Stanley Feld M.D.,FACP,MACE
I thank my son Brad for writing about my post “Electronic Health Record Part 2”
in “Feld Thoughts.” I was pleased with the many comments that we both received. There are many smart people out there.
I think the difficulty in developing an EHR has been overstated. Most of the software pieces of the ideal electronic health record are currently available.
Few developers have asked the physicians what they need. Fewer developers understand why they encounter such massive physician resistance. Those who have tried to understand the resistance can not get a straight answer.
The reason is many physicians do not know what they need. They have little experience thinking about relational databases. They have difficulty understanding the potential to the increased efficiency of their daily workflow (effective relational databases) in the practice of clinical medicine. Most of the effective information technology in clinical practice has been in financial medical management. Financial outcomes have not been linked to medical practice outcomes in an understandable way.
EMR developers also have had difficulty getting the physician to sit down and listen to them. Physicians are very suspicious of data collection devices. Most of their experience has been with data collection that has been used against them by the facilitator stakeholders (the government, the insurance industry, and the hospitals) to penalize them or reduce fees.
I believe all the pieces of an ideal EHR are now. However, most of the pieces are stand alone silos and are not interconnected. The physician is offered an expensive and unaffordable product that seems to offer little added value to his practice except to eliminate paper. The value to the practice is not translated properly nor could they afford it if it was.
Brad Feld (my son) and my brother Charlie Feld have taught me a lot about information technology and relational databases. We have had many discussions about relational databases. I have studied its potential value to physician practices. In my opinion, few companies understand how the physician thinks and what his needs are. They do not know how to teach the physician to understand the value of an EHR to his practice.
I think the reason is that software developers are oriented toward the hospital as their customer and not the physician. Hospitals have money to spend on capital improvements. Physicians do not want to spend large amounts of money on anything, especially something that they perceive will add little value to their practice. In fact, the EMR might hurt their practice. They hear many horror stories from peers about worthless EMRs. Most effective EHRs are out of the price reach for the average physician or small physician groups. Physicians have heard and seen big organizations like Kaiser Foundation get fooled out of hundreds of millions of dollars. Many have had the same experience in their own hospital.
An Ideal Electronic Health Record can, I believe, be easily synthesized from the current technology in use by other businesses.
The EHR should be leased to the physician and the practice to make it affordable. The EHR should be sold at a penny a the click just as Mastercard’s system is sold to small businesses. The data can be stored on site or off site or both with stout privacy firewalls around each practice.
Many businesses rely on relational databases. Two simple examples are Amazon.com
and Netflix. Amazon tells me what books I would enjoy and Netflix tells me which movies I should order from my order history.
The airlines let me schedule a flight online. Southwest has my online ticket buying reduced to three clicks.
Wal-Mart buys store inventory based on sales. It automatically sets up delivery routes and schedules of thousands of products delivered to thousands of stores based on velocity of individual product sales.
Frito Lay builds potato chips and buys potato futures on the basis of historical experience and timely conditions such as social unrest or sporting events on television. If volume of sales drops in a city, Frito Lay automatically puts the potato chips on sale in that city.
E-trade, Schwab and others make trades online and adjudicate sales at the point of trade. I remember the days when stock prices were caulked up on a blackboard.
Almost every merchant uses Mastercard, Visa or American Express. They settle the price of purchases immediately. Mastercard even questions a charge that is too frequent. I was at a gas station and the pump was acting funny. I stopped pumping gas from that pump and reentered my credit card in another gas station. I was denied access. I also got an instant call from Mastercard asking me if I lost my card. The software picked up an unusual event in the use of the card.
Stores, restaurants and gasoline stations do not have a universal software system. They interface their different software systems with First Data’s system. First Data has been able to flatten out many interfaces so that there is universal processing at First Data’s end.
The banking industry has adopted online banking. I thought the personal banking would the last to adopt. The software company selling to the banking industry has made the interface easy for the personal banking customer. The pain of reconciling the bank statements is gone forever. Customer service encounters are down. Everyone seems happy. The banks net profits have increased and expenses have decreased because labor intensive tasks have decreased. The individual banking institutions do not own the software. They lease the software. They also pay by the click. The software people upgrade and maintain the software with all the appropriate backups and firewalls.
The same can be done with appropriate data based driven legacy medical information systems. However, many of the legacy medical clinics EMRs are not worth much. They are word processing systems and not data processing systems. Those systems will manage to get the paper out of charts and off the shelves. However, you can not learn anything from them to improve a clinical practice.
Most practice management systems have relational data base capability. You can figure out a percentage of Medicare population in the practice. You can also get the names of all the males over 55 years old with diabetes mellitus, impotence, and hypertension.
The EHR I am talking about is the next step. What have we, as physician, done to improve patient care? What has the medical outcome been? What is the price in medical services for the medical outcome? Are there any suggestions available using evidence based medicine for the physician to improve his outcome?
Remember, 80% of the cost of medical care is spent on the complications of chronic disease. How can we learn from the patients record how to reduce these complications without the threat of penalty to the physician.
What have I taught the patient? How much of what I taught him did he learn?
What is his adherence to prescribed medication?
How could a physician measure adherence to prescription with an EHR? The entire informational technology infrastructure is available. It can be automated. It is waiting for an entrepreneur to put it all together. When I give six months prescription, the patient only gets a thirty day supply from the pharmacy. This is a little scam the CVS’s of the world in conjunction with the insurance company exercise. Why? If your co-pay is $10 for a generic drug, CVS might charge a total price of $14. You paid $10 and your insurance company pays $4. For a six month supply your insurance company would pay $24 and you would pay $60. If they gave you the six month supply of medication I ordered you would pay a co-pay of $10 and the insurance company would pay $74. I would say that is a pretty neat drug benefit for the insurance company.
If I, as the prescribing physician, demanded that the CVSs of the world notify me by email each time the prescription is refilled, each notification could go directly into the patients EMR. On the patient’s next visit, I would know whether the patient refilled his medications appropriately. Patients have told me they refilled the medication when in fact the pharmacy had not seen the patient in the previous 4 months.
As an example such a patient would not be able to properly control his blood pressure. Uncontrolled blood pressure can lead to stroke or heart attack. Both are a complication of the underlying vascular disease that causes hypertension. Appropriate control of the blood pressure can reduce the possibility of stroke or heart attack by 50%.
Simply understanding and controlling compliance can save lives and reduce the cost of medical care. Can this process be automated with present day technology? Of course it can. It could help us be better physicians and give better service to our patients without it affecting our daily workflow.
I do not think it should take forever to have a universal web based EHR. It can be as rapid as CD’s replaced vinyl records. It takes an understanding of the physicians mentality, the physicians needs and the physician workflow. I will present many concrete examples of quality care improvement across all five parts of the EHR in the future.
I believe the resistance in Primary Care to EHR is a reflection of the cynicism that has become pervasive. 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.
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...
Posted by: Dan Schmidt | February 22, 2007 at 12:33 PM