The first thing I noticed when I walked into the physician’s office were the tall cabinets filled with manila folders, tabbed with names and organized alphabetically. There were three of these cabinets, taking up the entire length of the back wall, filled with hundreds upon hundreds of patients’ records.
“I see you still have paper records. Do you plan on implementing an EHR anytime soon?” I inquired.
The doctor paused for a moment and said, “No, not really.” Surprised, I inquired why.
“Well, there are a couple of things holding me back. The first is cost. There’s an initial set-up fee, a maintenance fee, a technical support fee, a hardware and software fee. The fees just keep piling up and it isn’t sustainable for a small practice like mine. Second is compatibility. The local hospital here uses Epic, but we use an Allscripts based system for logging in patients. It’s not a full-fledged EHR, but the point is that it isn’t the same as Epic. There’s a lot of training involved in using all these programs, which means you need time to learn – time I don’t have.”
I shadowed him for the rest of the day, watching as he spent a good five minutes writing down pertinent information after every patient encounter. By the end of the day, I realized in the four hours that I had shadowed him, nearly an entire hour had been dedicated to writing. Wouldn’t an EHR system make his workflow a lot smoother?
Today, we have a plethora of new EHR systems – Allscripts, Epic, GE, ADP, and MediTouch are just a few of the many brands available. As a relatively new market opportunity, there are bound to be hundreds of offerings from all sorts of companies, big and small. Navigating this sea would be difficult for any physician pressed for time. A recent study on EHR adoption in New York, the state with the most incentives for EHR implementation, showed that even hospitals had adoption rates no higher than 25%. If the big budget hospitals can’t adopt it, why would independent physicians?
What’s more interesting, however, is the incompatibility between the market economics of emerging EHRs and the realities of medicine. Medicine, at its core, is about sharing helpful information through uniform and easily accessible scientific channels. Free market capitalism is essentially a competition for dollars that leads to product diversification and stratification over a long period of time. With the introduction of 32 million newly insured patients with the Affordable Care Act of 2010, the need for streamlined patient information is greater than ever before. If EHRs are going to flourish in the rapidly expanding world of medicine, we’re going to have to quickly implement two very anti-capitalistic initiatives: standardization and consolidation. I’ll explain momentarily.
Medical history is a mobile platform that moves with the patient. Considering the extent to which patients see various specialists, physicians need to employ patient-centric records that are easily transferred from one physician to the next in any clinical setting. This means a patient’s information from a primary care physician’s office should seamlessly integrate with whichever hospital or clinic that patient visits.
The Health Information Technology for Economic and Clinical Health Act of 2009 already attempts to enact this seamless transition by requiring EHR companies to build up software on standardized data formats. Congress rewards physicians who employ such EHRs with financial incentives, calling their decision an example of “meaningful” use of medical technology.
While this level of standardization is progressive, I would suggest we take it further – the user interface for EHRs should be uniform in geographic areas, if not nationally. It makes no sense that local clinics use Allscripts while the nearby hospital uses Epic, especially when physicians practice in both places. Asking physicians to orient themselves to a new user-interface every time they visit the hospital or clinic would be a waste of time and money. Even if the underlying data transitioned smoothly, the physician can’t access it as easily as on the EHR he or she was trained with. The usefulness of that patient information becomes moot.
What makes more sense is employing a uniform EHR throughout a geographic area such as a large city or county. As you expand the geographic boundary requiring a uniform EHR within, physicians practicing in that area will have an easier time consulting at hospitals and clinical local to them. No time will be wasted learning new program interfaces, which translates into more time with patients.
Capitalists would be eager to point out that as the EHR market is allowed to develop independently, a dominant EHR platform will emerge and the entire idea of a geographic EHR will be useless. While that’s true, it would take an exceedingly long time for any one EHR to jump to prominence. With newly insured patients flooding physicians’ offices, rules that can be quickly and easily implemented have to be put into play. A regional EHR is one such rule. If, in ten years, the inevitable dominant EHR develops, then we can reconsider our options.
This is where the concept of consolidation gains importance as well. Currently, EHR companies independently vie for individual physician choice, but, given the amount of EHRs, inadvertently make physicians’ choices difficult. The cost of having an incompatible EHR with local medical establishments can outweigh the benefit of having an EHR in the first place.
Regional EHRs will pave the way for a new business model that will likely be more successful than current ones. In this new model, companies can propose enterprise-class EHR software for a geographic area, which will directly lead to system-wide savings through regional consolidation. Local physicians will pay lighter fees into a pool for regional EHR hardware, software, maintenance, and technical support instead of taking on larger fees for a private EHR system. EHR companies benefit by having steady and stable micro-market dominance. When it comes to EHRs, value stems from uniformity.
Of course, nothing is simple when it comes to healthcare in America. HMOs, PPOs, and other insurance schemes may restrict patient mobility. For example, Kaiser Permanente, one of the nation’s largest HMOs, has their own EHR called KP HealthConnect. It allows for all Kaiser Permanente hospitals and physicians to access any Kaiser Permanente patient’s records. Any patient outside of Kaiser’s HMO policy may not be in the system. Having an EHR tied to an insurance policy makes it difficult to supply healthcare to patients who enter the emergency department without Kaiser coverage. This not only complicates the physician’s job, but may put the patient at risk. Furthermore, any single geographic area is likely to have multiple hospitals that accept a number of insurance policies. Restricting a hospital to a private EHR would hinder its ability to properly serve the public in this regard.
Healthcare is radically changing in the 21st century. We have more patients, fewer physicians, and less time for them to interact. If we want EHRs to have a substantive impact on healthcare, they need to be regionally standardized and consolidated. Only then can we be sure that EHRs will increase physician efficiency and efficacy while improving patient mobility.
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