A modest proposal for a truly useful EMR

I love computers. Really, I do. Despite my oft-repeated claims about the shortcomings of electronic medical records in their current form, I do believe that information technology has the potential to be of great help to me and other physicians in providing quality care to Americans.

Stop laughing. I really mean it.

I do not believe, however, that IT best serves the medical needs of our patients when used to create non-interactive silos of information sequestered in the offices and clinics of individual doctors. Even hospitals and large integrated health systems information remains stuck within that system, providing limited utility when patients travel, or even go to a doctor not affiliated with the system.

Although some (especially in government) seem to feel that expanding those kinds of integrated systems is the way to go, the problem is that not all patients want to get their care from Mayo Clinic clones across the country. Still, I have an idea for using currently available technology to vastly improve the way medical care is delivered anywhere in this country.

I would like to see a nation-wide database of:

  • every single laboratory test
  • every diagnostic image
  • every immunization
  • every prescription filled
  • every surgical procedure

received by every single person in this country.

Notice what I don’t want in that database:

  • Diagnoses
  • Allergies
  • Hospitalizations (all the labs and images should go in the database separately)

Lots of people come to me or other new doctors wanting a fresh set of eyes looking at their problems, a mindset that cannot be achieved when looking at a list of previous diagnoses. Not every diagnosis is correct. The allergy record is likewise subject to all kinds of mischief. I’d rather have a database available for objective information only, allowing me to put things together myself.

Notice that I’d like to see diagnostic images on the database, not necessarily including reports. What I’d really like to see is the technology advance to the point where ultrasounds and MRIs become significantly cheaper, and then not require a doctor’s prescription for an MRI. Not so with X-rays and CT scans, though. What’s the difference? Ionizing radiation. Keep that under prescriptive control, especially when a national database makes tracking cumulative radiation doses child’s play.

What about all those “worried well” who want MRIs for every headache and knee sprain? I say, let them. No doctor needed. Let everyone pay for all the ultrasounds and MRIs they want. What’s that, you say? You want a radiologist or another doctor — someone with years of highly specialized training and experience — to interpret the images, explain to you what they show, and make recommendations for further medical care? Well now, that’s not “just an MRI”; that’s a doctor’s visit. But if the images are all online, it speeds things up at the point of care.

Many states, including Pennsylvania, are trying to get state-wide immunization registries up and running. The interfaces aren’t user-friendly enough yet to make it worthwhile trying to access them, either to find or to record patients’ shots. Put it into a great big centralized database, though, and let it replace my office record. Personally, I would love to get out of the immunization business. No more worrying about thousands of dollars of lost inventory from a power outage. Make it part of the culture to get shots routinely at public health clinics.

Can you imagine how much time and effort would be saved if everyone’s med list were online? Not every prescription written, just those filled. It would still be helpful to see the actual bottles and go over with patients which pills they were actually taking, plus all their vitamins and supplements of course, but if you could log on to a national database for a current med list, every office and ER in the country would at least have someplace to start.

The nice thing about surgical procedures is that they’re usually permanent. No more worrying about an acute appy on someone who doesn’t have an appendix, or gallstones in an absent gallbladder. I’ve seen gastric bypass procedures and colostomies reversed, of course, but there are exceptions to every rule. Knowing that someone with chest pain had a stent placed two months ago would be quite handy, though.

I can hear the privacy nazis going berserk. “Anyone could find out anything about anyone! It would be a privacy nightmare!!” No more so than the current situation with things like credit reports. The thing to remember is that right now, anyone can already find out anything about anyone any time they want. That’s the key: they have to want to. If someone wants to find out something about you, make no mistake: perilously little stands in their way. Here’s the thing, though: NO ONE CARES!

Look at it this way: if you or someone you loved were in a horrific traffic accident and landed in a hospital far from home, wouldn’t the availability of this life-saving information far outweigh the theoretical embarrassment of someone finding out you were once tested for HIV? Anyone remember the aftermath of hurricane Katrina? Remember how privacy suddenly took a back seat — hell, it went straight out the window — in favor of expediting appropriate treatment for displaced patients. How much of a non-issue would that have been with the existence of this kind of database?

How about this for security: you need a patient ID number and a valid medical license (like needing two keys for a safe deposit box) to access the system. Set the default patient ID to the last 6 digits of their social security number if you want, then let people change it at will. That way they can go to a new doctor and easily cut the old one(s) out of the picture, if that’s what they want. Try to impress on people how valuable it would be to carry their current ID number in a way that’s easily accessible (wallet card; RF chip; medic alert jewelry) in the event that they are unconscious or otherwise indisposed and in need of medical care.

But who’s going to pay for it, I hear you ask. Tell you what: why not use some of that $73 million set aside by CMS to supposedly pay doctors as incentives to adopt EMRs. Don’t kid yourselves; the way they’ve got things lined up now, perilously few of those dollars are actually going to be paid out, at least to individual doctors. Granted, they’ve finally defined “meaningful use”, but the functions described (ePrescribing — dangerous in its present form; communicating with labs and other health care entities) are basically meaningless. Why not use that money to pay for something that would actually help with patient care?

So there you have it. A modest proposal for a truly useful EMR.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • http://stanleyquan.com Stanley Quan

    I agree. The nation needs a truly integrated health record system. Having all of these separate EMR systems only serves to digitize the current content of an inefficient and “privacy”-minded system. It taps only the slightest potential of the electronic and networked age to improve health care.


    It seems to me that the bottleneck is in a absence of a standardized *.emr format. With the current number of offices isolated from local institutions and each other by differences in their systems the handling of patient information becomes more disorganized than the paper form. Having to view scanned summaries of patient care rendered at institutions outside of the small bubbles of integrated systems is a terrible alternative. But perhaps we are beyond the point of impetus for creating such a system. I hope not.

  • rezmed09

    In the era of WikiLeaks and conspiracy theories, I can’t see this very excellent idea coming to fruition. .

  • Ed

    This is a really great way to see this. Forget all the different workflow issues etc etc etc. It all starts with data and having a full set of data is paramount.

    I wish those in DC would sinply understand the wisdom of your very straightforward suggestion.

  • John Ryan

    Too much money and power already arrayed again your very simple and logical idea. Who would pay for a bloated $45,000 EHR if you could just go online and review all the data? Very scary for the DC lobbyists, especially those EHR company executives who are cozy with Obama (like Glen Tullman of Allscripts-Misys & Todd Park, board member of athenahealth).

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    Well, we could encourage our patients to put their own objective data in the Google cloud, and carry their password, so it would be available to anyone who finds them lying around unconscious.

  • http://diagnosticinformationsystem.com Bob Coli, MD

    It is already technically feasible to input the results of the more than 30 billion patient diagnostic tests done annually in the U.S. into a searchable, centralized or decentralized (federated) database. (1)

    Unfortunately, the hundreds of vendors of ambulatory and hospital EHR, HIE and PHR platforms (2) are all still using infinitely variable formats to report the results of the tests done in ambulatory and hospital clinical labs and subspecialty testing facilities as incomplete, fragmented data that is hard to read and analyze.

    This is a costly and dangerous anachronism because test results constitute some 70 to 80 percent of data contained in a medical record and approximately 70 percent of clinical decision-making is based on or assisted by test results. (3)

    From the physician workflow, unnecessary testing cost reduction and patient safety perspectives, a major usability upgrade of the tests results user interface would support the efforts to achieve efficient and meaningful EHR, HIE and PHR use and create and sustain a national consumer-centered, value-driven accountable healthcare market.

    Unlike the HIT system vendors, Stanley Quan, ABADCAFE and many other physicians understand both the clinical need and the logical solution. What EHR, HIE and PHR end users need to efficiently view and share this key content is a standardized reporting format for all test results that is vendor and platform-neutral and is able to display complete, easily read, clinically integrated information on 50 to 80 percent fewer screens.

    Although physician input on improving EHR usability has been very limited to date, it will be interesting to see if the combination of emerging HIT vendor competition and government fiat will help catalyze this particular disruptive clinical technology innovation.

    (1) http://www.ehealthinitiative.org/2010-survey-health-information-exchange.html
    (2) http://onc-chpl.force.com/ehrcert/chplhome
    (3) http://www.chcf.org/~/media/Files/PDF/E/PDF%20ElectronicLabResultsExchangePolicy.pdf (page 2)

  • A Davis

    Nice idea. Not a snowball’s chance in he77 we’ll see it in our lifetime.

    The gov’t doesn’t want it. Patient care is low on their list of priorities. Their primary motivation is being able to justify the funds they pay out to members of Congress who ask why costs are so high.

    EMR vendors don’t want it. As pointed out, they can’t continue to charge the fees they do if anyone can look up any data any time. It’s no different than Microsoft “upgrading” Word to a new an incompatible format every 2-3 years – why would the average user by the new version if it were compatible with the old one?

    Insurers don’t want it. They have the programming staff and computing power to translate and read any record they choose to already, and it’s to their advantage to be able to read more data than doctors. Since their prices (and margins) are more or less fixed at the state (and now, the federal) level, the only way they can grow their profits is to ensure that the total cost of care grows; they tend to skim off pretty much the same percentage amount over several years.

    Hospitals don’t want it. Like the govt, they don’t really care about EMRs as health care tools, but rather as insurance/payment/internal efficiency tools. In terms of having vendors spend money on anything, including adopting a national standard, they are opposed to it because the costs get transferred to them.

    Patients don’t want it. The notion of a Personal Health Record was “pie in the sky” coming out of the gate, and the less than 1% adoption rates seen after 5 years of Google and Microsoft working on the project proves it’s a dead dog. Without a PHR, patients have no reason to care, other than to hope that any additional costs are avoided.

    Insurance purchasers (i.e. employers) do care, but they have enough business sense to recognize that advocating for it against the entrenched powers that be is a losing proposition. As long as they can pass on the costs of inefficiencies to both employees and customers, they won’t bother…

    Regulatory agencies are opposed. TJC prefers inscrutability in all their decision making, and to the extent that large scale data is available, it allows outsiders to potentially question their decision making process. If the government cared, TJC would care, but until that happens they’re perfectly happy with the way things are, despite what they say.

  • http://www.movetoemr.com Leo Bletnitsky

    This issue is similar to what came first, the chicken or the egg.

    In order to be able to have a national or regional database of valid useful patient data, a much higher percentage of providers need to move from paper charts to an EMR. Unfortunately, many providers point to a lack of a national database to connect to as one of the reasons to not adopt an electronic system.

    As many EMR/EHR systems have dramatically improved and continue to do so and the first rounds of ARRA money get paid out, we will see the scales tip over the next 5-7 years toward electronic systems. At that point, a HIE/RHIO or a national system of data interoperability will be possible and useful.

    Another thing to consider is that patients will start to push for ePrescribing and EMR’s and practices without will become the oddity they are in dentistry now (and that was without any stimulus money).