THCB

Bending the Curve with EHRs

The post you are about to read may not be suitable for wonks. Its claims are not fact checked. Its author is not a researcher. And its opinions are not fully thought through. Reader discretion is advised.*

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Productivity Optimization – Numerous carefully estimated anecdotal studies consistently show that introduction of an EHR in ambulatory practice can reduce provider productivity by 50% or more. This directly translates into 50% (or more) savings in health care expenditures for office visits. Unfortunately, the same studies also show that in most cases this reduction in office visits is transient, with most providers regaining ability to charge for as much as 80% of their pre-EHR visit volume within six months to a year. Still, 20% long term savings is significant and could probably be optimized further by introducing more speed tempering features into certified EHRs. Equally rigorous studies show preliminary evidence that the savings realized from introducing fully functioning EHRs in Emergency Departments far exceed those in the ambulatory sector. Unlike other Socialist countries that were compelled to nationalize the entire health care system just so they can reduce productivity and discourage utilization by creating long waiting lines, Yankee ingenuity is producing better results at lower costs.

Banishment of THE Pen – The Physician Pen has been long known for being the most financially devastating instrument ever invented. In spite of pharmaceutical reps efforts to the contrary, EHRs are successfully removing all pens from medical practice, including but not limited to, the Physician Pen. Where physicians used to carry several handsome pens in that little pocket right under their embroidered name and title, they now carry an EHR contained in a device that may or may not fit in a less accessible pocket and either way requires both hands, ample light and an adequate supply of battery power to order the simplest thing. The better EHRs also provide various speed bumps on the road to ordering by popping up multiple warnings and good financial advice equidistantly placed at 10 to 15 milliseconds intervals. Data from the very similar retail industry shows that impulse buying is greatly increased by simplifying the process, such as the one-click checkout at Amazon. The reverse logic must also be true, so increasing complexity should reduce impulse ordering in medicine. Judging by Amazon’s successful strategy, the savings in health care are expected to be spectacular.

Customer Intimidation – As EHRs become better at measuring the abysmal state of our health care non-system, and expose the horrors and frequency of medical errors by either careless omission or profit-driven commission, it is estimated that health conscious consumers will increasingly avoid dangerous encounters with the medical complex, thus further reducing utilization and cutting costs. Strategic publicity campaigns advertising security and privacy breaches in other computerized industries, and in health care if any are found, should eliminate another segment of customers. However, the largest cost savings are projected to come from customers refraining from seeking care for, or even mentioning, potentially embarrassing health problems for fear of public exposure through interconnected EHRs.

Accelerated Attrition – EHRs are very powerful tools. So powerful that the prospect of having to purchase and use an EHR is more than enough to prompt older physicians, particularly those in private practice, to consider retirement or transition to other occupations. The evidence shows that there is direct anecdotal correlation between negative reaction to introduction of EHRs and acceptance of cost-saving team approaches to provision of medical care. The semi-natural attrition of experienced and highly compensated physicians who insist on treating, and charging for, every sore throat and every knee scrape, in spite of mounting evidence that lower paid resources can refer those to appropriate specialists with equal outcomes, should in the course of time increase the amount of savings directly attributable to the prevalence of EHRs.

Free Labor Procurement – EHRs are particularly adept at encouraging and showcasing the historical selflessness and ethical conduct of medical doctors, by providing multiple means for doctors to contribute to the well-being of their patients practically free of charge, at all hours of day and night. From the ubiquitous email to the occasional webcam session to the continuous evaluation of uploaded self-quantification vital data from patients empowered to have their health expertly monitored, physicians using EHRs can provide this simple courtesy service to their customers from the office, the home, the yacht or the golf course. These proactive preventative measures should result in extensive reductions in disease burden. Constantly connected physicians, armed with the latest monitoring tools, could detect strokes, heart attacks and maybe even cancer years before actual manifestation of symptoms. And at no cost to society.

The implications for policy makers are pretty straightforward. EHR adoption should continue to be encouraged at all costs. EHRs must evolve to seamlessly and continuously connect to all consumer monitoring devices, which implies a preference for cloud based technologies, and a security breach here and there is not necessarily an impediment to success. EHRs should continue to increase the levels of automated decision support, improve analytics and increase frequency and scope of various alerts. Basically, keep up the good work. We’re right on target.

*Disclaimer partialy plagiarized from the UK version of The Daily Show

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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20 replies »

  1. Great goods from you, man. I have understand your stuff previous to and you’re just too wonderful. I actually like what you’ve acquired here, certainly like what you’re stating and the way in which you say it. You make it entertaining and you still take care of to keep it smart. I can’t wait to read far more from you. This is really a tremendous website.

  2. Thank you, Tim. I very much enjoy political disagreement and debate (ask Nate 🙂 ) and have great respect for diverging opinions.

    I love your last paragraph. I never thought about it quite this way, and you are of course absolutely correct. Being the naive optimist that I am, with a weakness for technology, I know we’ll eventually stumble upon that genius. The powers to be need to relax a little bit, now that they’ve successfully revved up the engine, and let things proceed at a natural pace.

  3. Margalit,
    I realize I’ve disagreed with your politics here from time to time, but from this practice manager (who has implemented one EHR with real doctors and is about to do another one) — you are somebody who actually gets it.

    I read these posts over and over that say “all we need to do is listen to doctors and we’ll make usable EHR’s” and I wonder what doctors those people actually hang out with. And for those doctors actually writing those posts, an incredible opportunity apparently awaits you. Just hire a programmer who will actually listen to you, and you can make a bazillion dollars and change health care forever. I’m sure you just haven’t yet been discovered by the smart people yet.

    The state of the technology is such that a focused, committed physician can INCREASE productivity with an EHR. But the OTHER 99% are hobbled. No technology has ever produced a success until it can produce results for those who are unfocused and uncommitted. That’s the genius we are waiting for.

  4. Margalit,

    “The bigger vision though, is that an EHR should capture, and assist with, the actual work that a doctor does. It’s supposed to collect all the nuances of the diagnostic and treatment process and it is endeavoring to provide decision-support and guidance to physicians at the point of care, and all of that is supposed to be personalized on the fly per individual patient.”

    I agree but let’s start by meeting more modest expectations. If we set too grand a goal, we’ll never get past seeing all the problems and won’t do anything — which is where we are now. Besides, almost anything we do will be a giant improvement over what’s available today! 🙂

  5. Merle, I completely agree with your last sentence. We should start doing what we can do and improve as we go. Just like we do in cancer care. We are doing better today than we did fifty years ago and we will do better yet in fifty more years.

    However, if you look carefully, you will see that much like other industries, computers are used every day in health care. There is almost no entity of any significant size that is not using computers for financials, for scheduling work and for inventory management. Most radiology is computerized. Most lab work is computerized. Surgery is increasingly computerized.
    But EHR is supposed to be more than just an itemized list of what was done to you, more than what my mechanic handed me the other day when I picked up my car. More than what I get from the bank, or the grocery store. You can get that type of list today from your payer and your lab. No EHR required. I do agree that your solution, and others maybe, can help organize these lists better.

    The bigger vision though, is that an EHR should capture, and assist with, the actual work that a doctor does. It’s supposed to collect all the nuances of the diagnostic and treatment process and it is endeavoring to provide decision-support and guidance to physicians at the point of care, and all of that is supposed to be personalized on the fly per individual patient.
    I am not aware of any other industry that deals with non deterministic processes performed on units of infinite variety of shape, form and content, that has computerized the actual work done on these units of production.
    Health care is blazing the trail, and any comparisons to flying airplanes or making cars or counting dollar bills is misguided at best.

  6. Margalit, the technologies you mention have never existed and still don’t exist but the whole world runs on computers anyway! If their absence hasn’t stopped progress in virtually every other industry, there’s no reason to let it stop progress in healthcare. Moreover, technology and circumstances will continue to change so we’ll never reach perfection.

    To me, our failure to date in healthcare IT results from pursuing misguided, grandiose goals, not listening to the two people who count in healthcare — patients and doctors, and trying to implement preconceived notions rather than solutions that work.

    The fact is that with today’s technology, we can accomplish a great deal that we aren’t doing today. We can turn paper charts into digitized documents incorporating structured data (much of which need not be keyed in) that enables a care provider to sort and search a patient’s records electronically. So let’s do it.

    We can aggregate these digitized paper records with electronically-generated records from disparate EMR systems — thereby making a patient’s complete lifetime medical record available in digital form so the patient’s records can be sorted, searched and read electronically by their care providers.

    We can aggregate these individual patient lifetime medical records in a secure, safe place that the patient controls and is not open to theft and breaches. And we can put that aggregated medical record in the hands of care providers without building elaborate hugely expensive networks or requiring every care provider to install a bloated, expensive EMR system. So let’s do it.

    We can do all of this with easy to use systems that care providers can master in a week or so, that don’t disrupt their work flow, that are free to providers and actually increase their income, that are financially self-sustaining, that enable providers to coordinate their patients’ care in ways that are impossible now, and that help them improve care quality and reduce care costs. So let’s do it.

    Will the systems we adopt today be perfect? No. Will technology change? Sure. Will provider and patient needs change? Sure. Should we let these shortcomings stop us until we have the perfect solution or the ideal technology? Absolutely not!

    As I see it, our path is clear. We start with what we have and can do, and we improve it as we go!

  7. I respectfully disagree, Merle. We may have some solutions that are incrementally better than others utilizing current technology. However, we don’t have the technology to allow capture of pertinent structured data without keyboards, mice and/or touchscreens. Voice recognition is getting better, but we are not there yet. Not by a long shot.
    We also don’t have the AI needed for the machine to make meaningful contributions to the cognitive process. Folks are working on it, but that is also in need of some lucky invention.

    Of course cancer and EHRs are different in nature, but both solutions will require something that is not within our grasp just yet. This does not mean that we shouldn’t use the imperfect tools that we now have, whether it’s chemo or the latest cloud based (or USB based) EHR.

    (I apologize if this comment appears twice. Not sure why it got moderated the first time around)

  8. I respectfully disagree. We may have some solutions that are incrementally better than others utilizing current technology. However, we don’t have the technology to allow capture of pertinent structured data without keyboards, mice and/or touchscreens. Voice recognition is getting better, but we are not there yet. Not by a long shot.
    We also don’t have the AI needed for the machine to make meaningful contributions to the cognitive process. Folks are working on it, but that is also in need of some lucky invention.

    Of course cancer and EHRs are different in nature, but both solutions will require something that is not within our grasp just yet. This does not mean that we shouldn’t use the imperfect tools that we now have, whether it’s chemo or the latest cloud based (or USB based :-)) EHR.

  9. Margalit, have to disagree with your cancer cure analogy. With cancer, we’re trying to solve a scientific problem to which we don’t know the answer: what causes cancer, and how can it be controlled? This requires a scientific breakthrough.

    With medical records, we know what we need and we have the tools to do it. We don’t need a technology breakthrough. All we have to do is take off the blinders!

  10. Seriously…. We don’t know how.

    Much has been said about the need to have “disruptive innovation” in health care and many times it has been likened to the Southwest Airlines business model.
    Well, arguably Practice Fusion (the “free” EHR) has done that and it is enjoying some success with its no frills low price business model. However, unlike Southwest, which offered a much faster travel option to those who could only afford ground transportation, Practice Fusion, and all other very cheap EHRs, just like their expensive brethren, are offering a slower and clunkier method of documentation than is widely available to physicians today – paper.

    The innovation required here, to borrow from another thread on this blog, is very much like the microprocessor was 40 years ago. Technology innovations like this cannot be achieved by huddling in a boardroom and figuring out a disruptive business model. They happen when they happen.

    To make a medical analogy, there is obviously a huge addressable market for a cancer cure, but nobody has been able to find one and it’s not for lack of trying. We all know what is needed – a way to get pertinent data in faster than you can write it and a way to get useful information out faster than you can flip pages.
    As of today, nobody has anything that can do that. I am certain that they will, but it may take a while. Just like I am certain that they will find a cure for cancer, but that may take a while too. In the mean time, we take chemo, which makes us vomit and sometimes it works, and sometimes it does not.

  11. Siva, a great question. My answer is that we are not defining the problem correctly. My conclusion is covered in a comment I posted to another blog last week. Rather than paraphrasing it, I’ll quote it here.

    “In my opinion, we’re not making progress because we’re defining the problem incorrectly. The problem isn’t how to make a patient’s records available over the Internet.

    “The problem is two-fold and requires separate, independent solutions. One is how doctors should keep records. The other is how to make a patient’s records available to their care providers when and where they need them.

    “There is no question in my mind that every doctor should have an electronic record system and the sooner the better! It can make them more productive, help them provide better care, and reduce their record-keeping costs. But most electronic systems available today don’t. They’re too hard to learn, too hard to use, have too many features doctors don’t want, are too expensive to install and too expensive to maintain. They simply do not meet the needs of most doctors or hospitals.

    “How do we solve this problem? Not by having government force doctors and hospitals to adopt these systems. We need to encourage the development of new systems that actually help and benefit them. If we build the right systems, most doctors I have spoken with will happily embrace them and will be able to provide better care. And the companies that build them will deserve the financial rewards they generate.

    “The other problem is making a patient’s records available to care providers. From everything I’ve seen and read, the correct solution is not to store them on web servers and make them available over the Internet. According to every poll and survey, that’s not what consumers want. So let’s stop ignoring them.

    “. . . we’ve been working for several years to solve this second problem, and I think we have the right solution. We’ve developed a unique, patient-focused system that we believe meets the needs of doctors and patients. I’m not trying to promote it here (if you are interested in its specifics, visit our web site, medkaz.com). I’m merely trying to demonstrate that by correctly defining the problem of healthcare IT, we can come up with better solutions than are being offered now, and to argue that we should do all we can to foster their development.

    “Regrettably, as the expression goes: “the train has left the station.” Our government is spending billions of dollars in incentives to encourage doctors and hospitals to adopt the systems that don’t work for most of them. We’re not about to derail this HITECH stimulus program now. But we can do everything possible to innovate and come up with better solutions to the two problems we face.”

    I should add to this that the Patient Record Manager (PRM) component of our patient-focused system presages what a new-generation EMR system might look like. It is simpler, free, far easier to use and captures the clinical information doctors need.

  12. Awesome bit.

    Seriously…
    With such a huge addressable market, and policy that is aligned to growth in this area, and the fact that we have CRAP EHRs (hospital-class) in the market today, why is it that we are not seeing break-through innovation in this space? Where are the real Next-generation EHRs – which 8 out of 10 providers 🙂 can really stand behind?

  13. I guess it depends whether you’re selling or buying, Merle 🙂

    Seriously, and to pcp’s point, we need to curb our enthusiasm a little bit (Larry David is on my TV right now…) and start thinking on how to make this a success, because it can be if we get it right.

  14. Spot on, as always.

    The irrational enthusiasm of the AAFP and other medical organizations for EHRs in their current state is truly mind-boggling.

  15. Mr. Gonzales,

    “Meaningful Use:” meaning to whom? As with Watergate, follow the money…

  16. Thank you Dr. Vickstrom. Glad you liked it.

    Daniel, meaningful use seems to be the lever by which policy is applied, and I have no doubt that it indeed has significant impact on EHR efficiency in more ways than one. The nature of that impact is likely to be perceived in very different ways depending on which side of the lever you find yourself on.

  17. Let me be the first to commend you on your witty post, Ms. Gur-Arie. I award you 10 Internets for your wit!

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