Electronic Medical Records and Obama’s Economic Plan

On Dec. 6, President-elect Obama announced the
three major pillars of his economic recovery plan: rebuild our
roads/bridges, enhance our schools including broadband, and deploy
electronic health records for every clinician and hospital in the U.S.

I can summarize all my advice to the new administration in one sentence: Allocate
Federal funds of $50,000 per clinician to states, which will be held
accountable (use it or lose it) for rapid, successful implementation of
interoperable CCHIT certified electronic records with built in decision
support, clinical data exchange, and quality reporting.

Not only
will this improve care coordination which will lead to better
health care value (reduced cost, enhanced quality), it will create jobs.

Just how many jobs would this create? For just the Beth Israel Deaconess Community Clinician project, here’s the list of jobs we created:

2009, we will implement 150 physicians in 75 practices, or 13
physicians in 6 practices per month. The direct staff we’ll need are:

Massachusetts eHealth Collaborative:  6 FTEs (5 practice consultants plus a project manager)

Concordant:  9 FTEs (5 on-site assessment/design/deployment/support, 2 technical lead/system architect, 2 project management)

eClinicalWorks:  4 FTEs (3 on-site trainers, plus part of a product specialist and a project manager)

At BIDMC, the project is run by 3 FTEs (Project Director, Technical Lead, Senior Practice Consultant)

we’ve created 22 jobs for the rollout and support of our EHR project.
Multiply this by the number of clinicians needing EHRs in the country
and you’ll see that the Obama plan will create tens of thousands of new
high tech jobs.

When I’ve discussed the Obama Economic plan with
my colleagues, some have said that it’s too early to invest in EHRs
because they are not yet standards-based or fully interoperable. I
believe that commercial EHRs are good enough and as of 2008, we have
many real examples of data sharing. Here are the statistics from our
work in Massachusetts that includes homegrown EHRs, eClinicalWorks, GE
Centricity, Next Gen, Allscripts/Misys, and Epic.

2008, we’ve done 60 million data exchange transactions a year from
EHRs, practices management systems, and hospital information systems.

– We’ve done half a million e-prescribing transactions among providers,
payers and pharmacies. Every discharge from the hospital and emergency
department at BIDMC generates a standards-based clinical summary which
is sent electronically to PCPs and referring clinicians. In 2009, we’ll
expand this to include referral workflow, community to community
exchange, and several additional hospitals including Children’s.

eHealth Collaborative – We’ve wired three communities (Brockton,
Newburyport, North Adams) with roughly 500,000 patients, 597 physicians
in 142 practices in 192 sites, and 4 hospitals including hospital-based
laboratories and imaging centers. North Adams went live in May 2007,
Newburyport went live in September 2008, and Brockton is 40% complete.
Data exchange includes problem lists, procedures, allergies,
medications, demographics, smoking status, diagnoses, lab results and
radiology results. Standards used include HL7 2.6, Continuity of Care
Record/Document, NCPDP Script 8.1, LOINC, CPT4, ICD9, and RxNorm. Over
90% of patients have opted in for community data sharing. Over 300,000
records have been exchanged, all from existing commercial EHRs.

Thus, the EHRs are ready, the standards are harmonized, the architecture is
designed, and the only barrier is political. The Obama commitment to a
nationwide EHR implementation effort means that 2009 is the tipping
point. Let us band together, payer, provider, employer and patient, to
make it happen!

See also: I’ve written several recent blogs about the cost of electronic health records, the state of interoperability, and my predictions for the early healthcare IT activities of the Obama administration.

John D. Halamka, MD, MS, is CIO of the
CareGroup Health System, CIO and Dean for
Technology at Harvard Medical School, Chairman of the New England
Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE, Chair of the US
Healthcare Information Technology Standards Panel (HITSP), and a
practicing emergency physician. He blogs regularly at Life as a Healthcare CEO, where this post first appeared.

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33 replies »

  1. The President made health care a centerpiece of his campaign, including investments in health care-related information technology

  2. The nurses always find most needed information when the patient is admitted. I always squish my joints back properly.

  3. Alex Papas, has been credited for creating and developing the prepaid phone card in the United States. He has now again created and developed another great product for everyone. It’s called the MedeFile Card. MedeFile’s centralized, confidential electronic portfolio gives everyone 24/7 access to there medical history. No more wasting time and filling out paperwork when you go to the doctor or the hospital. All Medefile Card members get a free MedeDrive (a small usb drive) that fits on your key chain, so now, just hand your MedeDrive to the receptionist its that simple…

  4. Sorry … that’s loss OF provider productivity. This means we are seeing fewer patients and providing less services to our patients because the computer takes up so much of our time.

  5. We have been using Centricity EMR in our community clinic for a year and a half now and we are losing money like crazy due to loss or provider productivity. I am a physician in the practice. I can understand that EMR will someday have the potential to improve patient safety and prevent errors, but the software has not reached that level of sophistication yet.
    There are many, many inefficiencies in Centricity.
    I could bore you all with examples, so I will choose one – The ‘red alert’ for drug interactions. This system failed to alert a prescriber who wrote a prescription for a statin when the patient was already taking one. For example, if the doctor prescribes simvastatin and the patient is already on lipitor, the system doesn’t recognize a problem. Why didn’t the doctor notice that the patient was already on lipitor? The med list on the computer is looks monotonous, does not show up on a single screen (you have to scroll down), and is difficult to read.
    But it pops up a red alert for every medication if a patient has medical equipment in their med list. Equipment has to be ordered as a prescription, so every prescription ends up on the med list automatically. The red alert says ‘unable to check interaction with incontinence pads’. I swear I will never click on a Red alert again when this happens, but of course a few days later I wonder if I am missing something so I click on another one: ‘unable to check interaction with four point cane’. I feel like a real sucker for listening to anything this computer tries to tell me since 90% of its advice is redundant, not relevant to the patient in question or just plain bad advice written by somebody who knows less about medicine than I do. The other 10% is mostly stuff I already knew before the computer told me.
    There are many aspects of this software that waste my time and reduce the amount of time I can spend actually interacting with patients and figuring out how best to treat them.
    If we adopt EMR nationwide, we should be sure that all hospitals and offices can communicate with each other; the softwares must be compatible. Also, it must be well-written with an eye to accuracy and efficiency. GE has a great marketing department, but a lousy bunch of software engineers. I joke that Centricity was the 6th grade science project at the local middle school.

  6. “…Federal funds of $50,000 per clinician to states”
    Terrible idea, although I think that the faster clinical data is digitized on a regular basis the better.
    Tax-payer funds at that level introduced into the medical services business will be almost completely “wasted” in the sense that the alternative is to spend next to no funds (i.e. tens of millions at most) on establishment of an Apache Software Foundation or comparable entity-sponsored open source project to enhance a given existing EMR/PM product openEMR for example. The FOSS paradigm works superbly. It should be used in this case. The same or a separate project can provide software frameworks for enhancing interoperability of disparate commercial and non-commercial systems.
    “1)new technologies which are more expensive and may add, but marginally, to quality of care and outcomes and 2) diagnostic and treatment for medico-legal and patient satisfaction reasons.”
    I agree with Bill on this in regard to the cost drivers in medical services, but from that does not follow this “Give me a break with the IT fantasy.”
    Making grandiose claims about the financial or other benefits of universal digitization of clinical data serves no good purpose, but there also is no question that the faster the data can be digitized on a normal basis, the better. Most of the benefits of the availability of digitized data are unknown at the moment in any case, but the reduction in valueless repetition of administrative form-filling, etc. will be immediately felt by physicians and patients alike.

  7. I do NOT want to be in a national data base so I guess I am DONE with doctors!

  8. As both a retired clinician who has used EMR and as a patient who has been victim of many clinicians who use the EMR (through the VA Healthcare system) EMR is a tool. Good, well trained clinicians will find it a valuable tool and improve care through its use.
    Clinicians with marginal ability and caring will use it as either a crutch, using only prompts to do clinical interventions or blaming the EMR for their lack of ability. Clinicians who never read a paper chart will not read an EMR, those with poor paper notes will have poor electronic notes.
    Nothing is more demeaning than seeing someone whose focus is the EMR or Paper Chart and not the individual being treated or being given the impression that you are “bothering” the clinician.
    Some people should not be in the Healtcare field and EMR does not change that. Funding should focus care outcomes.

  9. While an efficient and interoperable EMR will cut costs and improve efficiency in obtaining information and reduce errors I doubt it will end up saving money from a societal perspective. Will the gvt go on funding IT support forever? Who will the cost burden fall on when they stop? Will the cost savings really outweigh the implementation and ongoing IT expense? Will this massive infusion of money run up costs and stoke inflation, eroding the value of the dollar for patients and physicians. Show me the data scientists.
    Even if these efficiencies do save money will they make a dent in the real drivers of health care costs: 1)new technologies which are more expensive and may add, but marginally, to quality of care and outcomes and 2) diagnostic and treatment for medico-legal and patient satisfaction reasons.
    When I can tell a patient “no, no MRI yet, lets give it a month” or “no, you don’t need antibiotics” without concern about Press-Ganey scores or a nasty-gram to the administration, this is when costs will be controlled. Or how about “no, we are not going to intubate your 90 y/o mother who is already severely demented and has 0 quality of life.”
    Give me a break with the IT fantasy.

  10. Hey guys – for those of you interested in learning more about electronic medical records, specifically relating to ophthalmology, you might want to check out this fun and informative blog that was created by IO Practiceware (a company that makes EMR and practice management software):
    I haven’t really seen anything like it — go on and give it a look.

  11. “it was with a near complete sense of certitude” – I think you hit the nail on the head. I do think most of us have to eat more humble pie, both physicians and patients. Some physicians think they know everything, and some patients think they can self diagnose or treat themselves better with what they read on the internet (of course some of them are right, but this is rather the exception than the rule). Both is often unproductive and at times harmful (I am not talking about networking re. diagnosed conditions or doing research to find a good specialist, both can be very helpful – although the latter should be the doctor’s job). I personally do admit when I don’t have an answer to a question, and I do know that there are patients having a hard time with that, and patients who understand and are appreciative.

  12. There are so many factors involved in quality health care, and there is no one solution — including Health IT. Health IT is merely a tool — albeit a powerful one — and I would never claim it is the sole solution.
    In the end, good communication and trust between a patient and a provider or group of providers is the key. The patient has to become a full partner in their health care to the best of their ability. Will everyone do it well or even be interested in doing it? Of course not. But we must recognize that part of caring for the patient is education and information in a non-condescending, plain language, collaborative fashion. Not every patient is going to know what is appropriate or reasonable — it is our job to help them figure that out.
    I agree with rbilla’s points on physician quality — every physician should answer all questions thoroughly and offer a referral for a second opinion if it’s requested.
    We live in the wildest information age the world has seen so far, and this has amazing and frightening qualities. For health care, change will come when we share that information broadly and communicate it clearly and concisely. But, again, Health IT is only a tool — the change needs to come in human form through thought, values and action always keeping the focus on the patient.

  13. I apologize for my incivility.
    Whenever anyone almost accidentally killed my daughter, it was with a near complete sense of certitude. She was virtually the 100th diagnostic possiblity out of 100.
    Navigating a referral without records in hand is like driving a car blind. I spent three hours doing it today, with roughly a 50% success rate. If I didn’t know the CEO of the local hospital, the process of clarification on this particular issue would be double the time, six months instead of three.
    In the hypothetical MRI/MS case you mention, participatory medicine would ideally recount patient misinterpretation/naivete as well. On ACOR sarcoma, for instance, we help members locate expert physician teams. We never diagnose.
    I am here to remind professionals of what it is like for a patient to navigate these systems. They should work on logic rather than on whom you know.
    Henceforth I shall cultivate silence as a learning technique 🙂 (and get my iPhone case on correctly)

  14. Christine,
    I am sorry about bad experiences you may have made in the US healthcare system (that I find fundamentally flawed as well). I am glad that you apparently make better experiences these days. I hope that you are open to arguments from a different perspective that may be counterintuitive to the good points you make.
    I am sorry if my comments apparently did strike you as arrogant and condescending. That does not justify rephrasing and interpreting my statements in the unfair manner you did.
    If you read my comments closely, you will notice that at no point I advocate withholding information or chart copies from the patients (every patient actually needs/wants a different degree of information and involvement). If you feel the need to criticize the points I made, please refer to the actual statements I made and not some stereotypical interpretation
    The gist of what I said is that only a limited subset of patients qualify for the degree of participation that you envision. Maybe this subset is larger than I think – the nature of my practice involves many patients with cognitive impairments, and many older patients who have no computer skills and/or a more authoritarian doctor/patient relation). I personally encourage any form of participation by my patients, and I try to leave no question unanswered, and I provide written diagnoses, self authored evidence based handouts as well as web printouts; I also encourage further research.
    Let me give you an example what I mean by the limits of participatory medicine. More and more people are getting brain MRIs, often ordered by their primary physicians who themselves are at times overwhelmed bringing the findings into perspective. A solid percentage of healty individuals has spots on the MRI (so called nonspeficic white matter changes). Almost always, the interpreting radiologist raises the issue of these spots possibly being related to MS, although they might point out that “correlation is needed”. Patients looking up MS on the internet or elsewhere see a huge variety of symptoms that, to some degree, overlaps with physical experiences/complaints that many healthy individuals have (e.g. dizziness, fatigue, tingling). A lot of patients are terribly worried until they see a specialist. Quite a few patients do carry incorrect diagnoses of MS for that reason. Direct chart access (that you feel strongly would be a blessing) would make the problem worse.

  15. re: rbrilla
    I agree that most patients are dumb and half literate, certainly compared to physicians (that’s what you’re saying, isn’t it?). Certainly America is half literate (as is, some might say, our current President). And technology alone is no panacea for anything, including physician or institutional ineptitude.
    This said, we inhabit different universes. I direct your attention to the Recent Mentions/New York Times on the front page of this blog re: Health 2.0 and aggregatve knowledge http://www.nytimes.com/external/readwriteweb/2008/10/22/22readwriteweb-health_20_economics_of_aggregation.html
    Sophisticated IT planning might envision a role for aggregate knowledge/participatory medicine; a generation that is more technologically adept than are we; and parallel systems of education to support the new IT re: patient education.
    Among the new jobs that may be created in the new hc system are IT facilitators/intermediaries (if not the advice nurse at the PCP, the oncology nurse at the hospital, etc. to interpret basic information). Also, as Jane hinted, physicians might consider themselves on the new frontier in terms of using the new IT to create and encourage better informed e-patients.
    I would also refer you to Patient’s Rights, some versions of which, at least, offer patients a preference in terms of how they like their information. In my case, for a serious or potentially serious condition like cancer, that would be: be copies of major test results and reports (radiology, pathology, etc.); sent via email; BEFORE an evaluative appointment, not after.
    I would not use a physician who insisted or pressured me into the type of the outdated auditory/intuitive/uninformed system that you seem to favor, particularly, as you seem to imply, if your key points for patient satisfaction and the patient-physician interaction did not include patient access to important test reports, etc. in a timely manner. (This is basic protocol at MDACC.)
    In light of the above, I find it ironic that a common physician complaint about patients is that they don’t have instant recall as to the proper names and dates of existing conditions and/or prior diagnoses; names of previous physicians, plus phone and fax numbers, etc.
    What non-expert could possibly remember these things accurately, without written records in hand? I believe the “catch rate” of relevant reports on a referral is about 40%, particularly given the low level of education, commitment and reliability of many front desk staffpersons.
    Getting educated, compiling copies of test results, scans and reports, etc. is the first thing a cancer patient is advised to do. See for instance http://www.blochcancer.org/ What I don’t understand is why a physician in this day and age would not possibly know or appreciate this. I am not being mean or (just) sarcastic here. I am serious: We inhabit different universes.
    As I have noted elsewhere, that is precisely the kind of systemic/knowledge imbalance that keeps patients ril ignorant, physicians, ril smart.
    I just saw my young, smart and IT-adept PCP a few hours ago. Besides being collegial and an excellent diagnostician, she was quite at home with her computer/EMR system, even as she acknowledged that it wasn’t interoperable (she knew what that meant.) Nonetheless, she quickly typed in my email address as requested so I could receive a copy of the results of an upcoming test, in so doing, eliminating a cruel, two-week, holiday-induced wait period. That would be commonsense, compassion and education in a few keystrokes.
    And, we live in one of the most poverty-stricken agricultural areas in the United States. I would assume that users of this blog are far more sophisticated than country physicians. Wherefore the gap?
    Admittedly, my induction into the world of patient advocacy was a rough one [https://thehealthcareblog.com/the_health_care_blog/2008/10/mri.html], but still, there is more to it than this.

  16. All of this talk about EMR helping create a better patient/physician relationship is secondary to the most important issue we face. I am the IT manager for a small orthopaedic group and have been looking at EMR for over 2 years as a possible implementation in our practice. The problem is cost. Not only are they prohibitively expensive, but even according to Dr. Halamka’s article, they CREATE jobs. We don’t need more payroll right now, we need less. The current billing/reimbursement ratio is dismal at best and doesn’t appear to be getting any better under the new administration, and especially considering the declining economic situation, so why or how could I justify creating jobs and increasing payroll in my office. Before EMR can do anything to improve health care, we need to get doctors out of the survival mode, and we can only do that by shoring up their practices with better reimbursement levels and eliminate unnecessary insurance interference in decision making.

  17. All of this talk about EMR helping create a better patient/physician relationship is secondary to the most important issue we face. I am the IT manager for a small orthopaedic group and have been looking at EMR for over 2 years as a possible implementation in our practice. The problem is cost. Not only are they prohibitively expensive, but even according to Dr. Halamka’s article, they CREATE jobs. We don’t need more payroll right now, we need less. The current billing/reimbursement ratio is dismal at best and doesn’t appear to be getting any better under the new administration, and especially considering the declining economic situation, so why or how could I justify creating jobs and increasing payroll in my office. Before EMR can do anything to improve health care, we need to get doctors out of the survival mode, and we can only do that by shoring up their practices with better reimbursement levels and eliminate unnecessary insurance interference in decision making.

  18. Christine and Jane,
    I don’t think I have to stress again that I am all for EMR (and had the fortune to work with them for almost a decade), but I do think you have some misconceptions.
    “While the EMR is only a tool, it has the remarkable power to change many of the fundamental problems with health care in the United States. To change health care, we must improve coordination of care, provide value (better outcomes, safety and service), and reform the payment system.”
    The EMR is, IMHO, far from being the SOLE savior of the US healthcare mess. Other industrialized countries such as Germany and France did and do much better without EMR (or now, with EMR mostly in its infancy). In other words, EMR is not the prerequisite to better health care. However, Jane, I do agree with your three bullet points.
    Re. patient participation: I am more than happy about input from patients as long as it is reasonable/appropriate. Many patients (or relatives), both old and young, don’t have the insight to digest information and apply it to their situation. If you don’t realize that info from the vitamine shoppe is not equivalent to the Mayo clinic website, or if you cannot weigh the information in a scientific article you got of the internet (big surprise, many doctors can’t), I think that discussions with your physicians about medical notes (not: your care plan) will be productive.
    What I recommend to every patient concerned about physician quality to check is:
    -do I get answers to my questions with specific detail, but in understandable language, with the option to ask follow up questions?
    -does the diagnosis and diagnostic/therapeutic plan seem to roughly fit with what I read in an independent good source?
    -if not, do I get a satisfactory answer why there is a discrepancy?
    If the above is not the case, do not hesitate to get a second opinion (which costs the fraction of an MRI) – a good doctor probably would help you finding a qualified 2n opinion. Review of your own chart is only the last resort and probably should be done with assistance.

  19. Jane,
    Thanks for your comments. I was thinking of the age issue as I wrote. In particular, my daughter saying, “Mom, your iPhone case is upside down. Who does that!?”

  20. While the EMR is only a tool, it has the remarkable power to change many of the fundamental problems with health care in the United States. To change health care, we must improve coordination of care, provide value (better outcomes, safety and service), and reform the payment system. By sharing information, the quality of care that an individual provider gives to his/her patients CAN improve. Will the EMR alone do it? Of course not. But it can be one of the important steps to take.
    The EMR, if implemented broadly and with interoperability, has the potential to:
    *Improve quality of care through coordination and transparency. Imagine of all of your care providers can all see the same information — this can decrease repetitive, unnecessary testing; fully inform one care provider about what another is prescribing/treating; and ensure that the full spectrum of a patient’s health is visible. to all.
    *Improve the patient’s access and understanding of their own health status. I have seen patients come to us with medical records and images that it has taken them weeks to collect from various providers who have cared for them. When people are ill, the last thing they need to do is invest their energy in data management.
    *Improve safety. With a readily available EMR, the chances for medication errors alone decrease significantly.
    The Mayo Clinic Health Policy Center gathered health care providers, IT experts and privacy advocates to discuss what the requirements and next steps could be to design and implement a robust, accessible Health IT system. To see the full extent of recommendations, visit http://www.mayoclinic.org/healthpolicycenter/healthit.html .
    One final thought — adoption for the current generation of health care providers will be challenging. But think of the young health care providers (physicians, nurses, technicians, etc.) who are just beginning their careers — to them, the EMR and other Web-based tools are second nature. We have to not only think about this incoming workforce, but also tap into their knowledge, skills and talents so that we design systems that are intuitive and accessible.

  21. Here’s the contradiction: With all of the complaints and assumptions about patient ignorance by physicians on this blog, one would think they would WELCOME a more educated patient. I, for one, don’t process information well unless I have a document in hand (and a yellow marker pen). Or, if need be, a dictionary.
    The current system of authority/ignorance is so archaic that physicians just don’t see the ridiculousness of it. The physician cultural “bubble” is reinforced by the (now) longstanding failure to educate themselves about advances in e-medicine and participatory medicine.
    Yes, it’s slow coming, but which model, one has to ask, is the wave of the future?
    Five years ago my daughter’s Certified Case Manager attended a hc seminar in which the speaker walked around the room repeating the statement, “The Internet is here to stay. Get used to it.” Even when her patients were non-native speakers, they almost always had a computer in the home; their CHILDREN accessed basic healthcare information for them.

  22. To re-frame rbrilla’s comments:
    Patient-centered EMR (meaning you can obtain copies of relevant test reports, etc. before the next Ice Age) does not DIRECTLY change quality of physicians’ work. It does so indirectly, by providing greater transparency of physician work and more effective oversight by patients/the public.
    With timely access to copies of test results and reports (and physicians’ notes, if necessary), patients can better educate themselves AND evaluate the quality of care they receive. Transparency prevents physicians from hiding errors, including systemic errors (poor inter-departmental and inter-institutional communication). In tandem with other Internet capabilities (like e-communities), transparency provides the public better means of evaluating institutions, particularly in life-threatening situations (sarcomas/Kaiser CA being one case in point).
    The hc system in the US is broken, yet the assumption of physicians who enter into these conversations is that others are making the errors, not themselves. To paraphrase Meryl Streep in “Heartburn,” physician/institutional error is at best “a distant bell” in these discussions. Patient input provides a reality check.
    I think you mistake the import of participatory medicine. If I have a disease, I need a starting point for learning about it. That would be the test result or physician report. I in no way seek to replace physician expertise with my own. What I do seek is oversight, particularly if (as is commonly acknowledged on this site) physicians are overworked, underpaid, resentful, rushed and fatigued. If I buy a new printer for my computer, I have operating instructions. If I get a cancer dx from a physician, I have no “takeaway” except some verbal communication from which I retain only a few key words, heard in shock.
    In oldstyle AMA-type dominant medical culture, physicians are shocked and resentful of oversight/transparency wrought by the new Internet culture. In this they are far behind university professors, for instance, who had to get over themselves a long time ago. Yes, the process is messy, but, as Obama pointed out this morning, it’s hard to see how American hc can get much worse.

  23. Can anyone tell me who/what are the top 5-10 EMR programs used across the country? I mean, which companies are among the most popular among doctor’s offices? Do the top 5 or 10 companies represent 75% of the market?
    Any insight is greatly appreciated.

  24. Am I the only one finding that EMR are very important (and unavoidable), but that there are unrealistic expectations with regards to their benefit?
    Steven wrote: “CPRS does nothing to assist the physician in producing or interpreting records”. An electronic medical record is exactly that, a medeical record.
    Since 2000, I worked with 2 different systems (actually 3 if you count the old VA system) and was in contact with physicians using the new VA system.
    EMR are great in finding notes (by 1. making them available and 2. by organizing/filing within the EMR in a superior way to most paper charts).
    For the first time, I will use all caps in a message board posting:
    THE QUALITY OF A PHYSICIAN’S WORK GENERATING A NOTE OR INTERPRETING OTHER DOCTOR’S NOTES IS NOT IMPROVED BECAUSE THE MR IS AN ELECTRONIC ONE, with some possible exceptions (you can – and my MSG succesfully does – control certain standards such as eye doctor visits and low HBA1c for diabetics, BP readings for hypertensives etc., as Mr. Halamka indicates). BUT THE EMR WILL NOT IMPROVE THE DIAGNOSTIC ot THERAPEUTIC ABILITIES OF THE INDIVIDUAL PHYSICIANS.
    It is possible that one could improve diagnostic performance if there was a working decision support system that had proven to be beneficial (and not to produce a lot of low yield differential diagnostic considerations). (If such a system exists, I certainly would like to know its name and try it out if possible.)
    Christine, I am very skeptical re. your postulate that the EMR should be “patient centered”. I personally view all medicine as patient centered, as succesfully treating patients is the sole purpose of practising medicine. A good EMR should assist physicians to provide excellent care – but I would not know how, in practice, the EMR could be “patient centered”. If you are talking about having the doctor’s notes available and ready for discussion, both paper records as well as EMR are able to do that upon patient request. However, doctor’s notes are written in technical terminology, and most patients are not able to correctly read/interpret most of them without help. You might disagree, but I don’t think that all patients starting to browse their notes would be an improvement. Communication classes in med. school and residency and maybe testing doctors in that area might be more helpful, some programs already do it, and one should support their efforts and, after review, make them standard.

  25. While I agree that the government can improve connectivity/interopability with the right incentives, most well-known EMRs are too cumbersome for providers to easily integrate into their workflow.
    Limiting the field to CCHIT certified systems creates an artificial barrier to entry in the EMR marketplace. This barrier is supported by well-funded companies (NextGen, Allscripts) that tout systems replete with endless point and click templates.
    Providers spend all this time on data entry and still end up with a clinical note that is not as information-rich as a dictated one.

  26. As a non-tech person who is new to these debates, it seems to me that HIT, like all technology, operates on the principle of [G]uaranteed [O]bsolescence. Therefore, one has to start somewhere and add on or modify as necessary. The GO part does not mean you don’t start.
    At times I feel that folks who find nothing but flaws in HIT systems have some other agenda at work (opposition to universal healthcare, perhaps, or to a radical restructuring of the existing hc system), whereas some commentators get so focused on details they miss the big picture.
    What I do know for sure is that whoever is in charge of these transitions needs to be able to explain it clearly to the public.
    The simplest way to do that is to explain how any system or features affects the patient, i.e., the alleged customer/pawn/beneficiary of these changes.
    See, again the Great Kibbe Debate “Confessions . . . ” re: the patient who tried to access her EMR in the ER, to no avail.
    *Patient-centered explanations are, not uncoincidentally, the best way to reach the political base which will legislate these changes (or not).
    Kaiser, for instance, apparently “forgot” the patient when they adopted a new, hugely expensive and not all that successful IT system. Maybe there is a connection.

  27. I have been using the VA electronic health record, “CPRS” (computerized patient record keeping system), for nearly 10 years now. The software is in the public domain and is available now for any interested user. The implementation at the VA has been largely successful, solving problems, implementing electronic prescribing, vastly improving the access to records including imaging, and has been documented to have improved the quality of patient care and has saved lives. The great advantage this software brought to the VA was the almost guaranteed availability of patient chart materials (compared to a 20% or more rate of my not being able to obtain a patient’s chart when I started seeing patients there). There are a couple obstacles that I anticipate will prevent its widespread adoption in spite of its free availability.
    CPRS does nothing to assist the physician in producing or interpreting records. Physician notes are unstructured and cannot be formatted. The document writing portion of CPRS is an unformatted text box. Almost none of the standard word processing software features that have been taken for granted for more than a quarter century of personal computing are available within CPRS. Caregivers are much less efficient than they were using paper records. The software slows rather than speeds physician work. There is no provision for billing.
    It is possible to purchase or design hardware and software that assists the physician while improving patient care, and creates a structured record that could be leveraged for improving quality of care and researching patient care and its outcomes.
    – This document has been prepared with voice recognition software. Please excuse unusual errors. –
    “The contents of this message are mine personally and do not reflect any position of the Government or the Department of Veterans Affairs.”

  28. I am a big advocate for health information technology and have devoted my career to promoting health-IT adoption and optimal utilization. With that said, I disagree with Dr. Halamka’s statement: “Not only will this [$50K for CCHIT EHR adoption] improve care coordination which will lead to better healthcare value (reduced cost, enhanced quality)”. These [implementation of CCHIT EHR and healthcare value] are not in a cause and effect relationship. It would be like saying, we need to invest in the deployment of the Interstate system to lead to fuel-efficient vehicles. The Interstate system is a pre-requisite for wide adoption of fuel-efficient cars, but they do not cause there development and adoption. We need to tie the stimulus to the outcomes we want, continuity of care, coordination of care, quality and safety. Incent continuity and quality, and you will get continuity and quality. Incent EHRs and you will get EHRs.

  29. How does your proposed system handle the objections listed in The Great Kibbe Debate? [see top right link of thcb]. interoperability, etc.
    Please rate ease of patient use/access from 1 – 10. Are patients the first thought, or the afterthought in the systems you describe?
    Is your primary focus the insurance/physician nexus or the patient/physician nexus?
    If the VA has an excellent system in place already, how many components of what you describe emulate this system?

  30. I hope President-elect Obama takes a serious look at the EMR used in 155 VA hospitals and over 2000 VA Clinics. The VA has an integrated EMR with electronic provider order entry, bar coding of medication administration, and pharmacy dispensing information along with progress notes, reporting results and digital imaging including films. The system in place since 2000 was sucessfully tested with Katrina and performed excellent. The networking ability is strong and the system has high usability by providers.

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