That Which We Call a Rose

What’s in a name? Sometimes nothing much.

Sometimes a shift in paradigm.  The Medical Record in its current format was created over a century ago by Dr. Henry Stanley Plummer at the Mayo Clinic. When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine naturally named the new invention Computer-based Patient Record System (CPRS)

The Medical Records Institute chose the term Electronic Patient Record (EPR). Somewhere along the line the “patient” got dropped from the concept and the software used to compose and store medical records became known as Electronic Medical Record and the name EMR stuck.

As EMR software evolved and started exhibiting rudimentary information exchange abilities and some semblance of “intelligence”, it was felt that a name change was in order.  To differentiate the newer and smarter software from the original EMR, the term Electronic Health Record (EHR) was introduced and is now enthusiastically supported by the Federal Government. The term EHR is used in acts of Congress, rule makings from CMS and ONC and Presidential speeches. Since EMR has been around for quite some time, most industry veterans, as well as most doctors, are a bit confused about the new terminology.

Is it EMR or is it EHR? Is it just semantics? Would an EMR by any other name smell as sweet – or bitter?

In a recent ONC blog, Peter Garrett and Joshua Seidman argue that there is a significant difference between EMR and EHR. The former is just “a digital version of the paper charts” and “not much better than a paper record”, while the latter is “designed to be accessed by all people involved in the patients care”, including patients, and generally “represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual”.

This dramatic difference stems from replacing the word “Medical”, which implies disease, with the word “Health” which is “the general condition of the body”. Note that the word “Patient” is still absent. However, Health is supposedly from cradle to grave, while Medical is episodic in nature. Since, no matter what you call it, clinicians are the primary users of this software, would we say that doctors provide Medical Care or Health Care?

When we say that cost of Health Care is sky-rocketing, we don’t usually include costs for clean air, clean water, car seatbelts and gym memberships, and although we all know that an apple a day keeps the doctor away, the cost of apples is not included in our Health Care expenditures. To be sure, Medicine, “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease”, does include costs for direct prevention of specific diseases (immunizations) and efforts for early diagnosis of others (screenings). Historically, doctors, nurses and their less formally educated predecessors have been tending to the very sick. It is with this goal in mind that Dr. Plummer’s collaborative Medical record was created, and it is for this purpose that the American Academy of Pediatrics advocated for a Medical home for sick children, and it is Medical care for the sick which the EMR attempted to facilitate, one patient at a time. The EHR represents quite a different philosophy and places new and expanded responsibilities on the Medical profession.

The EHR is intended to serve the healthy as well as the sick, and the President’s vision is that every American should have one, whether that particular American is healthy or not. The ONC vision, shared by many innovators in the field, is that “EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care”. That broader view will presumably include lifestyle habits, diet and exercise and everything one may wish to record which pertains to one’s general health status. If and when a person becomes ill and is transformed into a patient, the various clinicians and care providers will contribute their documentation to the EHR, and since EHRs are easily shareable, all Medical care will be coordinated through the EHR and collaboration will flourish, as it should. This sounds almost exactly the same as what a Personal Health Record (PHR) is supposed to be. Is an EHR really a PHR?

No. EHRs include one feature that is not possible in a PHR: the ability to aggregate individual patients into populations. When physicians write introspectively about their work, you usually find stories about this or that particular patient, pondering whether they did too much for the 90-year-old Alzheimer’s victim, or too little for the misdiagnosed 40-year-old ovarian cancer patient. They talk about emotions, or lack thereof, about small victories and exasperatingly “non-compliant” middle aged executives who should know better. Each story has a patient with a name, physical details and most often character description. For those inclined to self-assessment, the day-in and day-out tally of these personal episodes is the decisive yardstick. When people recommend a doctor to a friend, they usually talk about “nobody could figure out what was wrong with Katie; he took one look at her and knew right away” or “you can get in today or tomorrow and she is so nice and patient ; always takes my phone calls and you know I can be a pain (giggle)” or “when Adam had that knee problem, he fixed it like magic and he did surgery on cousin Joe’s shoulder; as good as new, and I think he takes care of the Cardinals too; he is definitely the best in town”.

This unscientific, anecdotal method of both performing and assessing one’s work will be replaced by the broader view of EHR enabled population indicators and considerations. Instead of dealing with Mr. Wilson’s gout and Mrs. Wilson’s incontinence, you are now the keeper of the Health of Populations. The EHR can tell you that half of your under 40 patients are obese and doing absolutely nothing about it. You, or your team, will need to intervene because an ounce of prevention today will lead to healthier lives for this population, and lower costs for society. While managing Mrs. Wilson’s neuropathy is important (especially to Mrs. Wilson), having your population of 300 diabetics controlled within acceptable cost effective parameters will become the main focus of your practice. EHRs will provide you with the intelligence (information) to manage your numbers and with ongoing measurements to assess your performance against goals, and EHRs will continuously collect data for ground-breaking research and more effective recommendations.

EHRs, as imperfect, ineffective and downright primitive, as they are today may be our first glimpse of a future where curing or treating disease is largely a thing of the past. If populations are proactively managed and everybody gets their shots and recommended genetic therapy, or whatever they will come up with next, Medical care will be limited to trauma and exotic ailments that have not been researched just yet. While our generation will not be crossing the River into the Promised Land of perpetual Health, it is up to us to manage this transition so human dignity is preserved and collateral damage is minimized in the process of industrializing medicine, a process which starts with changing the M in EMR to the H in EHR.

Margalit Gur-Arie 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. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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6 replies »

  1. Bobby, I will be sure to read that entire book, but the model of ThedaCare is precisely the industrialization of medicine, complete with “lean” principles and Toyota methodology. I guess these could be construed as “patient centric” meaning that the instructions travel with the part, or the medical records travel with the patient. The same idea was behind Dr. Plummer’s pulleys and tubes which had the paper records follow the patient around the hospital. Still not sure what the novelty in patient-centric really means… 🙂
    As to Health being a totally different beast, I do agree MD as Hell. Not sure its quite the end of freedom, but it is a different paradigm and for now, it looks it is very much about population research and cost-effectiveness driven EBM. On one hand this is very tempting, on the other hand I get uncomfortable when folks start talking about “subtle and sophisticated experimental designs” (PCAST) and “issues of human subject research” (IOM).

  2. “Medical” is limited in scope. It is scientific and artful. It is professional and not intrusive. It is private.
    “Health” is political. It is the excuse for Uncle Sugar to intrude and invade every facet of American life in the name of “health” for your own good. It is the Pied Piper of giving up your privacy. It is the Commerce Clause equivalent for regulating individuals. It is the end of freedom.

  3. “I don’t really know what people mean by patient-centered”
    I would recommend Toussaint & Gerard’s “On The Mend” as one resource providing answers. Their ThedaCare work used “Lean” techniques directly appropriated from the “industrial” model and applied them to patient-focused collaborative care. Unless they’re lying about their trifeca positive outcome metrics — better outcomes, lower costs, improved patient satisfaction — there’s no mystery there.

  4. Bobby, the two terms – patient-centered and industrialized – may not be necessarily contradictory.
    I don’t really know what people mean by patient-centered and I assume different folks mean different things.
    If you look at the NCQA definition of a patient centered medical home, most of the items deal with data aggregation and ability to measure populations. Creating a scheduling policy and sticking to it may improve access, but I don’t see this as a patient-centered feature any more than a 24 hour supermarket. Perhaps consumer-oriented would be a better term.
    I don’t know that “industrialized” is necessarily at odds with consumer orientation or even tangible quality as measured by what we propose to measure.
    Everything was once hand-crafted and now most everything is mass produced and mass delivered. It’s just a matter of time before medical care takes the same route. Is it a good thing, a tragedy, a natural progression? I guess it depends on how it’s done….
    Yes, Anonymous Wonka, I was joking… 🙂

  5. “When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine … ”
    Did I just read that?
    For the love of god, please tell us you’re joking.