There has been substantial discussion about electronic health records (EHR) recently, much of it revolving around the application of stimulus funding to support implementation. But the real issues surrounding deployment make funding the simplest step of all.
A successful deployment of a fully integrated EHR/EMR (electronic medical record) system for U.S. citizens would have benefits, but much of what is being discussed falls short of the rhetoric on the nightly news, in articles, and on blogs. For instance, the Health Information and Management Systems Society (HIMSS) conference last month promised a bright future for the implementation of EHR systems, buoyed by American Recovery and Reinvestment Act (ARRA) funds, but that’s only part of the story.
Funding is available, but it comes at a price. The funding is slated for hospitals (referred to by the government as “meaningful EHR users”) and physicians must commit to working with a hospital exclusively in order to obtain funds for EHR. Further, the ARRA funding will sunset in 2013, after which the physicians will need to fund support of systems themselves. Costs will include continued software licensing costs and upgrades to hardware; added storage; training staff to use the systems; compliance with privacy issues; off-site storage of data; and so on.
That leaves a lot in the lurch. Patients with chronic conditions may have been in treatment for years, resulting in substantial amounts of information requiring conversion to electronic form from paper. A failure to convert prior records results in an incomplete picture of a patient’s medical history and the potential for improper diagnosis of conditions and care.
Any of this information in electronic form may be in proprietary formats, or unavailable because it belongs to other hospitals or unaligned providers. And going forward, who pays for conversion of records for these patients once the physicians are no longer associated with these hospitals? Patients are living longer, and their records must follow them as they relocate, change medical providers, move between insurance companies, and so forth.
Medical record formats change over time, compounding the problem. We can’t easily find record players for LPs, media drives for Bernoulli cartridges, or 8-inch and 5-1/4-inch floppies; and opening an MS Word 93 file is nearly impossible without loss of format, fonts, or other features.
There is also discussion about whether EHR information will be subject to industry best-practices and not legitimate standards. Is there a difference? You bet there is! A best-practice is simply a uniform method of doing something that meets the needs of a group of individuals, an organization, or an industry. A standard, on the other hand, is developed by a group under a rigorous set of requirements; it meets a consensus and is open to public comment and review.
By the way, the federal government has reason to be particularly mindful of these concerns, given that medical records of employees potentially exposed to hazardous conditions must be retained for 75 years beyond separation from employment. For those serving in the military, records retention is permanent.
In summary, the current approach to EHR puts the funding cart before the standards horse. This situation must be reevaluated to avoid spending countless dollars in vain, only to necessitate the continual re-collection and conversion of information due to a lack of a standard interchange format that satisfies all of the participants involved.
And yes, there still are concerns about privacy, but we can talk more about that later…
— Larry Medina has spent 37 years in the Records and Information Management (RIM) profession.
These are the provider problems with the technical application. It definitely will not solve the problem without interoperability and a better definition of reasonable use.
The previous efforts in health information exchanges have spent billions of dollars in building towers of Babel that can't connect with the next piece.
Until there are standards on key information components, standardized billing, security-protected data exchanges, and shared incentives with the providers in "building the database", we will have false starts.
I agree, though, that it is where we must go. If we spend time investing in building the system and also work with the public in incentives in building individual secured personal health records, we might move closer to your vision.
It is essential we get to the point where there is better and continuous information available.
While it may be just the start, I think it's the start of something big ...... and worthwhile. While some may feel their vital info being swiped and/or modified for ill, many healthcare professionals really like the idea, for the advancement of treatments and the conflict of medications.
Imagine having a critical health issue and being on vacation. Suddenly you are rushed to the hospital in this strange city and hospital. And suddenly, the attending physicians are able to determine your allergies and contradictions, even though you may have arrived unaccompanied and perhaps unconscious.
I know one person in my immediate circle whose life could have been in jeopardy and wouldn't have that risk if this were in place.
Larry, it sure sounds impossible, not from a technical standpoint, but from a practical one. I really don't foresee that anyone associated with EHR on the government level will make a sensible decision to smoothe the path in the near future.
Here's a citation to the declaration of 8.7M patients within a closed system (see last paragraph)
Although it IS a closed system, and this article IS from 4 years ago, it gives a good picture of the potential impacts of a failed EHR implementaion, or one hit by something as simple as a power outage.
And again, although it is a closed system, here are some examples of privacy breaches that can still take place- now this isn't to say it couldn't happen with paper based records, but it's easier to place physical controls on them. And YES, improved controls can be placed on electronic records as well, but it's more difficult to manage accees rights when staff changes regularly and patients are aligned with multiple medical professionals. Oh and yes, I have personal experience with this system- my 87 year old mother is a KaiPerm member.
While this doesn't cite any specific provider as being impacted by the Conficker case, it does say "The devices were used in hospitals to allow doctors to view and manipulate high-intensity scans like MRIs and were often found in or near intensive care unit facilities, connected to local area networks with other critical medical devices." which indicates it could have been any medical installation.
It's rather unfair to pick on KaiPerm, but they were the first to "boldly go when no man had gone before" and sure, they're going to experience problems as things progress, but the biggest problem is an early declaration of "Mission Accomplished"... and this has lowered the approval ratings of others as well.
Here's a blog from a practicing physician, complete with comments from other medical professionals on the problems experienced implementing EHR/EMR even with stimulus funding being promised.
Don't get me wrong, IT'S NOT IMPOSSIBLE and IT IS IMPORTANT... but a smoothly paved path is much easier to learn to walk on, and once you walk, THEN you can consider running.
Wow, John. Can you confirm that Kaiser P is really only using its EHR "for only 8.6 patients within a closed system"?
If government bureaucracy is still arguing over the shape of the table they should use for standards meetings, I can't see adoption of sensible technologies anytime soon.
Between you and Larry, I don't see much hope for EHR in our lifetime.
Although I have no argument with Larry's points I have some of my own to add. After being involved in Electronic Health Records (EHRs) since 1968 in one way or another, I have asked myself, "Why has there been so little penetration of EHRs in the US and Canada in all this time?”
I believe the answer lies in the fact that EHRs for the most part are perceived to have a greater benefit for “data miners” in organizations than they do for healthcare providers on the front line. This conclusion leads to the need for highly complex, very costly IT “solutions.” Example: Kaiser Permanente has been implementing a company-wide EHR for more than 6 years. The original cost was supposed to be $2B. The cost has now gone well over $4B. Despite the fact that its EHR is being deployed for only 8.6 patients within a closed system, it still isn’t finished.
If we accept the fact that most health data generation occurs at the time of care then the sad fact is that many EHRs degrade or even impede provider workflow. Why? Because the formation of structured data for activities such as coding and cost containment takes precedence over what happens in the examining room. To some extent this is also a driving force behind EHR interoperability. From a strictly clinical viewpoint, providers (physicians, nurses, etc.) simply need to be able to easily view and/or update the information relevant to the episode of care at hand. The fact that complete blood counts (CBCs) from 5 different hospitals might all look slightly different is irrelevant to me as a physician. I can extract what I need in a matter of seconds regardless of where it was created. Ditto for almost any other class of information.
Paper and other analog formats such as X-Ray film are very good for this purpose (witness the fact that Ancient Egyptian papyri are perfectly legible after almost 5,000 years). The problem from a provider’s standpoint is that they are not available 24/7/365.
So why not take a clue from the social networking sites and use two standards that everyone already uses today, namely PDF for static text and images, and Flash for sound and video? Furthermore I can dictate a note no matter what kind it is and have it transcribed either using a human transcriptionist or voice-to-text much faster than I can generate the same note using any menu/macro driven computer-based system.
If we wanted to really get EHRs rolling in the US then we could use these modalities to really kick-start things from the ground up. As long as data miners rule the roost, don’t hold your breath for a truly workable national EHR any time soon.
Too true Mary and they have to ensure the proces is open.
Speaking to a colleague recently, we relaized that although musch is being done here (in the US) and elsewhere (primarily in Canada and the UK) related to EHR, if the manner in which infoirmation is captured isn't open enough to accommodate input form other countries, when an US citizen travels abroad, or a foreign born traveler comes to the US, there will be little (if any) chance for their records to remain complete and in-tact if cared for during those visits.
Also, there is much concern about the lack of a "uniform identifier" for individuals. Even here in the US, where you are supposed to ensure all citizens have an SSN by age one. But for privacy reasons, the SSN is no longer considered the primary source of identification (by law in California). Should there be a concern this doesn't exisat? Yup, and here's examples of why:
Child is born to an unmarried parent, who later gets married- name change
Married couple gets divorced, children go with one parent who remaries and husband elects to adopt children- name change
Couple gets married- name change (possibly)
Couple gets married, divorced, remarried- name change (possibly 3 of them!)
And as mentioned in the original post, changes of physicians, labs, insurance carriers, military service, and on and on... every time one of these changes occurs, there is the potential of alienating records unless a unique identifier is assigned to each individual that remains with them indefinitely until death, and it's NEVER reassigned.
And yes, Terry, this is another brisk splash of water that people need to consider when speaking to their legislators about the need to establish clear Standards for management of EHRs to ensure persistent access.
Thanks for a depressing but thoroughly illuminating post, Larry. Clearly, the fight over who sets standards must be resolved before anything can happen. The problems of EHR are so complex that it's useless to try and please everyone. The government needs to pick the group to address the standards, and go with it. The sooner that starts, the better.
That's quite a bracing splash of frigid water on the whole electronic health records movement, Larry. Maybe a good chunk of what you point out as missing or questionable can be addressed in whatever legislation gets crafted in this reported healthcare "makeover." But long term-funding, coupled with mandatry adeherence to a clear standard should at least be a starting point there.
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