Monday, June 21, 2010

Deobfuscating HITECH

Software developers sometimes use a technique called obfuscation to protect their intellectual property. They use tools to add, remove and displace the original flow of the code until no human can understand what it does or how it does anything. Judging by the ample confusion expressed by large numbers of physicians, it almost looks like a giant obfuscator has been applied to the HITECH act leaving the medical community to wonder what to do, why do it and how to proceed. The prevailing wisdom is that, for some misguided reason, the Government is paying for EHRs, but there are so many strings attached that it is very unlikely anybody will ever see a dime of the much advertised $44,000.

First we should figure out what these EHRs can do, or more accurately, will one day be able to do.
  1. Store all your paper records electronically in a computer and make them accessible to many other providers of care, including patients. EHRs, if allowed, can also make all your records available to insurers, Government and any other agencies or corporations who manage to obtain access. There will of course be laws and regulations, consents and all sorts of policies in place to prevent or punish unauthorized access. Electronic data is much more liquid than paper based data, leading to better collaboration, better visibility and like all liquids, has better chances of leakage.
  2. EHRs can slice and dice your data and present you with flowsheets for an individual patient and many reports across your entire panel of patients. You could see how your patients are doing, which ones need to be reminded to come in, or schedule screening tests. It’s hard to do that on paper.
  3. Just like your data is available to others, theirs is available to you. You can see medication lists, specialist notes or PCP histories, hospital records, test results and even home monitoring devices input in real time. Coordination of care should become less time consuming.
  4. EHRs can help you directly communicate with patients (and other doctors) via secure email or even secure teleconference. It can automate making appointments, paying bills, obtaining pre-authorizations and even the entire check-in/check-out process.
  5. EHRs can provide you the latest guidelines and evidence, in a patient specific context. Perhaps even CMEs. Computers are supposedly better at calculations and cross checking large amounts of data, hence they could alert you when an error is about to occur or present you with the latest checklists.
No, all these things are not there now. Some of the simplest ones are, and the rest should become reality after enough physicians start using EHRs and enough EHRs get interconnected to form a critical mass necessary for progress.

OK, so where is the catch? Truth being said, there is more than one catch.
  1. You have to feed the beast. Computers cannot deliver any of the wonderful, or less wonderful, things above, unless somebody enters data into the EHR to start with. While most data can be entered by staff, large portions will have to be collected by the physician.
  2. Computers are intrusive. The EHR will make its presence felt in the exam room. It will alter your interaction with your patients. There are tips and tricks to minimize the change, but it cannot be eliminated altogether.
  3. EHRs are not a finished product. When you “adopt” one, you become part of a learning effort on how to computerize medical records. EHRs have “glitches”. The Internet and broadband have “glitches”. Computers in general have “glitches”. People have many “glitches” too. Nobody invented the perfect method for documenting encounters, for viewing longitudinal records, for ordering tests and most important, EHRs are not yet able to communicate with one another on a large scale.
  4. The Government will have easy access to your records. Your performance may be judged (perhaps inappropriately) and reimbursement may be affected. Patients (and their attorneys) will have unfettered access to your records. Mistakes will be found. Little notes you made just for yourself in the paper chart, are not just for yourself anymore.
  5. EHRs can be expensive. They don’t have to be, but they can be. Picking the wrong piece of software, not getting proper training, not managing the implementation process correctly and failing to continuously manage change may cost you a small fortune, mainly in lost productivity. There are no “lemon laws” for EHRs.
My first cell phone weighed over a pound and had huge buttons and a very ugly antenna. My second cell phone was a flip phone and my third one was Java enabled. I now have an iPhone. My first computer was a main frame IBM 370. I was madly in love with the power of that machine. My second computer was an IBM PC. I named him and took him with me on a long vacation overseas and back. I now have a thin and much more powerful Sony Vaio. I could have sat this whole thing out waiting for the iPhone and the Vaio to be perfect, which they still are not, but I would have been left behind I think. I would have certainly avoided the embarrassment of dragging a 30 lb computer through several airports and the excruciating wait for the modem to connect, or the inconvenience of dropped calls every time I drove by an electricity pole. But I would have also missed the ability to help a Hospital keep receiving lab reports on a Friday night and the opportunity to walk a technician through an entire database restoration from a mountain lodge in the middle of nowhere.

If I were a physician in a small private practice today, I would do my research and locate the cheapest EHR that can do what needs to be done relatively well. I would “adopt” the contraption, regardless of the promised $44,000, probably name it Lucifer and keep an eye on it to make sure it behaves itself. And I would try my hardest to become part of the future and part of the solution, because folks, whether we like it or not, paper is over.


  1. Great primer on EMRs that all providers need to read. Perhaps you may want to ask to post to

    "The Government will have easy access to your records."

    The government via the HITECH meaningful use initiative will not store individual records, but rather ask for general outcomes reporting that the EHRs are regulated to produce. There's a far greater chance a third party vendor will have access to a provider's patient records via exchanges of data. I posted on this very issue at

  2. No disagreement on your core message here, but if I were a physician in a small private practice today (like my own non-EHR-equipped doctor is), I would want to know how implementing an EHR, even for free, is going to improve my ability (or at least efficiency) to care for my paients or enhance the quality of that care, particularly when on day one, exactly none of the many years' worth of paper records I have on file now are going to be available in that shiny new EHR system. I would like to see the government focus less on subsidizing the purchase of the technology, and more on helping doctors quickly get to the point where the technology is a help, rather than a hindrance or source of extra effort - that is, incentivizing the transition of medical practice to an EHR-enabled version.

  3. Agreed Faisal. When data flows out, every facilitator has access and I am very hopeful that the ONC Tiger team can set the necessary rules in place to protect not just patients, but also doctors.

    Security Architecture, I couldn't agree more. I am hopeful (always) that the RECs will fill in that gap. A feet on the ground approach in the community should be able to help, if they manage to acquire the necessary talent and knowledge.
    Old records can be brought into a new EHR, with much effort and hassle. It won't be perfect and there will be no instant gratification. I hate to use this cliche, but this EHR thing is for the long haul....

  4. Curious to know what you think will be the impact on adoption if, as today's AMA article suggests, insurers start tieing MU criteria to physicians contracts. Here's the article link:

  5. In a word, exactly. I'm ever impressed by how you can succinctly but thoroughly get to the heart of the matter, Margalit. This one should be read by anyone concerned by HIT, or health in general.

    And you have a Sony Vaio? I just bought one recently (my first computer upgrade in five years). How's it held up so far?

  6. Carol, I think that yet another reason for all docs to move forward the best they can. Private insurers are always taking their marching orders under Medicare cover, so this is to be expected.

    Thanks, Michelle. So far the Vaio seems OK, except the mouse pad, which seems to have a mind of its own. I had to retype many comments when the page refreshes out of the blue... :-)

  7. I think it will also be interesting to see if Massachusetts goes through with making EHR adoption necessary in order to get a medical practice license. Of course, they do things a little differently up there and I can say that because I grew up there. On a side note, I read your blog pretty frequently and like to share posts with our readers, colleagues, etc. Any thought to adding a Share widget to make your posts easier to email/digg/share on linked in, etc.?

  8. I saw an allusion to that in Massachusetts. Wouldn't surprise me after they proposed to tie licensing to acceptance of Medicare.

    I am going to look for those widgets now and have them up as soon as I can figure the stuff out :-)

    Thanks for reading, Carol.

  9. Carol,
    Added a gizmo thingy button :-)Let me know if it's OK...