Electronic Health Records: What Is Missing?
Stanley Feld M.D.,FACP,MACE
Some very good Electronic Health Records have been created. Last week, I received an excellent comment from Dan Schmidt, whose practice bought one of these very good EHRs. The views and pain he relates is exactly why quality Electronic Health Records have not gained traction with physicians. Dan has one of the best EHRs in Centricity by GE Healthcare. Actually Centricity is potentially an excellent product. GE Healthcare has invested heavily to solve the EHR problem. They manufacture and sell many products for the healthcare system. One problem they have is that the various products are not interconnected with their EHR.
Centricity is a relational data base that converts data points of information into word paragraphs. It provides a good looking electronic medical record, gets paper off the desktop and charts off the shelves. GE Healthcare is on the right track with Centricity. Centricity is capable of being what I believe is the Ideal Electronic Health Record. However, it misses on several counts. Why? Because they never asked the physician what his problems are. Again if they did ask some physicians, the physicians probably did not know what they needed.
Dan Schmidt M.D. expresses the problem beautifully.
“I believe the resistance in Primary Care to EHR is a reflection of the cynicism that has become pervasive.
So the problem, as you stated, really comes down to what does the physician expect from an EHR? There are lots of good products…We installed and ran Logician (Centricity) for 7 years in a primary care office. Paid for it ourselves, with no government support,,,,And now we have a huge data base that we don’t have the time or capital(manpower) or enthusiasm to institute quality improvement…”
My reaction to Dan’s comment is the following;
1. Dan knows what he needs. He has to have the important questions about the effectiveness and efficiency of his practice answered with his electronic health record. These questions are not answered because he does not have the time or capital to get them answered. The answers to his question have to be built into the EHR as he is creating the patient data at the point of service. The data analysis should be for his education. The data should not be for the insurance company, the government, or some malpractice lawyer to use against him.
The Institute of Medicine has said only 10% of physicians practice evidence based medicine. A relational data based information system can cue the physician to the practice of evidence based medicine. This system must be built into the EHR. The physician is then free to use his judgment. Centricity’s EHR has this capability. It is not available to Dan Schmidt because of the added cost of capital or time. If our goal is continuing quality improvement, physicians need the tools for continuing quality improvement. These tools have to be immune from liability in order for the physician to be interested in using an EHR.
2. The care to the patient has to be connected to the financial cost of the care as well as reimbursement for care. The cost of care includes pharmacy charges and hospital charges. The prices must be completely transparent to the physician. Most physicians have no idea of the cost of various drugs. If they knew they might order less costly drugs. Presently, Pharmacy Benefit Managers tell us what we can prescribe even if it is against our clinical judgment. This is not the way to generate trust between the physician and pharmacy. The physician should make the judgment with an understanding of the difference in cost to the patient. The EHR could provide that information with one click if programmed correctly.
These are two of many needs the physician has from an effective EHR. I will cover most of the other needs in future articles on EHR. These two additions would add value to the physicians practice and promote his understanding of his practice patterns. These additions should be used as a learning exercise by the physician. The data should not be used to criticize the physician and reduce his reimbursement. In other word he should not be penalized for his practice patterns. Most measurements of practice patterns have the wrong viewpoint. The point of view is to grade the physician’s practice pattern and not teach him how to change constructively. The measurements used to grade the physician presently are mostly the wrong measurements. It becomes easy to see the physician resistant to collecting data at a very steep price that is useless to his continuing . The physician does not have the time or the money to invest in an EHR that adds value to practice.
Once again, I thank Dan Schmidt for his truthful comment.
“The enthusiastic primary care docs are the ones doing lots of procedures(indicated?) and satisfying demand. You mentioned the 80% costs on chronic care. Most docs can name these 20% of their practice off the top of their heads(without an EHR) and their definition of improved care is to SEE THEM LESS.. Since the marginal improvement one obtains( 1-2 less hospital admissions, 1-2 less ER visits/ year) is such an incremental improvement, most primary care docs dismiss this success.
And it is hard to quantify.”
The above comment is also very important. It highlights the difficulty in Repairing of the Healthcare System. The only asset primary care physicians have to sell is time. Educating patients properly about their chronic disease is time intensive. The education time is either uncompensated or under compensated. Taking care of a patients with a chronic disease is also time intensive. The primary care physician’s time has been devalued. The only way for the primary care physician to improve time effectively is to not take care of the time intensive patients. The primary care physician passes these patients off to a specialist. The problem is the primary care physician is the contact physician for most of the patients with chronic diseases. There are not enough specialists to take care of all patients with chronic diseases. Therefore, they are not taken care of using evidence based medicine. If all physicians practiced evidence based medicine we could reduce the cost of care by at least 40% because 80% of the cost of care is spent on treating the complications of chronic disease. If we all practice evidence based medicine we could reduce the complications rate by at least 50%. Fifty percent of 80% is 40%. The total healthcare bill presently is $15 trillion per year. In an ideal world that would be $600 billion per year.
I hope some of the EHR companies are listening.
Next time I will define quality medical care, evidence based medicine and the role the EHR can play.