We aren’t getting our money’s worth from electronic medical records

How many people would purchase phones if those phones only communicated with other phones in their household? Would a postal service create sufficient value if you could only send letters within your town? Would the value obtained by purchasing a $20,000 car that included a powerful engine, nice audio system, seats with lumbar support and a great air conditioner justify purchase if, after the fact, you learned that to be able to drive from the showroom to your home, you would have to buy a transmission at an additional cost of $10,000 when your total budget limited you to $22,000 and the salesman knew this at the start?

I suspect that you answered, “No!”

Why are we willing to spend millions on electronic medical record systems that offer similar restricted opportunities? Why does the market not demand that the stated purchase price for an electronic medical record system include the cost of various interfaces necessary to communicate with other applications, both inside and outside the organization, in a language-neutral manner? Why do healthcare administrators accept these hidden costs and the subsequent reality of purchases unable to fulfill organization information requirements after the ink has dried on the purchase contract?

Electronic medical records are one component of the digital bouillabaisse needed to launch us into the digitized future of health care. But absent certain vital components, this disruptive technology will remain pie in the sky—and disrupting to clinical work. Electronic records sold in this fragmented, constrained fashion will be an inordinately expensive way to deliver the value they are capable of delivering for financially struggling healthcare organizations.

And despite initial government help with the purchase of such systems, given that the biggest costs of IT systems accrue after purchase, where will the necessary money for those ongoing costs come from? The US healthcare system has significantly cut its direct care staff due to lack of funds. Moreover, consistent demonstration of sustainable savings and improvements to safety and quality resulting from the use of such IT systems is lacking, especially when deployed in resource-constrained organizations.

Which brings us back to the question of why are we willing to pay all this money yet get such limited return on our investment?  If the ‘90’s could be distilled by “it’s the economy, stupid,” then the present might boil down to, “it’s market demand, stupid!”

Those who purchase these systems should carefully consider the terms they are willing to accept…and that means getting healthcare administrators and executives up to speed on enterprise IT concerns, the cognitive science (hence patient safety and care of quality) implications of clinical information systems, the need for user-centered design, etc. It also means rejecting contractual terms that protect IT vendors from the fallout of poorly executed IT products taken to market.

It’s time to raise the bar of expectation so that the systems purchased perform properly and fully at a price that the healthcare sector— especially its smaller, less well resourced organizations—can afford.

Barbara J. Moore is a pediatric pulmonologist and medical informaticist. She is a clinical adjunct faculty member of Northeastern University’s Masters Program in Health Informatics and consults for healthcare information technology companies and healthcare providers.

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  • Anonymous

    In my geographic area, the major hospitals and healthcare providers have been working together to integrate a singular HIMS system.  So if you are seen in the ER of Healthcare system A and have a follow up appt with your physician in Healtcare system B the following day, the physician has access to the ER record.  This is being done under the understanding that the patient is the owner of the record and has the right to grant access at the point of care delivery.

    Understand that this is an initiative between competing providers to facilitate health care.  The initiative is so important that hospitals are providing access to smaller physician practices.  The HIMS does not want to worry about smaller practices (less than 35 physicians) and are facilitating access to smaller clinics. 

    This is a regional initiative and all hospitals have agreed to this integration, even though some hospitals that still have paper charts.  It is a model of cooperative effort.  It has begun to be implemented and two systems have integrated. All hospitals will be integrated by 2013.  I expect this will go state wide and probably nationwide at some time in the future. .

    • Anonymous

      We definitely need organizations to be willing to share their data or interoperability is a non-starter. But if the EMR does not include the appropriate interfaces, the organizations can’t get data into…or out of their EMR.  So, organizations need to be smarter about what they purchase and the price to do so has to be within the reach of more than just the big players. Small physician practices, safety net hospitals, rural hospitals, etc. should not be priced out of useful systems…

      • http://twitter.com/bayscribeV6 BayScribe, Inc.

        Willingness to share data is paramount, but willingness alone won’t solve the challenges of interoperability and Collaborative Care. EMR is a stepping stone to HIE/Collab Care and ACO, and until facilities wake up and realize that there is more than one way (EMR) to get structured data physicians will continue to not use EMRs because of the inefficiency.

        Structured Data — Interoperable Data — does not have to originate from an EMR. Physicians can dictate and hand-write notes and still generate Structured Data.  Maybe facilities should focus more on solving the ‘where-the-rubber-meets-the-road’ issue of usability and stop trying to force the EMR issue.

    • http://warmsocks.wordpress.com/ WarmSocks

      That is amazing. 

      Where I live, it’s completely different.  Hospital system A:  if you’re see in the ER and then admitted, the hospitalist and floor nurses don’t have access to your ER records, because the ER uses a different EMR than the rest of the hospital. The hospitalists recognize how inaccurate the EMR is, and insist on sticking with paper charts.  I’ve seen three different doctors in clinics owned by this system, and they all use different EMRs.  That adds up to one hospital system with at least five different EMRs that don’t communicate with one another.  Hospital system B:  even crazier.

      I would love for computerized systems to share basic information such as patient name, dob, vital signs, and meds list after the patient has confirmed that the information has been entered accurately.  Since I haven’t yet seen reliable data entry on those basics, I wouldn’t want bad data in cut&paste notes shared between doctors. 

      • Anonymous

        I agree with you about patient information but the way the system works is just like ordering a chart.  There is no cut and paste you can only view the chart.  Each hospital HIMS is customized to the care delivery system and each maintains a separate chart.  So literally at the follow up visit, the attending has access to the ER chart and real time information.  So, for a simple example, they can see if the patient received a tetanus booster instead of relying on vague information like “they gave me lots of shots with lots of needles.”

        Hope that helps

        • Anonymous

          “So if you are seen in the ER of Healthcare system A and have a follow up appt with your physician in Healtcare system B the following day, the physician has access to the ER record”
          We have a cutting edge system that does a GREAT job of that.

          It’s called a fax machine.

          • Anonymous

            I agree.  Unfortunately it takes someone to actually run the fax machine.  While everyone waits for someone to find the chart, find the record, print said record, and fax same before the end of the day.  Meanwhile front office staff is trying to room patients who are not happy about waiting for the one person who knows how to run the fax to get back from lunch.
            With this system all you need is your laptop…
            It’s called real time for a reason.

          • Anonymous

            If that’s the way your office is run, you have problems that no EMR in the world will solve.

            I’m being a little facetious, but my point is that, in 20 years in practice, I’ve NEVER seen a patient for ER follow-up without their records. I don’t pull up the records in real time, I have them on the chart before I see the patient.

            There is no technology in the world that can replace a well-trained staff.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, the horrible EHR vendors, and yes, it is the market. The people that actually sign the check for an EHR have “slightly” different goals in mind when buying software. Increasing revenue would be one such goal, best achieved by forcing users to document in certain ways. Few if any have had any interest in exchanging information prior to government intervening. EHR vendors built exactly what the market asked them to build.

    The other more delicate point would be that those who live in glass houses should refrain from hurling rocks.

    If you think that EHR vendors’ pricing schemes are deceptive (and they are), how about hospitals’ pricing schemes? Does a patient have even a remote clue on what the final charges will be on any given day? And no, this is not because of evil insurers.
    How about secrecy and protection from fallout of poor execution? Would it be too much to ask if we required hospitals to make public a daily list of “oops” events? I would say that opacity seems to be an industry feature.
    User centered design would be a wonderful thing to have in an EHR. It would also be a wonderful thing to have in a hospital where the user is the patient, but we don’t.

    I’m sure EHR vendors will be working diligently to meet customer changing demands (if they change). I am less sure of hospitals doing the same thing.

    • Anonymous

      I am sorry that is a ridiculous analogy at best. First of all, if you know your history, IT IS the insurance companies and medicare, same folks pushing EHR, that have made billing what it is today. 
      Daily “oops” list…not even worth commenting. 

  • http://profile.yahoo.com/R4QW5RHIJEEG5OQFPL6B37D6BM Barack Hussein Obama

    I’m glad it isn’t so integrated.  You can forget about any privacy once your information is available to the entire medical world that owns an EMR.  I think this business of EMR has gotten way too out of control.  

  • John Henry

    No true “market” demands any of this. The present state of EHR use is not a market phenomenon, with the usual elements of supply and demand, information transparency and the opportunity to calculate a value for money exchange. The makers of EHRs have not had to sell their products on a value basis; they haven’t had to show how their products save money or time or increase patient safety or anything else. EHR is a commanded purchase. The IT companies bribed the federal government, on the promise of eventual data mining opportunities, to compel doctors and hospitals to buy their systems, however they were offered. We were told to purchase under threat of penalty and a thin and difficult to verify promise of support (not reward, mind you.) What was left unstated was the long-term annual additional burden of updating software and hardware that will not be compensated at all out of the “up to $44,000″ available to those who are timely adopt one of these hard-to-like expensive systems, all the while doctors labor under the recurrent threat of unacceptable programmed Medicare cuts, which if ever imposed will at once cause Part B to fail and make the threatened penalties for non-adopters laughably moot.

    • Anonymous

      I agree. It’s government and insurance company mandates that are driving this market and the fluid user friendly product isn’t out there. What is, is costly to establish and maintain. If I really need medical records fast they can be faxed , attached to email, or their important aspects read to my staff via telephone.

    • Anonymous

      I am unclear why doctors would dislike EHR because of alledged market imperfections.  What have physicians ever advocated for that did not further pervert the market for health?

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Yesterday I read for the first time the new Stage 2 criteria proposals for meaningful use. In order for physicians to obtain the  $44,000 incentive reimbursement over 5 years the hoops they have to jump through will get more stringent year to year beginning in 2014. In reviewing my notes of 2 years of courses on the subject this is certainly a fact that was glossed over lightly by all promoting EHR systems and all educating physicians and administrations.

    Had the financing been handled differently by the Feds, by reducing the cost of these systems by $44,000 and promising the software vendors the $44K when the physician offices ( and hospitals) actually achieve and maintain meaningful use criteria then the training of doctors and offices would be more thorough and comprehensive with the software products being far more health care provider friendly. 

    While Margalit is quick to point out how dysfunctional health care spending and billing is, it is counterproductive to use that reasoning to justify just how poor the available software products are, how bad the training of their training personnel is , how inconvenient their call center assistance and help is and how disruptive , demoralizing and costly implementation has been for physicians, hospitals and staffs who are committed to a free flowing integration of medical information in a professional and secure manner.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Dr. Reznick,
      The point I am continuously trying to make is that perfection is nowhere to be found, at least in health care. EHRs are just one more thing that is performing in an unsatisfactory manner, and this is largely due to the fact that the system as a whole is incorrectly managed. There seems to be an unspoken assumption in this industry that buyers of everything from medical care to software are incapable of making decisions on their own and either way, the experts know better and we all should just comply with their decisions for some greater good that is astonishingly devoid of details.

      You have to buy EHRs or suffer a penalty because if you buy an EHR, cost of care will decrease while quality will improve. The average American will have to buy insurance or pay a penalty because if they do, overall cost of care will decrease and quality will improve. How exactly is this going to occur is not clear and there are no indications that systems with EHRs are either cheaper or better, just like there are no indications that  where the individual mandate to purchase insurance has been enacted, health care became cheaper and better.
      We are now told that health care in large systems is cheaper and better, although there is not one shred of credible evidence to that effect either. I fully expect that in a not too distant future, we will be forced to seek care in one of those systems, or… suffer a penalty. Regulations beget regulations.

      IMHO, there should have been no MU incentives. Either the government should have made available a simple EHR for free for all to use, with the benefit of creating a repository of pertinent health data, or it should have paid you directly to collect whichever data they deemed necessary, including “quality” measures. Micromanaging your software purchase, and where you click on which box, and what you ask the patient, and now (MU2) who you refer to and what software the person you refer to should or should not have, is in my opinion preposterous.

      This constant need to adhere to regulations may be optional for you, but it is not optional for EHR vendors and all the customer facing qualities you seek must be pushed to the back burner in favor of compliance, because EHR vendors don’t have infinite resources either, and because you are a captive audience now. Eerily similar to health care in general.

  • John Henry

    The proliferation of EMR vendors is not altogether reassuring. The so-called incentive, more threat than enticement, has permitted a large number of entrants to supply programs to do charting but without any assurance of their longevity or interoperability, both of which must obtain for these products to be of any value to the government. It would have been better had the federal government also insured any end-user/adopter of EHR  against failure of their supplier and abandonment of their product requiring purchase of a different product and conversion of their existing data to a new product’s format, should that be necessary. I strongly suspect there will be vendor failures that will result in orphaned and dead-ended software products and medical practices left with a potentially devastating costs to recover their data and replace their software. This is inevitable, I think. Also, one must consider the cost of system upkeep compared to the cost of paying penalties on Medicare collections. Spending $15-25K annually for system upgrades, IT services, software upgrades and the like might actually be more expensive than taking the hit on Medicare, assuming part B doesn’t tank for other reasons, like the SGR.

  • Anonymous

    We are getting exactly what we are paying for.

    Unfortunately, what we are paying for does nothing to benefit patients or physicians.

  • Chris OhMD

    The majority of physicians consider EMR adoption as a nuisance – something we as physicians are forced to do – however it is a fact that when used correctly, EMRs reduce medical errors, cut down paperwork and actually save money. Just like buying anything else you have to do your due diligence. In my case we’ve been using eCW for 7mth and it has saved money and improved efficiency and I love it. In every other industry IT is heavily used and people embrace it – in healthcare we are so behind in thinking that we see this as a nuisance.

    • Anonymous

      “it is a fact that when used correctly, EMRs reduce medical errors, cut down paperwork and actually save money”

      No, it’s not a fact, and there are no good studies to support your claims.

      • Chris OhMD

        Yes there are no randomized published papers because there are too many variables but as a full time PCP who uses EMRs actively I’m sharing my personal experience – those who cannot see this benefit should seek a consultant who can review your workflow and help you with the process.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          It depends where your starting point is. If the practice is already functioning like a lean and mean machine on paper, there are only incremental gains to be made with current technology.
          This may sound farfetched, but I know of one solo practice where staff (including the Mrs.) take turns vacuuming the floors. The doctor is exempt because he mows the lawn. And everything else is like a Swiss army watch.
          There are other reasons to get an EMR, and they are getting one, but I can guarantee that his efficiency will take a hit in the short term, and his expenses will increase a bit for the long term..

      • Anonymous

        Agreed. I am discovering medical errors I didn’t even know existed. Paperwork has simply become data entry and management, and in much larger quantities. And save money? No way. No one would be complaining as bitterly as they are now if they saved money. That’s why the whole concept had to be shoved down the throats of every doctor and patient in the country.

    • http://www.eepd.info/ Rupert David Fawdry

      EMRs reduce medical errors, cut down paperwork and actually save money.
      That may be true in a single highly controlled from the top organisation.  It will never be true of any electronic system without dictatorial powers. Only a paper record held by the patient will ever have the cost effective flexibility we need

  • Anonymous

    Use of computers/data captured have not gotten integrated uniformly into the medical practice like other professions, so different practitioners have given varying inputs on what EMR’s should do and need not do. Most EMR/EHR have rolled out functionalities that are extensions of administrative management of hospitals. Also due to lack of universal standards bodies to enforce some discipline, products built based on those requirements obviously are fractured and worse are always changing!. So I agree that EMR vendors based on system study should provide a least common factor solution to satisfy the practice requirements and do add-on’s clearly identified during project rollouts. But I also feel the practioners also have to come out and specify what they would expect as the minimal requirements from their practice perspective and make sure majority agree on it so that the software can be built uniformly!.

  • Anonymous

    If I may, as a EHR/EMR software vendor – my goal is to provide the Medical Practice an EHR/EMR solution that fits with their workflow.  I’m not in the ‘game’ to sell my product just to make “another sell”.  I’m in the game to provide value with the products I have and consult with my clients to resolve any pain points within their Practice, such as: the patient encounter, the workflow and/or claim submission processes.

    In my conversations with Providers there are three common pain points – cash flow, non-value-add processes and the budget.  These three pain points are either resolved, streamlined or eliminated with our software solutions, a road map and enhanced skill sets given to the Practice staff. 

    If the EHR software vendor isn’t “listening” to the pain points of your Practice and is just looking to make another sell…show them the door.  These days the key is value, period.  Find a vendor who believes in the value the product provides to the Practice and you’ve got a winner!

  • Phil Sharp

    Thanks for the great post Dr. Moore. I’m a bit saddened by the way that most EMRs charge doctors. There’s obviously a hefty fee up front, and then you get nickeled and dimed the whole way through — having to pay extra for support, maintenance, etc. Frankly, it’s not right. 

    I’ll admit that I’m biased since I work for Practice Fusion, but it seems to me like EMRs should be free AND should offer great support (also for free). Hopefully over the next few years we can move away from systems that cost tens of thousands of dollars, and move towards systems that all doctors can afford.

  • http://profile.yahoo.com/AW4W5L4TRM7BFNLAH7UCCNOELY cl7player

    Well, there is Practice Fusion. It has all of these deficiencies but at least you don’t pay for it.

    Steven D Epstein, DPM
    Lancaster, PA

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    When something has true intrinsic value, you don’t need to subsidize it or force people in order to get them to use it.

  • http://twitter.com/CVillacisMD Cynthia Villacis, MD

    I believe in the POTENTIAL of EMR’s. But we aren’t there yet. There are so many computer glitches in our EMR that it’s hard to believe that it was put on the market – and basic things like being able to have the call center easily tell whether you are in the office or having messages automatically routed to another provider if you aren’t or remembering that a patient needs X test repeated in 3 months and alerting you aren’t options.

    • Anonymous

      It’s the EMR’s responsibility to know who’s in the office?

      That’s a system problem, not an EMR problem.

  • kenneth Milligan

    My undergraduate training is in mathematics and I have experience in computer science. Now being in medical school it puzzles how little is know about open source technologies and the power they have to quickly generate innovative solutions much faster than proprietary software. Not once has any on here mentioned the prospects of OpenEMR or PatientOS providing answers to interoperability or platforms that are more user friendly. Is it that no one know truly what open source is or its potential?

    • Anonymous

      Very good point. 

    • Anonymous

      Being a reasonably educated person, there is no hope of you understanding the current state of EMR. Open source allows user driven dynamics to foster innovation. It would also prohibit the extortion level pricing of the current systems. EMR is a supply side creation. Interoperability is the LAST thing it hopes to achieve, right behind effective patient care.

  • http://profile.yahoo.com/JOF3FVDJ6EHD5V2H2HBHXRXRG4 Chris

    From a nursing perspective, EMRs allow patients to avoid responsibility for their health.  When I ask questions to confirm chronic illnesses and medications more often than not patients will respond “what’s in the computer?”  Patients are unable to discuss their diseases and simply rely on the computer to remember what they have and what medicines they take. 

  • http://www.eepd.info/ Rupert David Fawdry

    When will we all learn that there is a total technological difference between connecting mobile phones and connecting incompatible databases. One is like allowing free speech to be heard at a distance by other people, the other is about trying to connect two utterly rigid incompatible railway systems after they have been created.  The idea that it will ever be cost effective to write and re-write the hundreds of lines of precise computer coding which will allow one complex dataset to ever be “inter-operative” with other complex datasets is the biggest delusion since the banking crisis. However wealthy a country and however sophisticated it IT system the kind of integration dreamed about is never going to be practical.  The fact that many people would like to travel from the UK to Australia in 3 hours instead of 24 hours did not make supersonic travel inevitable, despite the millions of taxpayers money spent on Concorde.  Electronic patient records  may work for doctors such as radiologists or general practitioners in the UK who can spend all day logged on to a single integrated system within one building but any wider use of electronic integration depends on the naive belief of politicians and health care managers combined with the many snake oil salesmen in the IT industry who have never been personally involved with the rigid complexity of computer software coding. For many references to this problem see our article in the Journal of the Royal Society of Medicine Oct 2011 issue.  The only truly inter-operative record is a hand held record carried by the patient themselves e.g. the Pregnancy Health Record carried by all expectant mothers in the UK. No other truly inter-operative record exists anywhere worldwide.  The sooner we all realise that the comprehensive electronic patient record is an IT emperor with no clothes the better off we will be.  Until we do we will all continue to pay through the nose for the impossible.