this outside of a large system like the VA or Kaiser.
    From a purely strategic stand-point since over 50% of all health care is paid for my government (medicare, teachers, va etc) and once they are in the system there is a financial incentive in managing chronic conditions aggressively Medicare could use its purchasing power to strategically invest in e-prescribing, medication reconciliation then registries (problem lists) long before we force rural providers to move to full fledged EMRs.
    Sherry Reynolds
    Alliance4Health

  7. RBAR
    //I personally don’t know of any such efforts. Every patient is entitled to get copies of their medical record. //
    Ah, but how hard can they make it?
    1. At one major children’s hospital in California, the oncology team did not think to provide copies of reports or test results. The Records department was buried somewhere in the hospital. Very hard to think about your child’s cancer if you don’t have some document in hand to begin the learning curve.
    2. At the second children’s hospital, other end of the state, the Records Department was in the basement. You had to sign a statement, wait two weeks or so…. FOR EACH DOCUMENT. If they were this inefficient in person, imagine the mailing process.
    Our diagnostic team/process was working at the speed of light. Technically, I couldn’t get a copy of a test result for more than a week, but the real wait was indefinite. If this had been a business of any sort, they would have been out of business.
    My daughter tried their system over a protential knee surgery last year — NOT life threatening. She counts as your ordinary 18-year-old consumer. Not only could she not access records easily — they make it difficult if not discouraging if not impossible — when they finally came through after forcing her to do hours of contact work, they sent the wrong effing report!
    This institution has known about the Internet and IT capabilities for years and has done nothing to empower patients. It simply doesn’t occur to them, like it simply didn’t occur to many of the respondents on the recent Kibbe Debate.
    At this same institution, I found out from the surgical report that there were no margins on one side of my daughter’s re-excision but no one ever SAID that (and that would be basic medical talk, right? meaning her chances of recurrence were higher?).
    We wanted the slides sent out to a “niche” expert for as second expert opinion, but the hospital resisted(they all told us how wonderful they are, even though they had treated at best a handful of kids with her cancer). Someone ordered medical records to block access by our case manager, claiming that we had to go through a whole new round of HIPPA signatures/releases.
    Then they of course LOST the slides in the mail and DIDN’T NOTICE until I inquired.
    This is a children’s hospital rated among the top ten in the United States. Using HIPPA to frustrate second opinions stopped when I talked to the university ombudsman.
    3. Hospital no. 3, which is excellent, sends reports, etc. via email — the patient’s requested mode of communication. No problema.
    //
    I actually don’t see a connection between transparency/2nd opinions and EHR (maybe you could explain further). //
    See above. I currently awaiting a second opinion on a mammogram which the radiologist blocked, even when I showed him the Jane Brody article on same (see “In the Spin …” on e-patients.net.) The radiologist refused, saying the pcp (at a gyn clinic) made the decision about second opinions. The pcp at the gyn clinic refused, deferring to the radiologist. I did an end around to the local hospital, which made the referral to a high level radiologist, but radiologist no. 1 has yet to send the records.
    Here’s my favorite HIPPA interpretation. I ask for a test report to be faxed to my home while I’m at the office; they refuse, saying it violates HIPPA. They will fax it to my PCP, but not to me.
    I ask that they send a copy of the disc to me in the mail. No, they can’t do that, but I can pick it up in person (how many work hours does that take?). They will, however, send it to my pcp.
    As of today, it’s been a week and a half and neither the report nor the disc is at radiologist no. 2.
    What I learned from obtaining and learning to interpret pathology reports, surgical reports, etc.
    1. the chief of ped. oncology at a well known children’s hospital went on vacation after his path lab flipped a dx from malignant to benign on a sarcoma. We went through a week of terror — this is a child, remember — and the guy strolls in an hour-and-a-half late to the appointment a week later saying they had decided it was benign after all. Not to worry (except he then discusses doing radiation therapy on a benign tumor!).
    I called the lab, which confirmed that the final dx of benign came out a week earlier. I got a copy of the path report; it was issued a week earlier. So he FORGOT to tell us the tumor was BENIGN, then lied about misplacing or forgetting about the final lab result. This was an mpnst (malignant peripheral nerve sheath tumor). I will give you the link to the sickening “we love children” advertising at the hospital if you’d like.
    The guy did not follow “best practices” for sarcomas, which are difficult to dx, and send the path materials out for expert review. Nah! That would be a second expert opinion. So I did it, and he withheld the report from their surgeon. Furthermore, even though he was bragging about his sarcoma expertise, he was unaware of advances in his own field through the NCI. I also learned through a report that he tried to cover up numerous things, and incorrectly represented the nature of the malignancy (one of the pathologists at a specialty center corrected him on that one).
    2. We go to highly ranked children’s hospital no. 2. Lots of “handling,” very foggy, manipulative language to manage “the mom” and kid. Their own team “expert team” can’t decide about the pathology, so they come in with OPPOSITE tx recommendations in the same day, the surgeon and oncologist contradicting each other. (“Don’t worry, mom. We could even watch and wait.”)
    I obtain the surgical path report after the surgery and find out that there was no margin, or a “marginal margin.” They knew they would not get a clear margin in advance, yet never brought it up at the pre-surgical discussion. They also never discussed xrt. Controversial, yes, but they “forgot” to discuss it. Meantime, the xrt window closed. And no, they didn’t think the tumor was benign.
    3. By obtaining copies of every report in my daughter’s file, I learned that the oncologist was under review for his handling of my daughter’s case. The sexism, if it at all enters your universe of awareness, was quite stunning.
    4. We traveled a few hundred miles to get the MRIs. At one, during Christmas, we were sent home with assurances that everything was fine. But oops! I got hold of the final report in January, and someone, the machine, someone unnamed had “dropped” the contrast portion of the MRI. So not only were we sent home with incorrect information, my CHILD had to repeat a very painful MRI, further disrupting her life. I had the lovely task of informing the surgeon, which really didn’t do a lot for our relationship.
    So, at a minimum, getting records indicates where inter-departmental glitches are, which means they are no longer able to cover up ineptitude, which means they no longer get that great rating in US News and World Report. Wouldn’t you say that ignorant patients were in their interest?
    Personally I think someone should take a roto-rooter to the world of pediatric oncology. The whole subculture has not heard of Patient’s Rights.
    You also have to remember that I was a member of a first-rate ACOR list, so I knew that docs at MDACC are offering their patients copies of test reports at appointments, so they could go over the information later. I also knew best practices for pathology, etc.
    KEEPING COPIES OF RECORDS is rule number one for patient proactivity. Some institutions offer them to you in situ so you can THINK about hard decision making — like whether you opt for a surgery that will cripple your child for life or not — with a document in hand. Others deep six them.
    Signed,
    News from the Front

  8. hi
    Sorry to be late replying. This is an important point that need elaboration.
    If you read my pieces here and on e-patients.net, you will get an idea of why getting reports and test results in hand was such a challenge.
    More later. I will list the things I learned from test results in hand.

  9. Christine,
    “Physicians and health administrators commonly use HIPPA to block patient access to records. This of course keeps the patients ril dumb, the physicians, ril smart.”
    I personally don’t know of any such efforts. Every patient is entitled to get copies of their medical record. That does not change at all with the EHR, as I know from my own experience. With a paper chart, you get paper photocopies, with EHR – a chart printout. It is true that you simply cannot grab the chart and read, but I don’t think there are systematic efforts to block chart access … and chart access is, to my knowledge, part of HIPPA.
    I actually don’t see a connection between transparency/2nd opinions and EHR (maybe you could explain further). I don’t think EHR are meant to be open for patient reading online (I don’t think that would be a good idea). Almost every doctor will try to obtain the relevant old docs by fax, it just doesn’t always work because the patients don’t remember the name (“I saw this orthopedic doctor in Phoenix …”). Right now, I estimate my catch rate for outside documents is 60-70% (dep. on how old the note is); with a mandatory EHR, it should approach 100%.

  10. > Tom, you appear to have turned bitter
    > based on your sarcasm re. Cerner
    I have been exasperated that chart-replacement offerings relying on scanned paper and unstructured text have managed to pass for EHRs. I want a lot more than this, but practitioners don’t and they drive the decisions (at least for now).
    Cerner have the attitude that people should just buy everything from them, interoperability isn’t necessary. Well, OK, it is necessary: their products have to interoperate with their other products. To be fair, all the “big” vendors are like this, but my dealings with Cerner left me with the impression they were a special case. The place for details about any of these things is over on HISTalk.
    Bitter? Well, no. At least I hope not.
    t

  11. So rbar, treading carefully as you do re: lawsuits, what’s your position on patient- and care-centered IT systems versus billing- and coding-centered IT systems?
    I posed the question about apologies and second opinions to underscore what it’s like being a patientin the current medical climate and to drive home the broader point about IT innovation (or lack thereof), transparency and accountability.
    If even first-rate physicians think they are committing legal suicide if they apologize for medical error or even a poor outcome despite good medical care, why would they support greater transparency in record sharing?
    Ergo the point to David Kibbe and otherwise well-intentioned commentators on this blog: There is a reason why patients are at best an afterthought in the conversation.

  12. Christine, I communicate openly what I do and why, but apologizing for someting nontrivial is a different manner … I would gladly admit/discuss my mistakes if there wasn’t the threat of litigation (even for a competent, good willed – but mistaken – effort). I don’t buy into the studies suggesting that openness may have a protective effect (that may apply to some patients, maybe even the majority). Almost any patient can become disgruntled despite all my efforts, and my admission of a mistake would be used by the plaintiff’s lawyer.
    But re. a second opinion: many patients go for 2nd opinion on their own as I know from patients who choose me as the 2nd opinion. I tell every patient of mine who does not have a straightforward case or unanswered questions: you may want a second opinion … let me refer you to Dr. X (or, if applicable, to subspecialist Y) because I care about you seeing a good physician for your 2nd opinion (and not the first name on the yellow pages). I know that I am not the only one practising that way.
    Tom, you appear to have turned bitter based on your sarcasm re. Cerner – I know their product (nufortunately, I cannot compare it to the competing products) and I think it is adequate (albeit complex and often slow, although I have been told that that’s a hardware issue). If you want to criticize Cerner for their product or their attitude (feel free to do so, I don’t care), why don’t you do so openly, for my (and other’s) enlightenment?
    Re. the value of centrally scanning all records – it seems that you are aiming for a Lexus, while I would be happy with a beetle, even though it might be completely outdated … it still beats what we have now (i.e. fax and snail mail, and only if we know whom to contact), which I would compare to stasis or limping at best.

  13. Debate about HIT that foregrounds profit and focuses primarily on the insurance/physician nexus (coding, billing) with the patient as afterthought is like a dog chasing its tail. See “The Great Kibbe Debate” on thcb… [upper right]
    Physicians cannot be innovators for reasons listed in TGKD. The insurance/physician/technology cluster is incapable of innovation: 1) insurance companies have a stranglehold on billing; 2) physicians cannot ASSURE themselves of a profit; 3)HIT is both about sharing information (and information is power), which does not profit technology companies; and 4) HIT innovation is about transparency/physician accountability.
    Why would a physician group risk its profits to subject members to greater accountability? Physicians, particularly pediatric oncologists, are so used to withholding information from patients and remain so ill educated about e-patient communities, they practically go into cardiac arrest when they are held accountable.
    Dr. Kibbe does not address this point: Lack of transparency, i.e., withholding the fruits of IT from the patient (the Kaiser model), has a primary value of shielding physicians from patient and public accountability.
    Anyone heard a physician acknowledge lack of expertise or apologize for an error?
    Anyone here absolutely certain that his or her physicians welcome second opinions?
    The first step toward physician accountability AND patient education is easy patient access to reports and test results. Physicians and health administrators commonly use HIPPA to block patient access to records. This of course keeps the patients ril dumb, the physicians, ril smart.
    These arguments don’t work because representatives of the hc industry do not distinguish profit from utility. Patients may not profit from electronic record sharing. Indeed, what’s to insure that new HIT savings will “trickle down” to patients after insurance companies take a bite and physicians take their cut in support of the “good living” that is owed them after years of medical school, particularly as the economy goes bad? As the French might say, saving one’s own life or that of a loved one in the face of extreme medical ineptitude and dysfunction is quite utile.

  14. dr. rbar writes:
    > I wonder, Tom, whether you make it
    > more complicated than it ought to be.
    Well, in a former life I worked quite a lot on this problem — maybe everyone’s making it more complicated than it ought to be. Except Cerner. Everyone knows that Cerner is the last word in medical informatics. Just ask them.
    > If you can scan the docs not only
    > photographically, but in the manner
    > that the words are computer readable
    A great big “if”, and “not even close”. But even if we could, unless we solve the (non-trivial) lexicon problem, this isn’t very useful. Semantics are the big deal.
    You have not contradicted me — the system you’re describing solves the “location problem” but does not solve anything else. It’s a start, barely.
    t

  15. I wonder, Tom, whether you make it more complicated than it ought to be.
    When I referred to scanned documents, I meant that they need to be put into a useful filing system (this is actually the case in the system that I happened to use at 2 different institutions, Cerner powerchart, but probably the other EHRs have similar functions). The scanned docs can be sorted by 1) specialty and date, 2)date only and 3) provider name. If a doctor wants to read the out of state hospital discharge summary from 6 mos ago – go to hospital docs, subsection d/c summaries- voila. To find out whether the patient had a back MRI, he/she clicks on imaging, subsection MRI, and calls up the note. If the oncology note is needed, go to oncology; if in fact the exact pathology reading of the cancer is needed, go to pathology, and so on (if you are familiar with the filing, it takes you 3 mouseclicks and seconds only to find the relevant doc, MUCH easier and faster than a stack of photocopies). This would save a lot of duplicative testing, and I would guess that it would at least bring in the costs for the EHR, if not a little more.
    Re. the labs – most bread and butter lab tests are so cheap and time sensitive that special efforts are not needed (what do I care about the sodium level 18 mos ago … although I very well might care that the patient was hospitalized for hyponatremia in 2007). You could easily develop a similar filing system for the costly stuff that should be kept (e.g. genetic testing, autoimmune labs, paraneoplastic AB), and while you’re at it, you could also have a section for CBCs, metabolic panels, basic coags.
    If you can scan the docs not only photographically, but in the manner that the words are computer readable (I guess that’s called HTML, could be wrong), you could also provide an index … even when terminology and spelling might vary, this would be extremely helpful (and some issues could be fixed by software).
    Develop simple filing guidelines (all the above is, as opposed to the actual practice of medicine and medical decisionmaking, quite uniform and easily standardizable), put everything on a secure server, and give every licensed US physician a username that tracks which charts are assessed by whom at what time to prevent abuse. Doesn’t solve the whole US healthcare mess, but at least improves care quality. And might even save a few bucks.

  16. I am from a very small (15 member) radiology practice with 3 regional community hospitals of 150 to 300 beds each. By necessity, my practice installed a teleradiology system that essentially made available all imaging studies for patients in all three hospitals. the area covered was approximately 90 by 120 miles.
    i have been absolutely amazed at the number of duplicate imaging studies that have been performed, and now avoided, by the availability of prior studies. Asimaging is a small, but expensive, part of health care services, I can see nothing but good coming from a universal ehr that gives all information to providers, and eliminates expensive duplication of studies.
    one would like to think that the patient knows what he has had done…but that does not happen unless the patient writes the check for the service. that, as we know, does not happen anymorel

  17. Yes, dr. rbar, scope matters. The thing about mandating these EHR be “somehow” interconnected requires a great deal of standardization of medical terminology — the “somehow” first of all requires this. It isn’t primarily a technical problem.
    An EHR where handwritten documents are scanned and uploaded achieves document sharing, which is an OK start. Adding just a little metadata to these scanned documents drastically increases their utility, even if its only administrative metadata. Think about attaching scanned handwritten notes to an electronic billing record. This kind of thing. Its probably better than nothing, but I have seen enough “private shorthand” in clinical notes to know that these may be unintelligible to anyone but the doc that wrote them, or to his assistant. Better yet would be full-text, serchable notes and lab results, but this bit requires even nore standardization of terminology in order to be useful, and requires the docs to give up their “private shorthand”, indeed handwriting altogether.
    If Medicare mandated the use of an EHR, provided it for free, supported it for free, automatically generated electronic bills, orders, and prescriptions, and made it “open” to any healthcare encounter for free, it MIGHT gain some traction. I am not so sure any of this will save money — it would sure increase Medicare’s administrative overhead costs.
    t

  18. I wonder whether there is some confusion here.
    If a small independent practice inplements an isolated EHR, it helps little.
    If a tertiary care center and/or large MSG does so, it is a differenty story as I learned myself in the early 2000s during residency training. You always have info at hand, even if a patient comes comatose to the ER, and you certainly avoided doing duplicate exams/tests.
    Unless these tests were done out of the system. And that’s were the cost saving aspect comes in:
    savings will be significant if a patient gets virtually all care from the MSG using the EHR. Or if, by law, these EHR were somehow interconnected.
    If I was king of US health care, I would introduce a medicare EHR in which all participating doctors have to upload/scan their notes (and, as a side note, I would offer modified medicare for all). I am not an IT guy, but you could probably establish secure servers (such as Citrix servers) to bring the medicare EHR to every HC provider. That would save money and improve care considerably.

  19. In the absence of an alternative incentive model that rewards gains in systemic efficiency and quality while penalizing waste, EHR investment is unlikely produce a meaningful return. The current FFS model rewards fragmentation; one man’s “waste” is another man’s revenue. Better coordination of care ultimately will translate to improved care at the expense of someone’s income stream.
    Small wonder it’s hard to find any proof unless, of course, you take a look at the handful of prepaid systems already operating.

  20. Yep, what the above people said.
    EHRs are pie-in-the-sky. The first generation is so badly implemented that they actually decrease physician productivity. They weren’t developed with improved work flows in mind, instead they were developed with improved billing capability as the goal. On top of that they are overpriced and so many early adopters have been burned that introducing improved versions will be an even bigger battle.
    As Deron said, the care delivery system is the problem, not the way we store relatively small amounts of data. My dream? Even before single payer, I’d like to see a federally supported, secure web-based national EHR. I see it as improving care, but not saving money.

  21. You’d think that twenty years into the process of building and implementing EHR’s that there would be conclusive evidence of economic benefits to ANYONE in the health system other than the vendors. Go find it. In most other industries, automation leads to better process and quality control, reduced labor costs and improved customer service. Healthcare has invested plus or minus $10 billion a year in this technology for at least twelve years and where is the ROI? It isn’t just that providers cannot find it; neither can anyone else. This airy, speculative post could have been written a decade ago; this now ought to be a data driven discussion.
    The problem: healthcare remains highly fragmented and political, and a technology which could have convened all the fragments seems to have, as an angry physician put it, simply “fetishized documentation.” Bob Wacther’s plaintive post in THCB a few months ago about why EHR’s cannot be more like Facebook really nailed it: the EHR, thusfar, has merely created fancy new electronic silos for information, and has failed to evolve, as many in the industry hoped, into groupware for better co-ordinated care. EHR’s have become, sadly, the latest deux ex machina which is going to fix everything-the latest in a very long line of very expensive silver bullets.

  22. “we cannot effectively deploy technology like EHRs until the care delivery system is redesigned.”
    Single-pay first, EHRs next. Canada is still wrestling with EHRs. I’m afraid this will be like GM saying the new Volt is on its way so give us the $25B, but the reality is GM’s entire structure is broken and the mythic Volt, if it ever gets to market, will not fix GM. We’ll be trapped by the health industry trying to buy time doing the same thing, with the same prices, while they have us pursue the Holy Grail of technology to fix the system.

  23. Like I’ve mentioned in previous posts, we cannot effectively deploy technology like EHRs until the care delivery system is redesigned. We need to design the technology around effective processes, not vice versa.
    With that said, I don’t think enough attention has been given to web-based platforms. They could be a good option for smaller practices without big budgets, and ASPs could easily address the issue of interoperability.

  24. Jeremy,
    The literature is mixed on CDHPs. It is too early to make pronouncements, and the study you cite is far from nirvana. I am neutral on the subject btw and have no ax to grind. Additionally, as most readers know, only a small percentage of folks use a majority of the resources–not the likely demographic who will benefit from these products.
    Also, we alwasy tout the benefits of EHRs (including me at times). It is good to remember though that they are only a small piece of the “outcome.” Identifying the problem is one thing, but getting the patient in, the doctor or practice to communicate message, and the patient to comply is another. My ballpark is get a number for EHR savings and take a third–that is what you are looking at. Kind of reminds me of all the people talking about Internet efficiencies circa 2000. Yes, the Internet brought these to us (? save an hour a day), however, they never counted on workers wasting another hour or two surfing ESPN, CNN, or Amazon. In the end, unexpected and counterproductive. Anyway, I think you get the point. EHRs will only be one inflection point in the outcome of interest tree. If you are not familiar with it, listen to Orszag’s analogy of plugging in the toaster–drives the point home nicely.
    Brad

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