The Electronic Medical Record Stimulus Fiasco: Part 1

Stanley Feld M.D.,FACP,MACE.

All of President Obama’s goals are commendable. The United States needs to fix the education system, decrease its dependency on fossil fuel, increase production of renewable energy, and repair the healthcare system.

These are all big ideas. They must be implemented for the United States to prosper in the future. I have expertise in (healthcare). President Obama’s route to achieving healthcare reform is wrong. He is not attacking the basic problems in the healthcare system.

A PriceWaterhouse Cooper study showed $1.2 trillion dollars is wasted on defensive medicine and administrative costs. Where is malpractice reform on President Obama’s list of big ideas to eliminate the practice of defensive medicine?  If the $1.2 trillion dollars of waste were eliminated we would have an affordable healthcare system.

The administration’s stimulus package for instituting an electronic medical record (EHR,EMR) is going to create more waste and a larger mess than the fiasco that already exists.

“A recent Robert Wood Johnson survey of more than 3,000 U.S. hospitals found that only 9% were using electronic health records (EHR). “The numbers are disappointing and certainly lower than we thought when we went into this study,” says Ashish Jha, the lead author of the study and an associate professor of health policy and management at Harvard University. “

The survey is a well done. Survey responses were received from 63.1% of all acute care hospitals that are members of the American Hospital Association. This is a high percentage response rate for a survey. The survey looked for the presence of specific electronic-record functionalities. More discouraging than the 9% figure is only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units and fully functional).

Only 7.6% of acute care hospitals have a basic system (i.e.present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, urban area hospitals, and teaching hospitals were more likely to have electronic-records systems than small hospitals in smaller cities. Most of the hospitals spent over $100 million dollars for it EMR. The money spent did not enable the hospital systems to implement a fully functioning EMR.

Hospitals and hospital systems are experiencing financially hard times during this recession. They cannot afford the capital requirements and high maintenance costs to implement the installation of an EMR when the end result is not having a fully functioning electronic medical record. Hospital systems board of directors are not interested in going deeper in debt when the government is going to reduce reimbursement for non compliance.

PriceWaterhouse Coopers’ analysis of the stimulus package for EMR points out government subsidies are through the traditional EMR acquisition channels. Their analysis highlights the government’s punishing actions of non compliant providers. It is going to reduce reimbursement as punishment. Isn’t that silly? The government should be worrying about the financial health of these institutions and physicians’ practices

“The stimulus funding for health IT is a small carrot compared to the amount of resources it will take to deploy this technology over the next 5 years. Also, providers will feel a big stick of financial penalties if they fail to use government-certified electronic health record (EHR) in a government-certified manner beginning in 2015.”

It should be obvious that every physician’s office and hospital system should have a functional electronic medical record. One must wonder how physicians feel when they cannot afford an EHR that will probably not have full functionality.

Who will be the winner? Patients should be the winner. Patients will not win under President Obama’s stimulus package.

“With billions in new funding and government regulations, the health IT market will balloon far beyond the provider segment, providing new opportunities for health plans, pharma companies and other vendors.”

Powerful secondary stakeholder with financial vested interests will win.

The net result is will not be a universal and functional EMR. There will be little connectivity.

The government should invest in the purchase of a web based fully functional EMR with all the attributes necessary to build an effective electronic medical record system. The system would provide complete interconnectivity to physicians, hospitals, pharmacies, and insurance companies. Upgrades and maintenance of the software would be automatic and free.

The government would charge each provider entity by the click for the use of the universal Electronic Health Record. The government would recover its investment over a very short time and instantly create a system of price transparency. The system would be affordable to the healthcare providers. The present stimulus plan for EMR is going to waste the $36 billion dollars. It will try to force hospital systems and physician offices to buy an electronic medical record system that they cannot afford, do not want and might not work.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Comments

[EMR Medical]

Thanks for the view through this blog. A major US survey has shown lately that majority of doctors think implementing electronic medical records is necessry at this time.

[Jay Beaulieu]

As an IT worker I am also worried about the President's Healthcare IT reform. First thing I'd like to set straight is that you presented a serious series of issues about Healthcare IT and I'm going to try to address them. I don't stand to benefit at all from my solution. I also tried contacting the Obama administration and sent the following viewpoint that implied SOA (XML contracts, workflow) and DITA (data views, procedure workbooks) both are open source, but received no response:

I want to keep this letter at the concept level and not get into a technology whitepaper, but rest assured everything I’m about to suggest is at the cell-phone level of cost for physicians, a little more at the hospital level because of different needs but most importantly the technology already exists.

There are currently three basic types of medical records, paper medical records, the folder we all know so well, the electronic medical record used mostly at hospitals, think of a printout from a computer system and the Electronic Medical Records (EHR) which are XML-based records that have the ability to reduce costs and errors because they are programmable and can be validated (checked for accuracy and completeness.)

The first discussion we need to have is who should hold these records. If the goal is to fight disease, find new cures, to identify epidemics and to use these records as a basis for an unparalleled growth of healthcare knowledge over the next ten to fifteen years, we need the records easily and securely accessible. There are two groups that I think have the ability to deal with the billions of pages of medical records. The first is the Federal Government but due to the boom and bust of the budgetary process I prefer the telecoms because they are big enough, have the redundancy, the geographical reach, the competition, the bandwidth and their business model is based on providing reliable services at a low cost.

Next we need to look at what is the correct paradigm to use for our medical records. This is simple it’s an electronic loose-leaf notebook that mimics a paper folder but has pages that can be forms or entire computer systems like an MRI system. A simple example would be using the Kindle II to access medical records. Because most physicians medical records are in paper form we need to get them scanned into electronic form and sent to the telecoms. This is labor intensive but requires little training; we could use the workers already being assembled for the 2010 census, providing a very quick stimulus effect across the country. This is not make-work because the unfiltered raw data is the most valuable form of information to researchers if searchable. The census worker leaves behind a scanner, a printer driver (to write to the telecoms) and an electronic certificate of use that allows secure and audited, reading and writing to the medical record. The electronic certificate of use controls the type of information the holder can view or update. For instance, a state worker that monitors lead levels may be able to add a report to the book but never read any information and the same would be true of a Department of Children and Family welfare worker. This information could have a direct impact on treatment choices. The census worker also performs an audit of what software systems that are currently in use at the office, for later when we convert to XML.

At the hospital level we could use the same type of system as at the physician’s office but here since money is available we want to make use of it for future efficiencies. So the first step is to think of each computer system, medical device and medical personnel’s duties as steps in a workbook. The goal is not to run out and replace every computer system you have but rather to identify workflows and steps so that you can layer with an enterprise software service on top of whatever systems and procedures you are currently using. This is the best way to keep integration and training costs to a minimum. This first step sets the basis for measuring metrics across the hospital and after careful analysis selected systems could be replaced. The idea is that the use of EHR records can be implemented outside or on top of your current systems. Disk space is cheap and redundancy of information is not always a sin.

At this point we’ve minimized the risk of movement to XML. The physician’s office has had time to adapt their workflow to electronic records, has probably replaced the paper folder racks with another examination room and may have had some cost savings. And they no longer have to worry about marrying an IT person to practice medicine. The telecoms are trying to sell all sorts of services like billing, automated reminder calls, electronic prescriptions the list is endless. The hospitals have identified its different workflows, decided where XML would benefit them and possibly received bids from different software vendors to wrap the individual systems either wholly or partially to take advantage of XML. Now it’s time to move to XML.

The largest cost savings and reduction of medical errors comes not from the EHR record but from the workbooks. This type of workbook is really a best medical practice workflow, in it’s infancy it’s just an electronic record of symptoms, treatment and justification, sent to a third-party like a telecom. The purpose is to prevent a remake of the “Verdict” with Paul Newman except on the History Channel. But to do that the workbooks need to be created and maintained not by an individual software vendors or physicians but by a consortium of interested parties like the medical manufacturers, pharmaceuticals, medical associations, physicians groups and finally the Federal Government for an effectively rating. This allows for the creation and refinement of many backend programs that can check on the validity of treatments in so far as medical errors and options are concerned.

Next up are the healthcare insurance providers. Because the medical community has its own very precise terminology, what’s covered, partially, wholly or not at all by an insurer can be conducted in an XML contract in a matter of seconds. This would require a law to be passed requiring it from the insurers. But it should also allow the insurers to provide an alternative treatment to the patient. This provides the patient a cost with an effectively rating and maybe a couple of different optional
treatments so the patient in consultation with their physician makes the judgment.

We left the medical records as electronic medical records earlier we need to get them into EHR but I’m of three minds here. The first is that we could have done the conversion when the records were scanned in and using software and our census workers create the EHR, this provides the greatest stimulus to the most people. Or we could scan them in and have the conversion done in places like Elkhart, Indiana or other areas hard hit by this recession, because most people that have worked in a factory or assembly line already have the skills needed for XML. But we could also write software programs to parse, categorize, and convert the data to EHR which would produce valuable programs that could be used outside of our medical records, to XML and Artificial Intelligence programs in general. The programs are re-executable whereas using the census workers is more of one shot deal. The other thought is that when designing the XML processing procedures it should never be pigeon-holed into what we expect to collect for information. A notebook can have anything in it but a page or maybe even a chapter could be validated but it needs to be remembered this is a data collection system that must change frequently with the pathogens and treatments out in the field. Layered from the unknown but collected (notebook) to the known (page) outside in.

Now the medical office worker, physician and patient all check the accuracy of the EHR. From the physician’s point of view, forms can now be filled out on the hand-held device, new features or workbooks appear tailored to their specialty and particular treatments. Perhaps a table of relatives allows access or just querying the patients relative’s books for pertinent information, but of course this is up for discussion. The hand-devices could now have barcode readers, GPS units and biometric fingerprint readers for drug auditing, security and for access auditing. Deceased people’s books are constantly being sent to the National Archives or CDC for storage and research, a little like donating your body to science without the yuck factor.

Hospitals have spent there monies wisely, have color-coded hand-held devices so they don’t bring the wrong one into the operating room. But most importantly, they’ve changed from, a who can pay and who can’t, to true cost accounting and I don’t mean in the IRS sense. But we as a society need to actually advance not to just pay as you go. So therefore, charging ten dollars for an aspirin from an IT perspective, I can’t help you. However, if the reason you’re charging ten dollars is to
offset the fact that you have a separate DBA for each database or you need 24/7 support there I can reduce your costs significantly.

Finally, we’ve created a series of checks and balances in our healthcare engine that should help it stop leaking oil. We’ve given everyone a haircut to one degree or another but we’ve refocused on the fact that the goal of our healthcare engine should be on providing better healthcare for ALL Americans and that profits should be earned though innovation and hard work not just by exploiting leaks in the system or clever accounting.

[andy press]

Thanks for sharing your opinion with this blog.

A major US survey has shown lately that majority of doctors think implementing electronic medical records is necessry at this time. i agree with your acessment that this will be a huge challenge for us all.