Thursday, June 7, 2012

The Other Side of the EHR Mirror

For almost three years now, since the advent of the HITECH Act, and prompted by the exorbitant prices of health care, an animated electronic medical records debate has been unfolding on a national stage. It seems that every possible or impossible solution to our health care woes is in some shape or form dependent on widespread use of computerized medical records. Computers have been utilized to change almost every industry, making products and services cheaper, more accessible and in some instances better, so the hope is that computers can do the same for health care services. There are three fundamental ways in which computerization of an industry is advantageous: process automation, improved information processing and better communications. Arguably, we can use all three in health care.

Process automation need not be construed as referring to the processing of people, although it often is. Health care has plenty of processes that can and should be automated. The most ubiquitous automation is in the form of electronic claim submission and the respective electronic remittance advice (ERA) from payers. The vast majority of physicians are using computers for this process, but even the most advanced practices still have billers in the back office eyeballing most outgoing claims and overseeing the electronic posting of payments. Not to mention the ever increasing burden of patient collections, or the sometimes automated process of checking eligibility for services, or the rarely automated process of verifying status of deductibles. Referrals and pre-authorizations are another labor intensive and time consuming set of processes that can and should be automated. Transitioning these largely administrative chores to the computer requires that rules and regulations are standardized in deference to physicians’ and patients’ judgment (nowhere on the horizon) and that computer software becomes much more reliable and “intelligent” than it currently is (slowly taking place). I’m sure you can think of other business processes than can, or may even already be automated with assistance from computers.

When it comes to automating clinical processes, current day computerized systems have precious little to offer, and perhaps that’s how it should be. Sure, many software products come with clinical decision support, order sets, template based protocols, algorithms and pathways, but none of these qualify as automation of processes, even in instances when a health system mandates adherence to protocols, because manual labor is always required and by definition, variability is certain to occur. However, bits and pieces of the larger clinical process can be and are automated, e.g. orders processing, calculations of numerical values and tracking of events. Other processes, such as transitions of care, could benefit from some automation as well (e.g. automatically sending admission/discharge information to a known primary care physician). When judiciously utilized, computer software can provide some measure of efficiency and quality assurance to the overall clinical process.

There is of course a certain overlap between those bits and pieces of clinical automation and the overarching information processing afforded by computerization. In most other industries held up as examples for what electronic health care should be, there is one basic entity that is being measured, calculated, analyzed, tabulated and displayed: dollars. Dollars across time, dollars across populations, dollars across products and services, dollars in and dollars out. The business of medicine, a.k.a. payers, is as good and as advanced in its electronic dollar information processing as any other industry, if not much better. Unfortunately, clinical information processing lacks a universal unit of measure for all things, and therefore requires much more sophisticated software, and larger efforts to collect the information to be processed. Meaningful Use and the various Quality Reporting programs are meant to facilitate and accelerate the collection of information, with the hope that sometime in the future the collected information will be of sufficient quality to enable meaningful information processing beyond what the insurance sector already does.

Industrial computer enabled communications can take two basic forms, ad-hoc and process driven, triggered by and directed to one of the following actors: customers, or personnel and machines, both of which can be internal or external to the business entity. Process driven communications, which are initiated by machines, are obviously part and parcel of process automation as discussed above. It is interesting to note that even in industries that are heavily computerized, communications to and from external entities, where a buyer/seller relationship does not exist, are either mostly manual and paper based, or very simplistic (e.g. ATM networks). And these are exactly the types of communications we are attempting to computerize in health care by means of health information exchange organizations and the Nationwide Health Information Network (NwHIN). We must realize that this is unprecedented in all those supposedly more computer savvy industries, particularly since the health information to be exchanged is very complex and to some extent “mission critical”.

Interactions of personnel with machines, i.e. use of Electronic Health Records (EHRs) by physicians and other clinical staff, has been the source of much angst and passionate debates on feasibility, merit, timing and approach, and having written thousands upon thousands of words on the subject, I will just say that when you compare health care enterprise software to other industries, ours is no worse, may very well be much better and most definitely includes many more choices than, say, banking software or supply chain software. The only difference is that the President of your bank is rarely in need of using the software, while the “president” of a medical practice must use the software all day, every day. This is where the problem is, and this where a solution is needed. Rearranging boxes and buttons on computer screens will not provide much relief.

Last, but not least, are the budding electronic communication channels between health care customers (patients) and health care industry machines. Here we take the fateful step to the other side of the EHR looking glass to see what patients see. Health care was never too terribly concerned with patients’ interactions with their medical records. Health care, although usually paid for when possible, was considered mostly an act of kindness, hence the “care” in health care. People did not “deliver” or “provide” care. Instead they “attended”, “administered”, “nursed” and generally cared for the sick, the wounded and the dying. The result was a rather unique relationship based on gratitude, fear, hope, trust, deference, commitment and all sorts of other human emotions. Examining the books was not in the realm of considerations and most patients lacked the basic abilities to do so. Over the years, health care, or rather medicine, has transformed into a profession and now it is morphing into a service business with providers and consumers. Like a bank. And everybody knows that you must keep an eye on the bookkeepers. As the preferred solution to our health care crisis is beginning to emerge, in the form of transferring more costs to consumers, so they can control expenditures by only purchasing what they can afford, it is becoming imperative to have smooth and comprehensive communications between patients and health care’s newfangled computers. Like a bank.

When EHRs started out, no special provisions were made for patients (or communications in general). Financial software started out much the same way, but since banking was always a consumer business, the advent of the Internet and now the mobile Internet, brought us very slick, very useful and very consumer friendly Portals. And health care was left behind. First very slowly, and more recently at an accelerated Meaningful Use pace, EHR vendors began providing Patient Portals, and providers began buying them and deploying them. The online services in Patient Portals range from pathetic to pretty darn good, but there is a long way to be traveled before we reach the functionality and usefulness available in the financial or retail sector. It will happen though, because just like nobody would open an account at a bank without online services, pretty soon nobody will be willing to purchase health services from a provider without a useful online presence. It will become a differentiating factor first and then it will become a given that you can get most of your health services online. Just like a bank.

The time when patient needs were overlooked by EHR vendors has long since passed, and I am expecting to see significant advances in consumer facing software in the next couple of years. Your customer should not need to go to Walmart for a telemedicine quickie, and shouldn’t need to “transfer” information to Microsoft for figuring out his health status, and shouldn’t have to download “free” apps to manage whatever ails them. You as a provider, and your now computerized health business, should be able to provide everything your customer needs (and more) on your own customer Portal, for the web, the iPhone and Android devices. And you will, because this is quickly becoming a cost of doing business. Just like a bank.


  1. "The time when patient needs were overlooked by EHR vendors has long since passed." Amen. People are starting to notice that as EHRs get deployed, those who most need to be engaging almost always have multiple providers (and 50 million Americans move every year). This could mean 5 different logins for the patient which is almost as bad as none. The time has also passed for provider-centric proprietary patient portals that further the siloization of healthcare.

  2. Hi Dave,
    I don't think that it has to necessarily be one or the other.

    If you recall, the 1967 definition of a PCMH was really about a place where the kids' medical records should be aggregated. I still think that this original thought of the AAP was right on the money, and I believe it is the primary care doc's professional obligation to oversee the aggregation.
    I wrote about this here over two years ago and I just looked at it again, and it still rings true to me.
    Patient Centered Medical Home for Your PHR

    Of course other people may feel differently and may prefer to do the work themselves in an independent product. There should be room for both and maybe other models as well.