OP-ED

Op-Ed: The Government EHR

No, you didn’t miss anything, there is no Government EHR. But should there be one? And if so, what should it look like?

The argument in favor of a Government EHR goes something like this: If we have 19 Billion dollars to spend on EHR adoption, why not spend a small fraction of that money and buy or build an EHR and make it freely available to all physicians and hospitals? Not a bad idea. I would add that, if we must, we could spend the rest of those billions on training and supporting physicians in their efforts to computerize their records. So how would a Government go about accomplishing such monumental task?

The first option would be a “fixer upper”. Buy something like Epic, which has both an inpatient and an outpatient EHR, hire a team of software developers and hordes of usability and medical informatics experts and set them down to work on the existing product. A slightly less expensive option, which is frequently mentioned, is to use VistA instead of Epic. After all the Government already spent boatloads of money on VistA and many of its users seem satisfied with the product even in its current state. Epic has many satisfied customers as well. Either way, it shouldn’t take more than a couple of years to have a fairly usable product, migrated to new technologies, scaled down for small hospitals and practices and scaled down even more for patients.

The second option is similar to the process by which the Pentagon acquires new fighter jets. HHS would publish a set of requirements and various vendors would create a prototype and bid for the contract. For an EHR, one would expect the likes of Microsoft, IBM, Apple or Google to lead the pack. For this scenario the Government would be free to specify requirements to facilitate all the data collection the Government may need, and probably base the entire project on a Federal Cloud with Internet access either through a downloadable smart client (e.g. TweetDeck) or plain browser (e.g. twitter.com), or both, as circumstances dictate. We should have something to look at in three years or so and could begin rolling it out in earnest in four.

Either option will overcome most impediments to achieving an EHR for every American. A Federal Cloud containing all medical records will obviate the need of reporting to CMS or any other government agency. A true multi-tenant Federal Cloud will be able to uniquely identify each patient, with a very high level of confidence, and automatically create a National Patient Identifier without all the legislative and bureaucratic hassle. Since all data is managed by one entity, assembling a longitudinal, complete record for each one of us, either persistent or on-demand, will become almost trivial. One database schema, one terminology and a unified user interface would practically guarantee abundant and high quality data points for clinical research. Privacy and security policies, all residing in one place, could be driven by the patient, or consumer, through their own longitudinal, comprehensive view of the medical record. There will be no need for intermediaries and push/pull addressing systems with all the associated complexity. Every doctor, clinician, hospital, insurer, researcher and consumer will be accessing the same data, through the same software, within the scope of various privacy and security policies. And it will all be free.

For all those pulling “1984” out and looking to see if medical records are mentioned there, relax, this utopian EHR is not on the Government agenda at this time. There are as many obstacles to building the Federal Cloud EHR as there are to providing a “Public Option” for health insurance and neither one is politically feasible at this time. There is a large and rather influential Health Information Technology industry which will be summarily killed off by a Government EHR initiative. The need for instant gratification and the greater need for political campaigning material preclude anything with a longer than four years time horizon. Americans have a historical aversion to centralized control and would much rather have multiple smaller corporations control smaller chunks of activities and information, regardless of the administrative costs and pitfalls of such approach.

And then, of course, there is the freedom of choice issue. What if I don’t like the Government EHR? What if I want to build my own, or buy one that suits me better? And what comes next, a Government Automobile? And the right to privacy of both consumers and providers is not far behind. Why should the Government have access to every minute detail of my business? What would lawyers do if the Government would require that all their dossiers be uploaded to a Federal Cloud? What do the Constitution and Bill of Rights have to say about such practice? Certainly this is not what our founding fathers had in mind.

Of all the billions of dollars available for EHR adoption, the Government is timidly allocating $60 million to EHR research activities in areas such as security, usability, clinical terminology and some peculiar concept of making EHRs more like iPhones. I have very little hope of anything tangible materializing from any of these research programs anytime soon. In the meantime, tax payers, physicians and various providers of health care services, are spending billions of dollars on “fixing”, deploying and interconnecting fragmented software systems perfectly matching our equally fragmented insurance and health care delivery system. With enough duct tape, strings and wires, we should be able to pull something together. We’ll fix the rest later….

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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james walkerGARY LAMPMANElectronic Health Record SoftwareciphertextInfoMark Recent comment authors
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james walker
Guest

Margalit, What you want in your last comment is simply what needs to happen. I see little reason why it shouldn’t or couldn’t happen. The fact is, current vendor solutions can continue using and developing their innovative, proprietary E.H.R. products – but there would always be a basic standard set of transfer, database, and identifier protocols to which all vendors must develop patches / translations for, say, CMS-accredited HIE transactions. If you want to use alternative HIEs, fine; if you want to participate in silos, fine. You just have to make a core set of data compatible with the CMS… Read more »

Margalit Gur-Arie
Guest

“why hasn’t this product that is freely available via a FOIA request been more widely adopted?” Because it is not “free”. I still have to pay for the servers to install it on, the third party software licenses it requires, the development of custom interfaces to all those “standardized” pharmacies, labs, hospitals, imaging centers, etc., the “IT guy(s)” and the “developer guy” for any maintenance/enhancements I want/need, the clearinghouse, the clinical content/codes and so forth. By the time I add it all up I spent as much money as I would have spent if I bought a commercial product, plus… Read more »

ciphertext
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ciphertext

As to the Government competing or selling EHR, I don’t think it should. If they ever commission one from a private company, or actually endeavor to build one “in house”, the EHR should be provided free to providers as a SaaS offering. — Margalit Gur-Arie I believe the Dept. of Veterans Affairs did just that, or something similar, with the VistA program. Here is a link to other adopters (Federal Agencies) that utilize VistA. Here is a link to non-federal adopters.Perhaps the real question to be asked is “why hasn’t this product that is freely available via a FOIA request… Read more »

Margalit Gur-Arie
Guest

Gary, this may be true now, but it doesn’t have to be that way. Electronic Medical Records have a lot to offer to consumers. They can offer access to perform simple transactions like making appointments, requesting medication refills, paying bills, printing out school physicals and immunizations lists, all without the need to wait on the phone or drive to the doctor. They can also offer the convenience of having the patient and any care giver look at the records and keep an eye on what is going on, or share with another provider for a second opinion. From a care… Read more »

GARY LAMPMAN
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GARY LAMPMAN

Electronic Health Records Software does nothing for the consumer except to require Hospitals to pay hefty prices to pass on to the Consumer. Free Markets are only innovative when it has large sums of profits to soak their customers with inflated,overrated and extravagant products that have more bugs than Microsoft. Electronic Records also include extravagant maintenance Contracts that latches onto their Host like a Die Hard Parasitic Growth.Loaded with long-term experimentation at the expense of the Facility. Which in turns becomes a Consumer Expense. Electronic Health Records are no more progressive than government software. The only difference is the vastness… Read more »

Electronic Health Record Software
Guest

Thanks for the post about EHR and its implementation in healthcare industry.

Margalit Gur-Arie
Guest

Hmmm…. 🙂

Wendell Murray
Guest

ciphertext is off on some fantasy planet – other than Earth that is, presumably with Nate.
The reference to the possible, likely in fact, RFP for an EHR for the Department of Homeland Security provides a good starting point for a prototype for a federal-government website with a variety of FOSS EHR product, so I think it is something worth pursuing. More appropriate that responding with a FOSS proposal to an RFP for a State HIE in any case.

Margalit Gur-Arie
Guest

ciphertext, I just thought it worthwhile to ask the questions. I am not claiming to have the answers. As to the Government competing or selling EHR, I don’t think it should. If they ever commission one from a private company, or actually endeavor to build one “in house”, the EHR should be provided free to providers as a SaaS offering. I don’t see a need for penalties either. Incentives work much better. This does not preclude a private company from building a better mouse trap. The only caveat would be that the “private” EHR would have to be able to… Read more »

ciphertext
Guest
ciphertext

No, you didn’t miss anything, there is no Government EHR. But should there be one? And if so, what should it look like? — Margalit Gur-Arie I don’t believe that would be a viable option in a capitalist economy. Monopolies, whether public or private, are seldom tolerated. There is no incentive to improve upon a product when there is no market feedback. Monopolies are deaf to that feedback because they ARE the market for all intents and purposes. While regulations can impair or clarify the market’s performance (depending on the goals of the regulation and how they are crafted), monopolies… Read more »

InfoMark
Guest
InfoMark

The Indian Health Service has already taken VistA and scaled it to fit small and medium sized care facilities – apparently successfully. There is just no political will in this country to support an open programming solution to health IT in the private sector. As long as health is more business than public good, poor public well-being will be an economic anchor on the US. A sad failure of our system.
Great post Margalit.

Margalit Gur-Arie
Guest

Here is my concern with a pure Open Source paradigm for something of this magnitude: There will be many organization that will engage in customization to the point where the branches may become incompatible with each other and with the original trunk. If the schema is centrally managed, we will gravitate towards Dr. Walker’s suggestion rather quickly. Perhaps this is a good thing, but I am not sure. What do you guys think? On a different note, here may be a good place to start experimenting with Open Source – The Homeland Security folks are looking for an EHR for… Read more »

J. Stefan Walker
Guest

We need less a complete standardized EMR / EHR than a standardized transfer protocol, NPI, MPI authentication programs, and standardized data sets / parameters. Why not an NHIN health Internet using VistA transfer schemes / fields and any EHR vendor of choice for the ‘browser’? This simplistic approach solves problems of interoperability as well as unbundles the EHR from the EMR and practice mgt system, and prevents the perverse use of HIT as a means for power entities to control subordinate entities.

Mark Spohr
Guest
Mark Spohr

I think a lot of people assume that most of the work on free open source software is done by volunteers. The real situation is that a lot of people are paid to work on FOSS. For example many large companies such as HP and IBM have literally thousands of programmers who are paid to work on free open source software.
If the government paid programmers to develop/enhance FOSS, it would speed development and be a much better use of funds. It wouldn’t take a lot of money (out of the billions) to improve FOSS.

Wendell Murray
Guest

“make sure we are not depending only on freely donated time from the Open Source community.” Not necessary and maybe not even advisable. The FOSS development paradigm, as I note above, is a very well established one. If for some reason the normal development process does not materialize satisfactorily, then more financial resources could be devoted to development. A number of committers who are compensated if need be. The paradigm has proved itself many, many times over however. The results are arguably superior to comparable commercial product. The weakness in the paradigm tends to be documentation of all kinds, so… Read more »