In MRI's first eNewsletter, CEO
-Cost
-Information Capture
-Legality
-Information Exchange
-Continuity of Care
According to Waegemann, "It is time for all the committees, associations, and others who are touting EMRs to confront this dismal picture of health IT implementation and the reasons behind it."
What are your thoughts?
7 comments:
Nicely stated, Peter.
Curtice Wong, MD
Peter,
Thank you for calling the question as to what's wrong with our current strategy. You correctly identify several reasons for this poor showing. However, you left out a key area, that unfortunately is overlooked by so many systems, and that area is usability. For example, does the system reflect the mental model of the physician entering or accessing data, how easy is it for other staff members to get on board? I've addressed this concern for usability in several presentations at MRI conferences. Until this issue is adequately addressed by all players in the EMR field, the impact will continue to be an illusive goal.
Hal Miller-Jacobs, PhD
hal@usabilityCoach.com
Peter,
Many organizations are struggling financially and do not have the capital to invest in multi million dollar electronic medical record systems.
There are many assumptions about the benefits but quantifiable ROI is elusive. One could draw some assumptions about the benefits by simply looking at the nine clusters of functionalities. One could simply state that the investment is a current cost of providing health care. One hears that patient safety will be “enhanced”; that revenue will be maintained (P4P); or that transcription cost will be eliminated. Does the Institute have a summary of key motivators for taking the enormous risk of investing in EMRs if the actual utilization of them is in doubt?
Cory Gehrke
IMS Manager
Dear Cory:
Thank you for an important question. Principally, an EMR System brings your organization into the computer age. The various functions of EMR systems should help in a number of aspects from drug-to-drug interactions to better care processes. In general, the benefits practices have experienced fall into seven categories: (1) More money/savings/ROI, (2) Better competitiveness, (3) Remote working benefits, (4) Workflow benefits, (5) Better decision support, (6) Better information about patients, 7) Improved quality of care.
Not everyone is achieving each one of these benefits. That your organization should move to EMR is a given. The difficulty is selecting the right path for implementation. Maybe a comprehensive ‘big bang’ plan is not the best plan. Look at applications at your such as replacing transcription with speech recognition, link your outpatient services and visiting nurse activities to full interoperability, and so on.
But the longer your organization waits with the implementation, the harder it will get.
Peter Waegemann
Dear Peter,
I have questioned the viability of the current EMR business model as it applies to the ambulatory market for years now, as during that time doctors consistently complained that the products cost too much and were too disruptive to their practice and personal lives. The industry response to this was to blame the doctors for their obstinacy and establish a standards-setting body to make the products even more complicated and more expensive.
I propose that rather than try to solve the problem of lack of electronic records in healthcare as defined largely by academics, we support the development of solutions that specifically target removing discrete points of pain of physicians and patients in the system. It is far faster and cheaper to solve large problems by breaking them down into small manageable pieces than it is to design and implement single monolithic system solutions – think Crawl first, then Walk, then Run. Anyone who questions this notion should go back and review the spectacular failure of Healtheon for an extreme example. Our National EMR Strategy so far has been akin to seeking solutions to boil the ocean.
For example, by your own admission, most EMR information capture schemes require additional time commitment from doctors, but this is not the whole story. The frustration experienced by most doctors in trying to navigate EMR user interfaces causes such a distraction that productivity losses go beyond the actual time spent on the process. We have a doctor colleague who summarized his EMR experience, “I like having the record available on line, but I am absolutely exhausted at the end of the day from the extra time spent trying to get it there”. This is nonsense – we are turning the most expensive resource in the healthcare delivery system into a data-entry clerk to collect information that all too often won’t be used by anyone.
So how could this work? First, let’s agree to put all ideas back on the table – the open and honest discussion you call for. You identify “health informatics myths”. A huge myth is one you continue to advance: that medical transcription is a waste of billions of dollars. The fact is that as a process, medical transcription provides a significant ROI in direct savings of scarce doctor time. According to US Department of Labor compensation surveys, doctors’ earnings are on average six-to-eight times that of medical transcriptionists. The use of transcriptionists to capture doctor’s thoughts is not the issue.
It gets worse. The New England Journal of Medicine published an article in May 2008 entitled “Avoiding the Pitfalls of Going Electronic” citing systemic problems with EMR system documentation that is not only harder to extract meaning from, but which is often just flat wrong, as doctors try to find ways to shorten the time-consuming processes required by these systems.
If we really want to see broad adoption of electronic records, we need to address the ambulatory segment – it is the largest and most fragmented portion of the market. Consider that 80% of last years’ 1.3 billion patient visits in the US took place in ambulatory settings, and 75% of those ambulatory visits were to practices with 5 or fewer physicians. This is not a demographic with the IT infrastructure to support complex IT environments required to run a CCHIT-certified EMR system. Guess what? With current technological developments and industry trends, they don’t have to.
There is a very simple transitionary opportunity readily available with current processes and technology. Let’s let doctors use any information capture they want to use, including traditional dictation and transcription – the method preferred by some 90% of practicing physicians. There is perfectly good technology already being used by most good transcription companies to capture and store the transcribed notes in digitally useful form. From this starting place, we can add functions at whatever pace doctors have a reason to do so at very low cost.
There are now some very powerful bridging technologies that provide surprising functionality without turning a practice upside down to implement. I define bridging technologies as tools that help us get from a process that we use today to a different process that holds the promise of great reward, but the path to which appears daunting. Here are three that together when coupled with transcription address four of five areas of concern that you cite:
1. The Internet is a remarkably cheap, fast and secure tool for moving around large amounts of data quickly and safely. An infrastructure that cost tens of thousands of dollars ten years ago is now at your disposal for $29.95/month. And that infrastructure allows you to communicate with your vendors, your colleagues and your patients. But what about HIPAA security issues? Financial institutions have for years routinely used the Internet to communicate data that is every bit as security-sensitive as personal health information. It is time to embrace the Internet as our communication system.
2. Secure, web-based document repositories/data management systems can provide startling amounts of productivity gains for many practices, and they don’t cost much. Some transcription companies provide this as part of their service offerings. Benefits include faster turn-around of chart notes, ready access to charts and related documents by multiple users (practice staff don’t have to wait in line for their turn at the chart folders) and remote, secure access by physicians from any computer with Internet access. Any practice can have this access quickly and easily with little or no disruption to physician routines.
3. Web services, HL7 and XML data-tagging facilitate data exchange within and between different systems with comparative ease (compared to conventional practice, in any case). Large legacy vendors collect big fees for their interfaces to other systems, when they provide them at all because, well, because they can. But systems that are built on closed-architecture databases will not significantly penetrate that large mainstream market, precisely because they are self-limiting. Don’t expect the current industry leaders to get together next month and agree to publish a useful open standard – they have too much invested in the status quo and most companies just don’t eat their young. But it won’t matter, because the new generation of systems won’t have the limitations of closed systems.
These technologies added to contemporary transcription platforms largely constitute what the NEJM defined as a “basic EMR”. The result would be low-cost, easy-to-implement, easy-to-use solutions that have a reasonable chance for rapid adoption, and that provide a bridge to more sophisticated functionality as users are ready.
We have a mostly market-based healthcare delivery system and it is time to look for market-based solutions to upgrade processes and systems. I don’t know that there is universal agreement with your assertion that “continuity of care must become the prime objective for health IT”. But I do know that this is much too vague a goal on which a purchaser of health IT products can rely to make informed decisions on the ROI potential from system investments. We don’t need to reconvene committees of vested interests to make this work. We need to let the market do what it does best: matches people with definable problems with creative people providing targeted solutions.
Respectfully submitted,
Thomas Carson
Very good article.
However, the sociotechnical issues that impeded clinical IT appear not to be mentioned.
A national strategy must take into account these issues, written about by social scientists studying IT (of all types) for decades, or else the nation should expect to relearn these lessons at great cost and at risk of failure.
It is not inconceivable that repeated problems and failures will end the current exuberance for clinical IT; high momentum cannot persist indefinitely.
I believe the clause in the proposed House Energy & Commerce PRO(TECH)T Act of 2008 (H.R. 6357) that calls on ONC to prepare a report on "lessons learned" from HIT implementation begins to recognize this issue.
Mr. Waegemann:
I agree that a central issue in the slow migration to EMRs is the issue of Information Capture. To capture clinical data, you need to get the buy-in of clinicians and offer them a superior alternative to paper charting. Electronic charting must be faster than paper charting and must add value. The user interface should be in familiar clinical format and easy to use. The value added would include guidance for data entry relevant to the clinical encounter (office or ER visit, hospital admission) and feedback as to the relevance of the clinical finding. Electronic charting should be universally available (Internet), and mobile.
By using the clinical format for the EMR, the basis of Functionality and Information Exchange are addressed. Chart elements (Present Illness, Exam, Lab, etc), Organ Systems and Clinical Findings are universal in healthcare and have been already standardized. These standardized units are easily exchangeable between organizations and proprietary systems through XML.
By making EMRs free, costs are eliminated as an issue for clinicians. The financial burden of providing EMRs can be born by ads.
As a physician with 40 years in healthcare, I feel that the road to quality and lower costs is through Internet-based healthcare. I have developed on-line clinical charting with encounter-based prompts on a single screen, without requiring repeated "submits" to the server. My web site umsource.com presents clinician-centric electronic charting.
Thanks you.
Peter Stangel MD FCCP
peterstangelmd@umsource.com
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