Deobfuscating HITECH

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, large 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.

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10 replies »

  1. Also the introduction of REC’s through the HITECH act. is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.
    Looking the funding provided to the REC’s, the staggered grant allocation system also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the
    ’safe vendor challenge’ as discussed by many critics.

  2. Nice post. Seem true on most accounts but I also think that today medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits.
    This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties.
    Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.
    I think ROI is very important factor that should be duly considered when look achieve a ‘meaning use’ out of a EHR solution. Though one may get vendors providing ‘meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment. Found a pretty useful ROI tool that is pretty customizable and easy to use. It also accounts for the different specialty EHR’s too.
    Some of the other useful resources on this topic:
    REC’s putting EHR’s to meaningful use
    Certification criteria for EHR

  3. Thanks, David. We should just keep everybody’s options as open as possible.
    bev, I wonder why the FDA didn’t get involved with EHRs from day one, since they obviously oversee all sorts of other HIT software in hospitals. If anybody knows the historical reason, I would be very curious to know.
    PT Software, you guys are addressing a real need. PT workflow is not easily integrated into a “classic” EHR (been there :-). Perhaps you can market it as a PT module to plug into any other software.

  4. Great post. I have to agree with much of what was said. EHR’s are still far from being reality. Everyone knows that they are great and that they should be used, but are not any further down the path of adopting them.
    Too many parties need to be involved and too many systems need to talk to one another in order for EHR’s to become efficient and effective.
    At Mavenlive (a software for physical therapists) we are developing a web application which allows for a flexible interface for therapists to enter their patients assessment and have that point and click assessment data automatically generate letters and suggested treatments.
    It is an ideal interface for therapists to use when adopting EHR’s because it merely presents the user interface where the data can be input, but behind the scenes that data can be translated into nearly any format that any receiving system requires.
    We realize that there will never be ONE system… but each system needs to be flexible enough to talk to others.

  5. Gary;
    The FDA regulation part, please God it should occur in some form, will be the vendors’ problem, not the users’. When our blood bank bought software or experienced an upgrade, the FDA had already dealt with the vendor before they could even sell it to us. Frankly, I think this should be financed by the same “user fee” system now used by the FDA for drugs – despite the criticism that this makes the agency cozy up to the vendors, I think this has been a consequence of past weak FDA leadership rather than of the system itself. Go back sometime and look how many years out of the last 20 that the FDA has had permanent leadership. It is a substantial minority of the time.

  6. Gary, I agree about certification and about a need for FDA oversight. However, for small private practices in particular, getting electronic is more than just getting a government handout, it’s about survival.
    Payment models are going to change, delivery models are going to change (PCMH, ACO and whatever else they will come up with). All these things require ability to collect and exchange clinical data. Those without ability to do so will be unable to “roll with the new punches”, and the alternative is selling out or retiring.
    Granted, it may take a couple more years until the writing is clearly on the wall, but IMHO, getting on board now will make things easier and the government money (plus the subsidized help from RECs) is as good as anybody’s.

  7. Other factors to consider.
    Another factor in the equation is that EHRs can be considered to be medical devices, or even ‘biomedical equipment”. I think most of you can see where this is headed. The Food and Drug Administration (FDA)regulates medical devices as well as pharmaceuticals.
    Consider this: Biomedical equipment must be annually inspected and certified by the appropriate biomedical engineer to be used for patient care. Devices usually are subject to a ‘clinical trial’ or reports, or an IDE (Investigative Device Exemption)
    EMRs are intimately intertwined with patient care, and involve patient safety issues.
    Where the feds are involved expect to see more bureaucracy, regulation and oversight. The feds are just not going to incentivize without regulation. Build in more overhead for regulation.
    Certification will not be the end of the story. Just as new drugs require approval by the FDA, so too will software upgrades. After all who knows what an upgrade might cause?

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