By MARGALIT GUR-ARIE

Software developers sometimes use a technique called obfuscation to
protect their intellectual property. They use tools to add, remove and
displace the original flow of the code until no human can understand
what it does or how it does anything. Judging by the ample confusion
expressed by large numbers of physicians, it almost looks like a giant
obfuscator has been applied to the HITECH act leaving the medical
community to wonder what to do, why do it and how to proceed. The
prevailing wisdom is that, for some misguided reason, the Government is
paying for EHRs, but there are so many strings attached that it is very
unlikely anybody will ever see a dime of the much advertised $44,000.

First we should figure out what these EHRs can do, or more accurately,
will one day be able to do.

1. Store all your paper records electronically in a computer and
   make them accessible to many other providers of care, including
   patients. EHRs, if allowed, can also make all your records available to
   insurers, Government and any other agencies or corporations who manage
   to obtain access. There will of course be laws and regulations, consents
   and all sorts of policies in place to prevent or punish unauthorized
   access. Electronic data is much more liquid than paper based data,
   leading to better collaboration, better visibility and like all liquids,
   has better chances of leakage.
2. EHRs can slice and dice your data and present you with flowsheets
   for an individual patient and many reports across your entire panel of
   patients. You could see how your patients are doing, which ones need to
   be reminded to come in, or schedule screening tests. It’s hard to do
   that on paper.
3. Just like your data is available to others, theirs is available to
   you. You can see medication lists, specialist notes or PCP histories,
   hospital records, test results and even home monitoring devices input in
   real time. Coordination of care should become less time consuming.
4. EHRs can help you directly communicate with patients (and other
   doctors) via secure email or even secure teleconference. It can automate
   making appointments, paying bills, obtaining pre-authorizations and
   even the entire check-in/check-out process.
5. EHRs can provide you the latest guidelines and evidence, in a
   patient specific context. Perhaps even CMEs. Computers are supposedly
   better at calculations and cross checking large amounts of data, hence
   they could alert you when an error is about to occur or present you with
   the latest checklists.

No, all these things are not there now. Some of the simplest ones
are, and the rest should become reality after enough physicians start
using EHRs and enough EHRs get interconnected to form a critical mass
necessary for progress.

OK, so where is the catch? Truth being said, there is more than one
catch.

1. You have to feed the beast. Computers cannot deliver any of the
   wonderful, or less wonderful, things above, unless somebody enters data
   into the EHR to start with. While most data can be entered by staff,
   lare portions will have to be collected by the physician.
2. Computers are intrusive. The EHR will make its presence felt in the
   exam room. It will alter your interaction with your patients. There are
   tips and tricks to minimize the change, but it cannot be eliminated
   altogether.
3. EHRs are not a finished product. When you “adopt” one, you become
   part of a learning effort on how to computerize medical records. EHRs
   have “glitches”. The Internet and broadband have “glitches”. Computers
   in general have “glitches”. People have many “glitches” too. Nobody
   invented the perfect method for documenting encounters, for viewing
   longitudinal records, for ordering tests and most important, EHRs are
   not yet able to communicate with one another on a large scale.
4. The Government will have easy access to your records. Your
   performance may be judged (perhaps inappropriately) and reimbursement
   may be affected. Patients (and their attorneys) will have unfettered
   access to your records. Mistakes will be found. Little notes you made
   just for yourself in the paper chart, are not just for yourself anymore.
5. EHRs can be expensive. They don’t have to be, but they can be.
   Picking the wrong piece of software, not getting proper training, not
   managing the implementation process correctly and failing to
   continuously manage change may cost you a small fortune, mainly in lost
   productivity. There are no “lemon laws” for EHRs.

My first cell phone weighed over a pound and had huge buttons and a
very ugly antenna. My second cell phone was a flip phone and my third
one was Java enabled. I now have an iPhone. My first computer was a main
frame IBM 370. I was madly in love with the power of that machine. My
second computer was an IBM PC. I named him and took him with me on a
long vacation overseas and back. I now have a thin and much more
powerful Sony Vaio. I could have sat this whole thing out waiting for
the iPhone and the Vaio to be perfect, which they still are not, but I
would have been left behind I think. I would have certainly avoided the
embarrassment of dragging a 30 lb computer through several airports and
the excruciating wait for the modem to connect, or the inconvenience of
dropped calls every time I drove by an electricity pole. But I would
have also missed the ability to help a Hospital keep receiving lab
reports on a Friday night and the opportunity to walk a technician
through an entire database restoration from a mountain lodge in the
middle of nowhere.

If I were a physician in a small private practice today, I would do my
research and locate the cheapest EHR that can do what needs to be done
relatively well. I would “adopt” the contraption, regardless of the
promised $44,000, probably name it Lucifer and keep an eye on it to make
sure it behaves itself. And I would try my hardest to become part of
the future and part of the solution, because folks, whether we like it
or not, paper is over.

Margalit
Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at
GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing
services for physicians. Prior to GenesysMD, Margalit was Director of Product
Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large
non-profit hospital organization.