Electronic Health Record Part 2

Stanley Feld M.D.,FACP,MACE

An effective Electronic Health Record must consist of five components

Electronic Medical Records
Personal health records (PHR)
Continuity of Care Record (CCR)
Electronic health record (EHR)
Financial Management Record

In order to have a fully functional Electronic Health Record, all of the components of the EHR have to be integrated and in a relational data base format. This is the only way we are going to be able to determine if certain approaches to disease management in a clinical practice setting have positive medical outcomes and positive financial outcomes (reduce the cost of care for chronic disease).

The interoperability of all components of the EHR is the key to a successful EHR
In the United States, the development of standards for EHR interoperability is at the forefront of the national health care agenda. I believe without interoperable EHRs, practicing physicians, pharmacies and hospitals cannot share patient information properly. Without an interoperable EHR we can not evaluate medical outcomes and financial outcomes effectively. Therefore, interoperability is essential if the EHR is going to help reduce the cost of care.

I explained how you can create your own instant Personal Health Record last month. I believe it is important that we, as patients, assume this responsibility now. We need to start getting our physicians used to our needs.

Every examination and every test done on you by your physician or a physician you are referred to belong to you. You or your insurance company paid for the test or the examination. You paid the physician to interpret the test. The test results should be in your possession. You could move to another city, change physicians, your physician could retire, or close his practice. If so, an important piece of your medical data could be lost forever. It should be your responsibility to maintain your data base.

Ideally, if your physician had an EMR he could electronically transfer your test result data and his interpretation to your PMR. He then has a copy and you have a copy. Both copies could be web based and well encrypted for privacy.

The Continuity of Care (CCR) part of the EHR should also be interconnected with both the EMR and PMR. The CCR should be the core data set of the patients disease record. In should contain a summary of the patient’s medical problems, treatment, medications, response to medications, and issues of care(compliance, adverse reaction to medications and treatment).

The CCR is the perfect place for the interactive section of the medical record. It can be used to teach the patients how become a “Professor of their Chronic Disease.”

If we think about Diabetes Mellitus as the chronic disease in point, the CCR should become a customized Diabetic Education Center. A newly diagnosed diabetic should have formal teaching about Diabetes in a Diabetes Education Center. After those initial encounters, depending on the patient’s learning skills, modules can be customized online by the physician to improve that patient’s skills in self-management. (See AACE guideline for Intensive Self Management of Diabetes Mellitus: A System of Intensive Diabetes Self Management. Obviously, this effort should not be uncompensated or undercompensated as it is presently. With an MSA the patient would be making the decision and not the insurance company who is interested in paying as little short term money as possible despite the long term benefit.

The continuing education piece of the CCR could feed back information interactively to both the physician and patient on the course of the chronic disease. It could continually monitor the patient’s response to treatment and changes in the self-management of the illness. The CCR could be customized with suggestions for the patient on how to improve self-management of the chronic disease to increase the quality of care and decrease the complication rate. Tim Wolters of Collective Intellect is trying to figure this out.

The immediate response of physicians is that such a system would cost too much. They also think integrated systems like this could never become universal in our chaotic healthcare system.

I think it could become universal with the proper visionary intervention and leadership. Rather than selling a complete software system to physicians, a clever software company would simply have the complete EHR in a web based format on the internet. Instead of charging the physician fifty (50) to eighty (80) thousand dollars per physician, the physician and the patient would pay to use the system by the click. The physician would not bear the burden of the initial capital expenditure and ongoing support costs of the EHR. He would have the ideal EHR with free upgrades.

Patients would not feel a burden of cost to access their record either because they would be billed by the click. The advantage would be an integrated communication system. The system would have the advantage of being data formatted, interconnected and relational with medical and financial outcomes.

PMR and EMR must be synchronized to other components of the EHR. A vital connection would be with the Financial Management Record. There is no reason in a price transparent, consumer driven healthcare system where the consumers own their healthcare dollar that the consumer can not make the instant decision about the charges. The insurance claim is generated at point of service and integrated with the service. The patient makes the decision to pay the bill by credit card, just as the consumer does in during a typical store purchase. The bill is adjudicated instantly by credit card and deducted from the patient’s Medical Saving Trust Account.

The physician’s office has saved the expense of filing a claim, waiting for the claim to get adjudicated and then receiving payment three months later. The new electronic system (EHR) eliminates the $150 billon dollars of administrative waste in the healthcare system.

Why hasn’t someone in the insurance industry thought of this? Maybe they make too much money from being inefficient and having administrative waste.
Paul Krugman (New York Times February 16,2007) says it beautifully in the article entitled “ The Health Care Racket”

I have pointed out previously why hospitals do not want to change the faulty DRG system. It could be Insurance companies do not want to eliminate administrative waste because they and their subsidiaries’ profit from this waste.

Physicians who bought ineffective EMR’s might not want to put them aside for an effective system However, a powerful incentive could be instant adjudication of payment of claims by the patient.
It is going to take leadership and innovation plus the demand from the people, to create a much need paradigm shift from the way the healthcare system does business presently.