EHRs need to talk to each other, but make sure they work first

I’ve written several times before about my love/hate status with my EMR. While I enjoy using mine, I long for it’s usefulness to get to the next level. While the EMR is useful at tracking data, it’s greatest handicap right now, is that it can’t talk to other systems. Data is still locked in individual systems and can’t be shared across platforms. This lack of interoperability has thus far been the EMR’s greatest handicap, and I have longed for the time when EMRs are able to share data.

But as I see more and more systems being employed in my area and talk with other physicians about their experiences, I am becoming increasingly concerned that  the inexorable march forward is going too quickly.

Shouldn’t we get these systems right before introducing interoperability into the equation?

The administration and the public are now clamoring that the information in these systems should be able to be shared among providers. In effect, that the information should not be “held hostage” by each providers respective system. These are fair and reasonable requests that should be expected in the long run. To that end, some EHR vendors have agreed in principle to begin writing standards that would allow interoperability between systems.

The unfortunate problem here, and one that the public does not understand, is that these systems are not like the  computer operating systems that they accustomed to using. It’s easy to forget that Microsoft, Word, Windows, PowerPoint, and Macs are more than 20 years old.  They’ve gone through several generations and hundreds of billions of dollars in development by the worlds most talented programmers. All to now finally be at a point where the program does not routinely stop working for some unknown reason.

In December 2012, Microsoft made $21 billion in revenue. In the same period, Cerner, one of the largest health IT outfits just made 3% of that. How could anyone reasonably expect that  Cerner could put out a system in it’s first generation that is anywhere near as well thought out and user friendly as a current Microsoft or Apple product?

The $27 billion that the administration put aside in the 2009 stimulus bill included certain stipulations in order for EHRs to qualify for government subsidies. These stipulations, also known as “meaningful use,” are being rolled out in several phases. They include several measures of functionality in order to document and track health care quality measures with the hope that they could be used to improve patient care. Among these measures were financial penalties for physicians who did not adopt the systems.

From the time the bill went into effect,  the race was on. Health IT companies have cobbled together a growing healthcare IT infrastructure which is being adopted by physicians on a massive scale. To the EHR vendors, it’s been a buffet. All they had to do was create systems that met those specific meaningful use targets that the government had created, and physicians would have no choice but to purchase them. Unfortunately several important parameters were not included among these targets.

For example there was no requirement that the systems be good.

There was no requirement that the systems be intuitive, or time saving, or reliable. There was no requirement that the systems should not stop working inexplicably, or that they work with your printer, or your fax machine.

Don’t get me wrong, I’m relatively happy with my system, I never want to go back to the days of dictating every patient encounter in the office. But my system was in place long before the government got involved, and we’ve had years to refine it to our specific needs. Most other physicians have not had that luxury. Furthermore we are a small office with only a few users, not a large hospital or hospital system which must apply the technology on a large scale to be used by thousands of people.

In places like those, and in small physicians offices where physicians are new to the technology, things are getting pretty ugly.

Most physicians are not happy with the systems currently in place. They knew that these would be first generation systems which would need to be refined. But they expected that at least the systems would be designed around physicians, and be intuitive.

Instead many physicians now  feel that they’re being forced to buy overpriced, sub-standard, half-baked systems designed by polytech school dropouts.

What is it like to use these systems? Put yourself back in 1990 in front of a  Windows 3 machine, to give yourself a good picture of the “modern” EHR experience.

Should EHRs talk to each other? Yes, absolutely. But they have to work first.

Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.  He can be reached on Twitter @Caduceusblogger.

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  • ninguem

    You need OPERABILITY before worrying about INTEROPERABILITY.

    • buzzkillerjsmith

      Very well put. And the thing that Dr. R ignores is that a big part of it is simply the typing. Typing is slower than dictating or writing. An extra hour or two in the clinic. And Dragon doesn’t work for a lot of people.

      I know of a peds who does her typing on vacation, when she’s out of town and such. This is a lot to ask of people.

      An ophtho where I used to work has a scribe.

  • Margalit Gur-Arie

    The “public” doesn’t clamor for anything (other than obtaining reasonably priced medical care). The interoperability hype is artificially induced by professional “patient representatives”, because we “believe” that exchanging information in this particular way (as opposed to fax and phone) will reduce costs and improve quality (and there are tons of money to be made here). Perhaps it will, eventually, maybe…. hopefully…..

    • ninguem

      The vast overwhelming majority of people have medical histories, that they could care less if the information were on the front page of the New York Times.

      Every day I run into people who seem more than anxious to publicize their medical history to anyone within earshot.

      Those people, put the medical history in a text file on a smart phone, a flash drive, and it’s nothing more than a high-tech version of a MedicAlert bracelet.

      Agree completely, the biggest advocates for the national health information database, have strong vested interested in profiting from such a system.

  • Guest

    “The administration and the public are now clamoring that the information
    in these systems should be able to be shared among providers.”

    As a member of the public, I am not “clamoring” for any such thing. I don’t want the world and its dog to have access to my private medical information (uncorrectable errors and all), and I don’t see how it would benefit ME in terms of either cost or quality of care received if they did.

    Of the top ten things I’d like to see improved in our health system, having all of my private medical details available for data-mining by faceless strangers is not up there.

  • Guest

    Only use Google products if your patients are happy with government functionaries and their clerks pawing through their personal medical records, and passing them on (without warrants!) to anyone who asks nicely.

    • Michael Chen, MD

      I’m not suggesting that Google products should be used for personal health information. Just using Google as an example of the available technologies that exist that is being used in other industries to provide a modern user interface for doctors without being tied down to specific computer devices or operating systems. Like my open source project.

  • Tom Garvey, MD

    Recently, a patient who was on vacation paged me with very worrying symptoms. I told him to go immediately to the nearest emergency room. I then printed out a face sheet containing his diagnoses, medications, adverse drug reactions, and most recent vitals and labs. I then called the emergency room to which he was headed and spoke to the attending physician. This physician later informed my patient that my thorough handoff was part of what saved his life.

    This should not have been a remarkable handoff. There should be interoperability so that the information exchange is instantaneous and automatic even when I am not near a fax machine and do not have access to the medical record.

    In every other aspect of society, your privacy is for sale to anyone who wants to violate it. Only in medicine, where effective information exchange can save lives, is privacy protected so jealously. There are endless administrative costs, delays, redundancies, and avoidable errors created by medical information siloing. I don’t just mean notes (which are burdensome to enter into any system). I mean radiology, current and previous med lists, adverse drug reactions, diagnoses, other providers’ contact information, patient contact information and next of kin. Don’t think this is important? How well do you think a hospital would work if, every time a new doctor walked into your room, they had to gather and record this information from scratch? How much extra time and money would they burn repeating studies or consults that had already been done or trying medications that someone else has figured out do not work for you? How much more likely would you be to die if some important information were not available to them? That’s what happens every time you move between systems without interoperability.

    Sophisticated patients can mitigate this somewhat by keeping their own copy of important health history, but if you have had a serious illness, your history quickly becomes immensely complicated. It is hard for even a medical professional to always know what parts will be important. This is nothing compared to the challenge for those who are just not sophisticated in the ways of medicine or computers or the people who tend to be the sickest–patients who are demented or otherwise intellectually or psychiatrically impaired.

    Calling that ER physician was no heroic act. It was doable because I happened to be in a location where the information was easily accessible, and I had the time and means to transmit it. But such handoffs are not common. That is a shame on our system.

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