The Complexity Of The EMR Issue

Stanley Feld MD, FACP, MACE

In my last post a comment referred to the difficulty with Kaiser HMO’s EMR. The following was reported in the San Francisco Chronicle November 7, 2006.

“Kaiser: Critical Need To Cut Rising Costs”

“$7 billion in losses if no action taken, HMO report says”. Kaiser has invested $3 billion in data system created by Epic Systems Corp. Kaiser’s project supervisor e-mailed 180,000 employees detailing his frustration with Kaiser’s Electronic Health Record System which he considers inefficient and unreliable. The project supervisor brought his concerns to the Kaiser HMO’s board. He said the information was not taken seriously “because of conflicts among top executives.” Doesn’t this sound typical of the hierarchical bureaucratic systems we live in? One simply has to recall the problems in the CIA and 9/11. Kaiser is supposed to be the best of the best.

The creation of an effective electronic medical record is extremely complicated. Physician practices and hospitals have different needs and therefore different EMRs. In fact the EMR is just one health record. The system that is needed is an Electronic Health Record (EHR) with multiple components. There is much confusion between these two terms. The confusion leads to the hesitation by physician to adopt an EMR.

The goal is to convert medical records from paper charts to digital electronic charts. The goal is to enhance the flow of information about patients and their care to all who might be involved in the patients care. The physician’s office practice work flow is very different that the work flow in a hospital. Therefore one size EMR does not fit all in our present environment. The issue of trust in handling records between primary stakeholders and facilitator stakeholders also represents a barrier to adoption.

The theory is that a paperless chart will decrease the waste and inefficiency in the system. The handling of each chart per physician patient encounter cost the physician $7 in labor and material. One click can save $7 per chart, if there was an efficient, reliable, and affordable EMR.

However, a paperless chart is in reality worth little unless the information entered is usable in data base format rather than word processing format. Only then, can patient care be enhanced. I will explain this in detail as we proceed. Many EMRs sold are simply word processing of records. Only in a data base format can one piece of data be related to other pieces of data to truly decide on best practices for enhancing quality and decreasing the cost of the complications of chronic disease.

There are many needs in health care information systems (Health Informatics). An electronic health record (EHR) is a personal medical record (EMR) that can typically be accessed on a computer or over a network. An EHR almost always includes information relating to the current and historical health, medical conditions and laboratory tests of the patient. In addition, EHRs may contain data about medical referrals, medical treatments, medications and their application, demographic information and other non-clinical administrative information.

The non clinical administrative information includes the financial charges and collections. All of these data points must be able to be integrated via relational databases in order to determine the relationship between the disease or diseases, medical steps taken, charges, costs and payment in relation to clinical (medical) outcomes. To my knowledge, the ideal EHR system has not been implemented by any software company to this date.

As of early 2007, adoption of EHRs and the multiple components of EHR have been extremely slow. I believe the reason for this is because the stakeholders are unsure of what they are buying. The software companies are unsure of what they are selling or are unsure of the primary stakeholders needs. The cost of the product is also beyond many primary stakeholders’ means in a medical economy of falling prices.

Less than 10% of American hospitals have implemented semi robust Health Informatics Systems. Only 16% of primary care physician have put an EMR in place. Most of those EMR are word processors. These EMRs get paper off the table eventually and cost large amounts of money to buy and maintain. Physician find these EMRs do not do what they need and are forced to buy add-ons.
The government wants paperless records so there is portability for the patient and ease of chart inspection by the government. This represents another reason for suspicion and caution on the part of the physician.

There Are Many Types Of Electronic Records In Use Presently.

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

Somehow all of these electronic records have to be combined.

Interoperability Is The Key To Any Successful EHR

However, interoperability can only be exercised at the request and permission of the patient and the physician. This becomes another barrier to adoption. I made a negative comment about Regional Health Information Organizations (RHIO) a while ago. I said I did not think they would work. There are many reasons for this view. First, how is this information going to be collected? What are its potential uses? Some uses are good, but many uses are bad for the patient and physician. Remember, they are the primary stakeholders.

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, which is necessary for timely, patient-centered and portable care. Interoperability is essential if the EHR is going to help reduce the cost of care.

I believe that Medical Saving Accounts can help this process along. I plan to develop this belief. This portability should be for the benefit of the patient and the physician. It is not for the benefit of secondary stakeholders, especially those secondary stakeholders that see a widening of net profit with these new complicated systems that someone else pays for.

Aside from administrative waste of $150 billion dollars a year, 90% of the Medicare dollar is spent on the complications of chronic disease and 80% of the overall healthcare dollars is spent on the complications of chronic disease. The elimination of administrative waste could be reduced by present state of the art healthcare informatics systems if the proper motivation was created.

However, if we are going to repair the healthcare system electronically, the healthcare informatics systems must function with fully integrated interoperability. There must be systems of continuous quality improvement built into the EHR that are not punitive to the physician or the patient.

Presently, we have a healthcare system where the electronic information (incorrect information for the most part) is punitive to the patient and the physician, and lacks interoperability or continuous quality improvement. Several software companies have the infrastructure to achieve this goal. However, they do not seem to understand the physicians’ mentality in order to reach the goal. They key question again is who is your customer? The answer is the patients (consumer) and the physicians.

The concept of interoperability systems is embedded only in the Electronic Health Record. Interoperability cannot be attained with the Electronic Medical Records software companies have available. Remember, only sixteen percent (16%) of us have bought an EMR. Most of these records are potentially out of date. The EMR has gained some efficiency, but so far short it has been far short of its monies worth to the physician, the patients, or the cost of care to the healthcare system.

I will next discuss my vision of the idea Electronic Health Record.