MAY 23, 2013 12:59pm ET

Impatient About Electronic Health Records

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I’m impatient about realizing the benefits of electronic health records—we all are. But, as the futurist Roy Amara once cautioned, “We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”

Amara’s law came to mind recently when six U.S. Senators published a report called “Reboot” that questioned recent government investments in health information technology. Like me, the Senators are also impatient to see results.

The report, released by lead author South Dakota Senator John Thune, is critical of the Health Information Technology for Economic and Clinical Health Act, a portion of the President’s 2009 stimulus bill that encourages physicians and hospitals to swap paper charts for electronic records.

The HITECH Act, as it is known, included an appropriation of $35 billion in Medicare incentives. To get those funds, health care providers must install software to manage patient records, eliminating much of the paper that we see today. But that isn’t enough. They also have to become fluent with the technology and incorporate the software into the way they practice, demonstrating what policymakers call “meaningful use” and then report on their progress regularly.

The Senators, in their report, make some good points about the incentive program, and how it can improve. But they come to the wrong conclusion.

They say that too many physicians and hospitals have been paid for installing records ($13 billion so far in incentives) without evidence that they are in fact gaining all the benefits. One aspect of meaningful use, interoperability, is especially slow to manifest itself.

When you go to the hospital, most of the time it is still too difficult to pull your health records from a rival hospital or even from your own primary care doctor. Different electronic health record systems rarely talk to each other.

The report also bemoans that software may result in “over-coding,” where bills are inflated because diseases are better documented. And, the Senators highlight the cost to maintain this technology. After Medicare pays up to $44,000 per physician, which is usually more than enough to install most computer systems, the rest will be shouldered by providers themselves.

These arguments, while not new, are not entirely wrong. It is true that the agencies overseeing the incentives should insist on better compliance with interoperability. Some software vendors, including one of the largest, build walls around their data when they should be building roads into it instead. 

The industry is stepping in where the regulations have not been aggressive enough, having recently announced an initiative to promote information exchange and interoperability. It’s similar to what the banking industry did to link together rival ATM networks. It’s tough, but so was establishing national standards for banking and cellular phones.

The problem of over-coding, meanwhile, plagued the system throughout the era of paper records—and, it’s only getting more attention now because electronic records give us a means to track and address overuse and abuse. If coding abuses are a problem, it will become clear by having more robust patient information in the record.

The Senators’ last point, about maintenance, is a weak one, since it is far less expensive to maintain a computer system than a huge file room and staff, and it’s safer. When Hurricane Katrina hit and tens of thousands of paper records were lost forever, putting thousands of patients at risk, no one said we should return to paper. The Institute of Medicine’s now famous report (“To Err is Human”) made that clear years ago. Paper charts are a safety issue.

As someone who helped start and grow one of the largest electronic prescribing and electronic health record companies, my main response to the Senators’ report is concern that it might slow our progress.

The “Reboot” report identifies manageable issues that the industry has been grappling with for some time. The good news is that these critics are focused on a few trees while the forest as a whole keeps growing and growing.

As of February 265,000 physicians and 4,000 hospitals had either completed or begun the process of qualifying for meaningful use incentives. Many of these providers had already embarked on digital health transformations before the legislation, and will be rewarded for it. The rest are benefitting from a nudge.

Typical of Washington, while critics complain, they present no viable alternative. What should we have the health care industry do instead? Do we really want doctors to continue or go back to filing patient information in charts that can’t be backed up, easily read, easily shared, analyzed for improved care or submitted efficiently for payment. Prescription pads (and physicians’ illegible scrawls on them) could make a return. 

Right now the industry is in a position where one foot is on the dock, holding on to the way it used to be. The other foot is on the boat, as it motors off into the future. There’s an unsteadiness. The Senators are right that changing direction is hard.

Cars became more transformative when they were later supported by the government investment in the interstate highway network. Computers changed the workplace when they became connected to an electronic network called the Internet. Mobile phones became more disruptive with the availability of government standards and inexpensive broadband data plans and apps.

Many of us remember those late night searches to find an ATM that connected with our bank’s card. But we worked our way through it, and today virtually all bank cards work securely, almost anywhere in the world, in seconds. That’s important because it’s your money.

What’s more important than your money? Your health. Electronic health records will only get better as more physicians, nurses, and caregivers log on, as vendors become more open, and as information is more widely shared.

As Amara’s rule portends, it is easy to focus on the limitations of an innovation before it fully matures. Washington needs to see the future benefits from having a connected system of health with patients, physicians and caregivers empowered with information. That’s a future that won’t need to be rebooted. Now as to booting a few of the folks in Congress, that’s something worth discussing.

Glen Tullman served as CEO of Allscripts from 1997 through last year and now is Managing Director at 7wire Ventures, which focuses on investing in health care, education, and energy.

 

Comments (2)
Thanks Glen. Nice post.
However I think one point that you did not highlight is the archaic E&M coding structure. Docs are forced to document excessively to meet a specific coding level. For example 'padding' the note to get from a level 3 to a level 4 code is all too common. This leads to long rambling notes that nobody can understand. The E&M coding system was designed when we were all on paper. It does NOT work within an EMR.

Several years ago I used an EMR when I practiced in the UK. Charting was easy - "left otitis media - amoxicillin 250 tid". The chart was not full of useless review of systems and lists of negative findings.

With the current EMRs we have converted physicians into data entry clerks. This has to stop ASAP. They are not saving time - they are leaving the office later and don't see any benefits right now.

Get rid of the E&M coding system. Make documentation shorter and easier to read. Delegation re data entry should be preached more ( I preach to our docs that EMRs are NOT a physician tool - they are a PRACTICE tool- hence the need for delegated workflows). Docs are not trained to do data entry.

Just my 2 cents.

Adrian Rawlinson MD
Posted by ADRIAN R | Friday, May 24 2013 at 3:13PM ET
Glen, I'm not sure we read the same white paper (I did). The white paper's thrust was the poor way in which the various governmental agencies have handled the whole meaningful use issue. The Senators see much of the benefit for both patients and government in the area of interoperability. As a 30 year provider veteran and a tax payer, I certainly agree with them.
They criticize the governments lack of fiscal oversight, the fact that little has been done towards reaching the goal of interoperability, which is one of the main goals of this legislation, and the confusing plethora of governmental agencies involved or influencing attempts at standards setting. They did express concern regarding possible payment to providers for meeting "Meaningful Use" criteria without any verification that this had occurred, as well as concern over a possible increase in over-coding. Both of these are valid concerns for a senator and a tax payer.
The Senators seemed to me to be very supportive of the overall goals of the legislation, they just don't wish to spend billions of taxpayer money without achieving the goal. Although spending money may serve the needs of the IT industry and in some cases providers, it does nothing for the taxpayers or the patients. I saw no evidence that they needed to present an alternative as you suggest since they only want the goals of the legislation realized. There was also no mention of going back to paper records which was one of your straw men.

In short, it's my opinion that you either didn't read the white paper or you chose to write a "hit" piece for reasons unknown. I think most citizens would agree with the content of the white paper.
Posted by Jerry M | Thursday, May 30 2013 at 2:22PM ET
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