Stanley Feld M.D.,FACP,MACE

Billy Beane, Newt Gingrich, and John Kerry wrote an op-ed piece in the New York Times October 24th that brought into focus several fuzzy thoughts I have had about Newt Gingrich and John Kerry’s concept of e-prescriptions and electronic medical records.

My first thought is they do not have an in depth understanding of information technology nor an understanding of medical practice or the medical profession.

Newt Gingrich sounds good sometimes but on close inspection in only sounds good because he picks one aspect of a problem and frames it in a simple solution.

John Kerry has the appearance of being an intellectual but does not understand the complexity of the problem or the mentality of the medical profession.

This op-ed article about electronic medical records demonstrates both these “experts’ ” weaknesses. I refer you to my electronic medical record series of articles.

Electronic Medical Records are a great idea and will save money, increase quality of care (after we define improved quality of care) and avoid medical errors. The great issue is how to execute the implementation of the electronic medical record that is fully functional.

Messer’s Beane, Gingrich and Kerry make a tepid argument comparing baseball’s data driven information revolution to medicine’s need for an information revolution.

“In the past decade, baseball has experienced a data-driven information revolution. Numbers-crunchers now routinely use statistics to put better teams on the field for less money. Our overpriced, underperforming health care system needs a similar revolution.”

There is no argument in the medical profession that we need a robust information technology revolution. In fact the medical profession is slowly evolving toward the goal of information driven medical care. The op-ed authors sound like they have made a revolutionary discovery.

Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.

Like most politicians Gingrich and Kerry do not get to the basic questions. The main issue is how can our healthcare system distribute a uniform information software system, at an affordable cost, with an education module that decreases the steepness of the learning curve for physicians? How can the software be compelling to physicians so they will abandon their ineffective software? How can the data produced by the software be rewarding rather than punitive to physicians?

How can the data be a teaching experience to physicians rather than a test of a physician’s ability that could be used to decrease physician reimbursement in an environment of stakeholder mistrust?

Many physicians have invested heavily in electronic medical records only to discover that the electronic medical record they purchased can not be fully functional.

“Another example is Intermountain Healthcare, a nonprofit health-care system in Utah, where 80 percent of the care is based on evidence. Treatment data is collected by electronic medical records. The data is analyzed by researchers, and the best practices are then incorporated into the clinical process, resulting in far better quality care at a cost that is one-third less than the national average. (Disclosure: Intermountain Healthcare is a member of Mr. Gingrich’s organization.)”

I challenge the authors to provide the data that the Intermountain Healthcare electronic medical record is fully functional. I challenge the statement that Intermountain Healthcare has data based evidence of “better quality care at a cost that is one-third less than the national average.” The investment of an EMR started in 2005 by Intermountain Healthcare will be $100 million dollars over ten years. How many clinics can afford $100 million dollars over a ten year time period?

Our healthcare system should have all physicians practicing data driven evidence based medicine. The question is how do you produce a uniform electronic medical record that is fully functional and affordable for all physicians? The authors do not offer a solution. My article on the Ideal Electronic Medical Record offers viable solutions to the problem.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Stanley Feld M.D.,FACP,MACE

The follow comment is from a good friend and steady reader of Repairing The Healthcare System. It does not matter what policy wonks think. This is a sincere reaction from an excellent physician.

“Hi Stan 

I have thought a lot about EMR from my days in academia to my days in private practice. Based on my hands on experience with computerizing labs I realized that computers work best for essentially mindless, repetitive tasks or tasks that are the same each time, like accumulating, holding, reporting and filing data. It can also deal with machine control, bar code tasks, etc. Any higher order functions (like thinking) is still not workable. That is what makes computerization of cognitive processes so difficult and is probably at the root of why EMR is not practiced more widely. Add to that the punitive action by insurance and gov’t. use or potential use of the data makes EMR a non starter.

If basic patient data (demographics), clinical findings (take your shirt off ma’m or sir), history and treatment could be hooked up with a large data base to guide the physician to make her/him more effective, efficient and better paid, than  it will fly.”

Your grouchy buddy,

B

On Aug 4, 2008

There is no doubt that perception equal reality. It is a barrier that must be overcome. I believe it can be overcome with a universal EMR paid for by the click that will be able to be used by physicians and patients for educational purposes and not for data collection to be used against patients and physicians through the use of inaccurate data making judgments about quality care delivered. Quality care has not been defined accurately at this point in time. Quality care is related to clinical outcomes and monetary outcomes not whether a particular test was done on time. It depends on the participation of both patients and physicians. It does not depend on insurance company and government judgements.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Stanley Feld M.D.,FACP,MACE

The New York Times article presents me with an opportunity to discuss the issue of the adoption of EMR in physician terms. Media reporting tries to be neutral and informative. It usually produces nothing but confusion.

“The report published in the NEJM also found that electronic health records were used by 51 percent of larger practices, with 50 or more doctors.”

The EMR adoption rate by large physician groups of physicians is still low. 49% of large practices still do not have an EMR.

“Indeed, electronic health records are pervasive in the largest integrated medical groups like Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic, University of Pittsburgh Medical Center and others. These integrated groups not only have deep pockets. By combining doctors, clinics, hospitals and often some insurance they can also capture the financial savings from electronic health records.”

A year ago Kaiser Permanente had was embroiled in a scandal concerning its 3 billion dollar investment in information technology system which includes an EMR.

“ In the e-mail, Justen Deal, a project supervisor who has worked for the company for two years, detailed his frustration with Kaiser’s electronic health record system, which he considers inefficient and unreliable.” “Deal was placed on administrative leave.”

We have little information about the effectiveness of Kaiser’s EMR presently yet it is presented as a successful system in the New York Times article.

The promise of an EMR must be realized in the next few years. Only innovative thinking will precipitate the necessary paradigm shift toward EMRs rapid adoption. It must be done quickly before it is too late.

Using an EMR can provide finger tip information to physicians about patients they treat. If set up correctly it can speed up data entry on patients and be a guide to complete data entry for particular diseases. It can serve to improve the quality of clinical decision making by interconnecting to clinical practice guidelines. It can be used to avoid medication errors with the use of e-prescription and can point out potential drug interactions. It can be used as a guide for patient education to prevent the complications of chronic diseases. It can increase productivity of physicians by electronic delivery of laboratory findings. It must be formatted as a physician extender and not a physician substitute.

After a sometime steep learning curve physicians are satisfied with the electronic medical record. The NEJM study was a little exuberant with its statistic reporting that over 80% of the physicians were happy they had an EMR when the EMR was fully functional (3.2%). Not all EMRs in large clinics are fully functional.

The study found that a paltry 4 percent of the doctors had a “fully functional” electronic records system that would allow them to view laboratory data, order prescriptions and help them make clinical decisions, while another 13 percent had more basic systems.

Within a large clinic the electronic medical record should be totally transparent to the physicians across clinical and business functions. Patients can log in and get their records and laboratory results, physicians interpretations and radiological findings immediately and have a PMR (Personal Medical Record). The EMR could also improve communications with other physicians.

Dr. Peter Masucci, a pediatrician with his own office in Everett, Mass., embraced electronic health records to “try to get our practice into the 21st century.”

He could not afford conventional software, and chose a Web-based service from Athenahealth, a company supplying online financial and electronic health record services to doctors’ offices.

There are not many physicians in the United States that would trust their records to be outsourced at this point in time. However with the proper protections web based online electronic medical records could work.

“Dr. Masucci was already using Athenahealth’s outsourced financial service, and less than two years ago adopted the online medical record.”

Today, Dr. Masucci is an enthusiast, talking about the wealth of patient information, drug interaction warnings and guidelines for care, all in the Web-based records.

“Do I see more patients because of this technology? Probably no,” Dr. Masucci said. “But I am doing a better job with the patients I am seeing. It almost forces you to be a better doctor.”

This is a reason we need a ideal and universal EMR. However, the ideal EMR must have the ability to be used as an educational tool for patients and physicians. EMRs should be standardized and then customized by physicians to mimic physicians practice patterns. They should make medical care more efficient and less costly. Dr. Masucci is simply a testimonial stating that he has gotten rid of his paper record. However it might not be increasing his problem solving ability or his ability to transfer information or treat chronic diseases using evidence based medicine. The problem with most EMRs is they do not provide full functionality needed to solve the many problems in the healthcare system.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Stanley Feld M.D.,FACP,MACE

The common impression is that physicians are resistant to the use of Electronic Medical Records. I believe there are important reasons adoption by physicians is slow.

Dr. Paul Feldan, one of three doctors in a New Jersey practice, said switching to electronic records did not make economic sense for his practice.

“Certainly, the idea of electronic records is terrific,” Dr. Feldan said. “But if we don’t see fewer patients during the conversion from paper to computer, we don’t get paid.”

Dr. Blackford Middleton, a health technology expert at Partners Healthcare, a nonprofit medical group that includes Massachusetts General Hospital in Boston hit the nail on the head.

“We have a broken market for electronic health record adoption because the people who gain financially are not the people who pay.”

“To fix the market, Dr. Middleton recommends that the government play a role in providing incentives or subsidies to speed the use of computerized patient records in the United States.”

Wouldn’t it be simple if the government and healthcare insurance industry along with input from practicing physicians created the ideal electronic medical record? I believe adoption of an EMR would be rapid under certain circumstances.

I emphasize including practicing physicians of all specialties in creating an ideal EMR. If policy makers happen to ask for physician input it is usually from high profile academic physicians with little private practice experience. Academic physicians do not understand the practice problems of the private practice physicians.

The ideal EMR must contained strong patient privacy rules. Patients should have ownership of their EMR. Patients must have the exclusive decision making voice in how the information is distributed and used. This concept is totally opposite from the newly introduced HR6357 that is rapidly moving through the House of Representatives.

Private practices should be able download the EMR software for free. Customization of the generic EMR could be fitted to the physicians practice style. All measurable entries would be formatted as a relational database. Physicians would pay a minimal transaction fee for each click making the EMR affordable to physicians in all sized practices. All maintenance and upgrades would be web based and downloadable at no cost. (nomadic software as described in the Unfinished Revolution)

The saving to the government, the healthcare industry and the healthcare system would more than offset the cost of providing a uniform and upgradable electronic medical record to all the physicians in the U.S. The system must be easy to download and its use must be intuitive.

It is estimated that the healthcare system would save 5 billion dollars over five years alone if every physician used an e-prescription system. If would avoid many prescription errors due to handwriting misinterpretation.

For some reason government policy makers can not think about physicians needs. Someone must think innovatively. An EMR must be created that provides incentives to physicians to want to convert to an EMR. An EMR would not be used against physicians punitively but rather by physicians educationally.

Instead the government has just initiated a $150 million dollar long term pilot study that will fail because of its design.

“The government took a step in that direction last week, announcing a $150 million Medicare project that will offer doctors incentives ($58,000 over 5 years) to move from paper to electronic patient records. The program is intended to help up to 1,200 small practices in 12 cities and states make the conversion.’

I believe the government is making another costly complicated mistake. Winston Churchill was correct. “Americans eventually get it right after they try everything else.” The intent of the study is to test the impact of incentives on the adoption of electronic health records. Wouldn’t it be easier if someone used some common sense and asked private physicians and patients what they need rather than create a study that is destined to failure? The physician incentive is too small and the dangers to the patients and physicians too great.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.