About Electronic Health Records

So I was out walking in the cold early this morning in my never-ending Battle of the Bulge, when an idea occurred to me. Amongst all the heated debate on healthcare reform over the past few years, one thing I have consistently heard from multiple sources is a call for greater implementation of electronic health records.

As a physician, I have heard many folks not involved in providing healthcare decry physicians for not embracing this great panacea, as though a profession which typically dwells on the cutting edge of technological achievement when it comes to diagnostic and therapeutic modalities is for some mysterious reason determined to remain total luddites when it comes to maintaining records of their patients.

Well, the simple fact of the matter is that physicians are not opposed to embracing information technology.  However, unlike the academics, politicians, journalists, etc. who all condescendingly criticize the medical profession for it’s lack of alacrity in implementing electronic health records, practicing physicians do have to make their living in the actual environment of medical practice.  In a nutshell, if a new technology enhances their ability help patients and/or makes them more efficient, they are pretty quick to embrace it.  If, on the other hand, a new technology simply adds financial burdens without any clear benefits, or worse yet creates barriers to effective and efficient medical practice, they are understandably going to be hesitant to embrace it.  The later is the current situation with most iterations of electronic health records.

As a practicing physician, I am very much in favor of using the latest technology to store and retrieve data on my patients.   I have spent countless hours exploring various software packages and systems in the hope of finding a good system that can be implemented into my own practice to enhance patient safety, improve my efficiency, and ultimately lead to better and more effective patient care.  Unfortunately, like most physicians, my search has been largely in vain.  The overwhelming majority of systems I have encountered have either been prohibitively expensive, poorly executed or both.  Most of the systems I have reviewed actually have the effect of making me slower and less effective in my practice.   The most recent one I tried actually took over an hour for me to finish the documentation of a single patient encounter and the resultant document was a disjointed mishmash of little clinical value.  Using a pen and paper, I can still produce a superior document in a few minutes.

So, why is it that other industries are able to integrate computers so well into their systems, but the healthcare system has so much trouble?

It has to do with the overwhelmingly disjointed and confusing documentation and billing requirements dictated to us by the bureaucrats at the Centers for Medicare and Medicaid Services (CMS).

Integrating their bizarro-world requirements with the various bits of information associated with each individual patient is difficult to say the least.  Unlike other industries where they are simply inputting and storing demographic data, medical records include all the demographics plus information from multiple sources such as reports from specialists, lists of medications and dosages, allergies, medical and surgical histories, family medical history, values from hundreds of laboratory tests, etc., etc.  All of these various other sources present their information in a variety of formats ranging from handwritten notes, to electronic documents, to hard-copy x-ray films, and more.

On top of all of that, the physician must be constantly vigilant to document his or her records with the assumption that they will potentially be read to a jury by some ambulance chaser some day.

Software companies that attempt to create an effective system soon find themselves in a situation not unlike trying to “herd cats.”  While not impossible, it certainly isn’t easy.  As alluded to earlier, the overwhelming majority of systems I have toyed around with fall woefully short.  The relatively few systems I have encountered which do a passable job have been ridiculously expensive, typically requiring a tremendous investment not only in equipment and in time implementing the system, but also in continued product support to keep the “cat herd” moving.

So, what was this idea that occurred to me as I was out walking this morning?

Well, of all the electronic health record systems I have used and explored, there was one system that I actually grew to like.  After using it for about a month or so, I actually found that it started improving my efficiency and speed.  Further this system seemed able to satisfy the draconian documentation requirements put forth by CMS and was able to translate patient information into billing information pretty reliably.  Finally, this system was designed to beautifully integrate the health record across various practice settings automatically.  In other words, if a primary care physician saw the patient, he could easily pull up records from the various specialists, x-ray reports, laboratory reports, prescription history, etc.

To be sure, this system is not perfect.  It does require an investment in equipment as well as product support, etc. and does have somewhat of a learning curve, but overall, it’s the best system I’ve fooled around with.

Where did I encounter this system?

I encountered it while working in a U.S. Army clinic in Germany.  The system was knows as CHCS II, which stands for Composite Health Care System II.

Basically, this is the electronic health record being integrated into the military healthcare system.  Since my time in Germany, it is my understanding that it has been renamed AHLTA, which stands for Armed Forces Health Longitudinal Technology Application.

Man, the military sure does love its acronyms!

Anyway, here’s my brilliant idea that occurred to me this morning.

The U.S. government should make this system available for free to the civilian world.

There are many good reasons for our good ole Uncle Sam (not to be confused with our good ole DrSam) to do this.

1. CMS has a long stated goal of forcing electronic health records on the U.S. healthcare system.  This would go a long way toward achieving this goal.

2. There are currently about 10 million U.S. citizens (military personal and their dependents, etc) who already have their personal health records contained within this system.  When they leave the military or otherwise have to interact with the civilian healthcare system, their information would already be available.

3. As future people enlist into the military, their civilian health records could seamlessly follow them, enhancing the military healthcare providers ability to deliver good care.

4. Most folks working within the military healthcare system, eventually leave the military and go to work in the civilian sector.   They would already be familiar with and well versed in this system making this transition much easier for them.

5. Finally, and perhaps most importantly from a strategic standpoint, the military would benefit from the inverse of number 3 above.  For the most part, folks working within the military healthcare system do all or most of their training in the civilian world.  By having the same electronic health records system in place in both the civilian and military healthcare environments, folks entering the military would already be familiar with the system, allowing them to quickly integrate into the military system and get busy with caring for patients.  Strategically, in the worst case scenario where the U.S. finds itself involved in a large war requiring conscription of large numbers of medical personal, the value of having those folks able to get to work efficiently and quickly cannot be overstated.

CMS has been increasingly demanding use of electronic health records.  Until now, this has been essentially a monumental, unfunded mandate.

The idea I present above, gives our dear Uncle Sam the rare opportunity to actually put out a funded mandate.  Our Uncle has already spent several billion dollars of OUR money developing this electronic health records system.  Similar to the Interstate Highway System and the Internet, which were also originally implemented for military purposes, but soon proved highly beneficial to our society as a whole, I think making AHLTA, (or whatever acronym the guys in uniform decide to call it next month) available for free download is a win-win for almost everyone.

I say “almost” because I am sure that an army of lobbyist for the companies currently marketing various electronic health record systems to the civilian healthcare marketplace would do everything in their power to prevent my proposal from ever happening.

To me, this would be similar to companies operating bumpy, pot-hole filled, two-lane toll roads attempting to block civilian access to the Interstate Highways.

So, how about it folks?  What do you think of my idea?

5 Responses to “About Electronic Health Records”


  • Dr. Sam,

    I was directed to your blog via a posting by StanR on the Obama Transition Team’s website change.gov. I find it refreshing that a physician is contemplating the Electronic Patient Record. I represent a coalition of healthcare data providers who are also thinking about this, but from a more specific aspect of data standards. We will not argue the need for EPR or other industry-related data, we are just advocating for standards in how the data is collected, transmitted, and aggregated. We are drafting a White Paper on this subject, and while it is not yet ready for release, I think you may be interested in an excerpt:

    “…The good news is that leading edge health providers which have adopted these standards report hundreds of millions of dollars in annual cost reductions, which translates into lower healthcare costs for patients. Premier, in conjunction with the Centers for Medicare and Medicaid, conducted a Hospital Quality Incentive Demonstration Project from 2003 through 2006. The Project required the participating hospitals to report clinical and financial data in detail which had never before been done. One of the more intriguing findings was that the participant hospitals which had the best clinical outcomes, also had the lowest cost for providing the related care. The obvious message for American healthcare is that better data can translate into better care and lower costs for all Americans. …”

    Specifically to your suggestion, while it shows that you are giving serious thought to this issue, may I offer that adopting a government solution to a national problem is a non-starter. No matter how good the government solution is, commercial enterprises offering competing platforms will do everything in their power to halt any progress, rather than risk corporate failure. A better solution might be to provide the details regarding the government’s solution to commercial data system providers, recommending that they adapt these new ideas to their current offerings. Health reform will come more quickly, and the outcome will be more perfect if commercial enterprise is not shut out of the process.

    ####

    Thanks for the feedback.

    If you read much of this blog, I think you will find that I am in no way the type of person who thinks that government has the best answers or that commercial enterprises should be shut out of the process.

    The software system I talk about was actually developed for the government by the private sector. The feds have already spent billions of dollars developing this system.

    In a perfect world, I’d have the government get out of the healthcare business almost entirely.

    This is not my perfect world however. This is the real world and in this real world, we’ve just elected a President and Congress who seem hell bent on having a further takeover of the nations healthcare system by the government.

    Part of their proposed actions involves mandating universal coverage and that all patients have electronic health records.

    If they simply mandate this as a requirement of healthcare entities (doctors, hospitals, etc), they are essentially saying to them, “Hey guys, here’s this big mandate. You better get ready to cough up some dough to meet it.”

    In spite of whatever studies you might wish to cite which show that in the long run these healthcare entities might save money by using electronic health records, there is still a huge up-front cost. By far, the biggest part of that up front cost is the actual software that commercial enterprises are currently offering on the market.

    Naturally, this represents a huge hurdle to any such entity that might be thus affected by the mandate.

    Contrary to popular belief, many hospitals, doctors, etc are currently operating on very thin margins, and in fact many are currently operating at a financial loss.

    Such a huge unfunded mandate could be the final nail in the coffin for many of these entities.

    Naturally, such a huge unfunded government mandate can expect to be met with resistance from the folks on its receiving end.

    So, the natural inclination of the big government crowd will likely be to try and use a carrot and stick approach, offering punishments for those who don’t comply and perhaps offering tax incentives, grant funds, etc to encourage compliance.

    Of course the commercial enterprises you mention all stand to benefit greatly from this (at the expense of the healthcare entities and the taxpayers).

    What I am proposing is that rather than offer silly tax incentives or bureaucracy heavy grants, etc as the carrot, why not simply offer for free download, the software that currently exists, already works and has already been paid for by the taxpayers?

    Ultimately, the rational used by the politicians to try and mandate use of electronic records is supposedly so that healthcare costs will go down and delivery will be safer and more efficient.

    Why should the purpose of pushing for electronic healthcare records be subverted into some sort of corporate welfare program for software vendors?

    As mentioned toward the end of my post, I am in agreement with you that the current corporate entities would certainly do everything in their power to stop my proposal. Naturally, they would love to have their coffers enriched, and my proposal would get in their way in this regard.

    Again, use the Interstate Highways as a model for comparison. Should Eisenhower have simply scrapped the idea because of fear that commercial toll-road enterprises would stand to lose money and therefore lobby against a federal highway system?

    And before somebody tries to say that my proposal is some sort of corporate welfare program for healthcare entities, I say bullocks. Even with the software for free, this will cost plenty of money, time and aggravation for any and all hospitals, doctors, etc that are forced to adopt this software to replace whatever medical records systems they are currently using.

    It will be a giant pain in their ass and in their wallets. Offering a standardized already existing software package for free download would at least soften that blow somewhat. It would also soften the blow to the already strapped taxpayers since this is an electronic health records system that they have already paid several billion dollars for, rather than forcing them to spend billions more for some other system or systems to be developed and implemented.

    Again, thanks for the input.

    And thanks to StanR for directing you this way.

    Sam

  • Kaiser Permanente Northwest has a wonderful system, and all the doctors and nurses love it. When I lived in Southern California, the Kaiser there still used pen/paper, and things took longer than with a chisel! Awful and annoying for all. When we moved, Kaiser SoCal was supposedly supposed to be changing over. Anyway, I have been very pleased with the efficiency for me and my family as patients.

  • Hi Sam,

    I think this is a great idea!

    I’m going to print this post out and mail it to my congressman, my two senators, and to the White House!

    I’m also going to send a link to everyone on my email list and tell them to do the same thing.

    We need more good common sense ideas like this to make their way to D.C.

    Keep the good ideas coming, Doc!!!

  • ATBoy Doc, You have hit it on the head. With this blog, I loved the system that the military uses for their hospitals and clinics. I don’t see why no other civilian or veteran who happens to be a doctor and in the goverment didn’t suggest this before but like you said it wouldn’t go over well with the lobbyist or with those who make emrs. Hope someone will in office will take a look at this plan of your. AND KEEP UP THE GOOD WORK WITH THE IDEAS THAT MY HELP US ALL.

    ###

    Robyn,

    Thanks for your kind words.

    Regarding your hope that someone in office will take a look, I think Joe above has a good idea in his plan to forward the idea to the folks in D.C. and to everyone on his email list.

    I’m content to simply put my ideas up here on the blog, but I’m certainly not opposed to folks directing others here to have a look.

    Cheers,

    Sam

    ###

  • We implemented EMR many years back and the cost was not prohibitive and we are in the process of switching to more unified PM/EMR with patient portal and other bells and whistles.

    Your argument is analogous to PC is much cheaper than MAC computer. I used to be believe in the hype as all of you are believing in the hype that EMR is expensive. Well, after switching to a more expensive MAC, I actually saved quite a lot of money. Here is how: No virus, no blue screen of death (BSOD), very reliable hardware (my MacPro is over 4 years old), and I actually use it to be very productive. If I had a much cheaper PC, I would have spent countless hours trying to fix and have very little time to actually work.

    EMR/EHR are the same way. You get what you pay for. Obviously a well developed EMR (eClinicalWorks, AllScripts etc) will save countless hours for the doctor in the long run, better patient care (ePrescribing, Drug interaction, pre-built database queries, patient access to charts by web, chart access to MD at home, PDA etc).

    It is very interesting that people like us who implemented EMR/EHR are quite happy but you see articles from Docs who are afraid of making the switch to EMR.

    I believe these Docs should stop griping, grow up and get EMR/EHR.

    IMHO

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