The Promise of Electronic Healthcare Records

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should frustrated that he was never confirmed.

In his parting interview with the press,  he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Patients are over treated

When I was an emergency department resident 20 years ago, the faculty and staff of Harbor-UCLA medical center taught me best practices for safe, quality, efficiency care.   When I make decisions today, I reflect back on that intense training.  However, thousands of journal articles have been written since then, there’s new evidence suggesting more effective treatment plans, and new therapies are available.   How do I ensure the just the right amount of care is delivered – neither too much, nor too little? Decision support embedded in electronic health records.

EHRs can provide alerts and reminders – just in time advice as to what my patients need.  Educational materials and literature can be embedded in the workflow for easy reference.  Population/panel health tools can identify those patients who need followup or are deviating from care plans.

There is not enough coordination

The United States does not have a healthcare system – it has a disconnected array of clinics, pharmacies, labs, hospitals, and imaging centers.   Meaningful Use Stage 2 is likely to require significant healthcare information exchange as well as the transport,  vocabulary, and content standards needed to support it.  Although the journey to a completely connected healthcare system will take a few years, the next 24 months will include a quantum leap in care coordination as state health information exchanges connect patients, providers, and payers.

US healthcare is burdened with excessively complex administrative system

Like the tax code, healthcare regulations are dizzying in their complexity and volume.   Some are so arcane that experts cannot agree on the interpretation.    If rules can be built into EHRs such as the precise definitions for quality reporting, automated electronic coding of visits based on structured documentation/natural language processing, and payments made on objectively measured processes/outcomes instead of the quantity of care delivered, regulatory complexity can be reduced and money saved.

The enormous burden of the rules

Approximately 25% of my IS staff work on compliance related software requests – building new functional or purchasing new products to meet every increasing numbers of rules.    We all want to do the right thing, but if no one can understand the rules and the amount of overhead needed to comply is financially unsustainable, the rules are too burdensome.

Electronic health records can enforce automated care plans, provide feedback at the point of care and support administrative simplification with bidirectional electronic transactions between payers and providers.


Although no system is foolproof, electronic health records can reduce fraud by automating the kind of data transfers that will help detect fraud and abuse.    Emerging new analytics companies are already working on techniques to discover patterns of care that do not make sense – Medicare billing for deceased patients, redundant procedures or services, and variation in billing practices among physicians that can identify outliers.

In addition to these 5 areas of waste reduction, electronic health records are an essential part of a learning healthcare system which gathers data for clinical trials, clinical research, and unique population health measurement such as pharmacovigelence, syndromic surveillance, and immunization compliance.   Don Berwick is a great supporter of the EHR’s potential to increase quality, safety, and efficiency while reducing waste.

Although healthcare reform is controversial, healthcare IT reform – the federal 5 year plan to increase the use of electronic health records and healthcare information exchange – has broad bipartisan support.

As Don Berwick returns to the private section, I’m hopeful that he’ll turn his energy back to fixing the US healthcare system and that he’ll be a tireless champion for electronic health records.

John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.

18 replies »

  1. “You got a six page note from another doctor and an incorrect diagnosis, and it’s the fault of the computer the other doctor used? Really?”

    No, it is not the fault of the “computer” nor of the software the computer runs. Rather it is the fault of those who promised that said computer and software would make things better, when they clearly do not. I understand that the reasons for this are complex, and are in no small part the result of our dysfunctional coding and payment system. But THEY KNEW about those limitations even as they promised that their product would solve all the problems inherient in paper charts. They lied.

    “use the available technology…to solve the shortcomings in your care”

    Or how about “reject the technology that doesn’t solve the shortcommings or that introduces new shortcommings.” Do we get that choice? Why not? Because there is no EHR that solves the shortcommings without introducing other shortcomings.

    Now understand I am using an EHR and have used many over the years. I choose to do so for my own reasons, but overwhelmingly I find that the HIT industry has over promised and under delivered.

  2. The arguments by Dr. Halamka are feeble. He and others have failed to heed the warning of those doctors and other health care professionals who have witnessed their patients die from shoddy care caused by failed communication and lost data of EHRs and CPOEs.

    He, as do other HIT champions, always blame the user and user error, when, in fact, the errors are promoted by the devices themselves.

    The blogger Silverstein on Health Care Renewal has written about the error promotion by these devices; and, there have been peer reviewed articles in the med lit.

    The automaticity of HIT errorgenicity begs for disclosure, FULL disclosure, John H.

  3. You are so correct. EHRs introduce new categories of errors even as they solve some of the issues paper charts have. It is interesting (in the same way that watching an automobile accident happent is interesting) to see how the warnings given by us early adopters continue to go unheeded by the EHR champions.

  4. Halamka is just a wee bit biased. EHRs that have been approved as being safe, effective, and usable by the FDA may provide some benefit.

    In their present form, as stated by the IOM, they are dangerous with the incidence of injury and deeath from these devices, unknown.

    I personally have seen deaths and injuries from flawed and defective CPOE functionality; not to mention the disruption of cognitive processes and creativity because the devices are so terribly unusable.

  5. Oh!! its nice to know about that the electronic health care record. Really this use of electronic in medical science is enhance the medical facility. If doctor are able to do something better in their medical line and that is only the great help of electronics and the computer system..

  6. Unfortunately, the incentives (primarily financial) are such as to promote the use of technology in ways that make the problems detailed in the original post much worse.

    “How about doing what every other profession has to do”

    Has any profession or business ever adopted technology for the specific purpose of reducing sales, revenue, and income? Don’t expect it to happen in medicine.

  7. I love it that the physician community is offering the rest of us their insight that technology can used for good and also used for bad.

    You got a six page note from another doctor and an incorrect diagnosis, and it’s the fault of the computer the other doctor used? Really? And in the next breath, you all want to make patients more “accountable”?

    How about doing what every other profession has to do: use the available technology in an accountable way, to solve the shortcomings in your care that your customer base is telling you they will solve if you do not.

  8. I don’t think it is about distraction, but, enslavement, and not just of physicians, but also patients. One system under one roof, wow, what an opportunity for control and manipulation. Just think folks, if PPACA survives the Supreme Court, what a way to take care of your political enemies, by using health care access as a weapon. Just have the PPACA “Board” turn down treatment opportunities of your opposition and their family/allies.

    Oh yeah, I forgot, Obama can just declare them an enemy of the state and have a drone drop in, or better said, ‘on’ said “enemy”.

    Just read this and tell me I am way off mark!


  9. EHR is a distraction. The goal of each patient encounter now (without it) is to take care of the patient. With EHR the goal now is to construct an entry for the EHR.

    I recently saw two patients previously seen elsewhere. Each had a shiny note from an EHR. One from an urgent carevisit lasting 20 minutes that was six pages long. Very impressive. But they blew the very easy diagnosis. The second was seen in a Georgia hospital ER complaining of “chest pain”. Pages to the end, the diagnosis was “atrial fibrillation”, which the patient knew they had when they arrived. Their complaint was “chest pain”. The first line of the discharge instructions was “seek medical care if you have chest pain”. I kid you not.

    No amount of documentation changes bad care into good care. Why do you want to distract the doctor with this foolishness?

  10. Dr. John. Dead on. What we need is simplification. One coding schema for all providers (icd10). Simplified payment, and a drive back to patient accountability.

  11. Agree.

    A local academic medical center has their ER EHR configured so that residents cannot complete their notes until they have documented to meet level V standards. If they are absolutely determined to code a III or IV, they have to go through the hassle of finding an attending to enter the system and “allow” the lower level of billing.

    EHRs have the potential to improve all five parameters that Dr. Halamka lists. They also have the potential to make all five of them much, much worse. I think that’s what we’ve seen so far.

  12. How does an EHR “enforce an automated care plan”? Yikes! Sounds scary – like Peter Venkman in Ghostbusters! Maybe I’m deviating from my care plan and don’t know it!

  13. I didn’t see any mention of the primary purpose of the EHR for me – that it is easier to upcode. I mean cutting and pasting all that meaningless, er, I mean important information from one part of the EHR to another, the ability to reuse the note from the last physical for today’s note about a cold and bump the code from 99212 to 99214 is just marvelous. It really shows the quality of care you are providing when you can send out a hardcopy of your progress note for the day and you have to replace the toner twice during the printing. (Make sure you find a cheap source of copy paper if you have an EHR – printing those notes or receiving the faxes from other offices with their wonderful EHRs really chews through the reams.) It really is great to be a part of reducing waste in the health care system and to get paid so handsomely to do it.

    //Sarcasm off

  14. Only a computer can save the day. How self serving can this blog and usual suspects be? Oh yeah, by the way, if Don Berwick was such a savior for the day, where is this loud defense to get the Congress to reconsider his reappointment. Wow, that silence is deafening, Democrat hypocrites.

    Almost as loud as their republican counterpart hypocrites. Hey, you vote for these selfish uncaring bastards, so yell at yourselves first before you start carping on me!

  15. This post will surely draw a lot of comment fire, most of it of the “Perfectionism Fallacy” flavor. Let the carping ensue.