EHR Adoption is Like Treating Cancer

EHRs are not ready for prime time. EHR benefits are questionable and there are documented instances where patients’ deaths were directly attributed to an EHR. EHRs are cumbersome and slow. They are unnecessarily complex and built on very old technology. The people who build EHRs have no concern for the end user and therefore EHR usability is pretty abysmal. And EHRs are expensive to buy and expensive to maintain, not to mention that they can completely derail your practice through loss of productivity. The fact that some users seem to do well with their EHRs, and even derive some joy from using them, is not a valid counter argument since most users are not so fortunate and through no fault of their own. There really is no excuse for such failure in this day and age. Just look at the iPad and the iPhone. You can walk into any Apple store and 5 minutes later walk out with a fully functional product with a delightful, intuitive interface, loaded with hundreds of interchangeable apps that even a three year old can use right out of the box. All for a few hundred bucks.

If you happen to be diagnosed with cancer, you will most likely be subjected to years of unpleasant treatments. You will be injected with poison and irradiated with more poison. You will lose your hair, suffer bouts of vomiting and diarrhea and be physically debilitated to the point where you cannot leave your bed. You will most likely have to go through painful surgeries, take all sorts of medications that were shown to kill thousands of rodents and never recover your old self again. And this entire ordeal will cost you a medium size fortune. The fact that some lucky patients go on to win the Tour de France is not really an acceptable rebuttal. Most do not. And there really is no excuse for such incompetence in this day and age when one little pill can cure you of an yeast infection in 24 hours and a $4 course of antibiotics will render you as good as new if you happen to develop a sinus infection. Not to mention the innumerable vaccines that will miraculously prevent you from contracting the plague.

Yes, this is a farfetched analogy, but replacing paper charts with an EHR is not like playing Angry Birds, and if you want a fair chance at survival, you have to tolerate the side effects imposed by the current state of technology. Just like you cannot postpone your cancer treatment until the doctor from Star Trek figures it all out, you cannot postpone transition to EHR until EHRs are “ready for prime time”.  And make no mistake, in today’s reality, paper charts are as big a threat to the survival of an independent medical practice, as any garden variety cancer is to a human body. Paper charts will gradually and irreversibly deprive your practice from the nutrients and oxygen needed for survival, i.e. reimbursement, until it shrivels and dies, or it gets absorbed into a larger organism. The common wisdom seems to favor these outcomes. I do not. If you are one of the fewer and fewer physicians who has no desire to either shrivel or practice Wal-Mart medicine, here is one way to think about your current EHR predicament. [Note: Considering the gravity of the situation, you would be well advised to seek a second opinion.]

Diagnosis – Look around you. EHRs are slowly gaining ground. You would be hard pressed to find a medical group of significant size that does not have one. Data collection is not as voluntary as it is being portrayed, unless of course you think that you are overpaid and can easily absorb cuts in reimbursement. You can choose to make believe that this too shall pass and once Obama is no longer calling the White House home, all will be as it was. Alas, computerization of medical records has bipartisan support, and it always did, due to a rare alignment of powerful financial interests and progressive ideology. If you want to continue the practice of medicine, you will need to use the tools of the trade. For better or worse, both the trade and its tools are being redefined. Barring a global disaster, the chances of spontaneous remission are nil.

Staging – How bad is it doc? Well, it won’t kill you tomorrow, but the longer you wait, the harder and more expensive it will become, the fewer the choices and the lower the chances of a good outcome. Both public and private payers are experimenting with new reimbursement methods. These pilots, or projects, are cropping up everywhere, supported by grants and all sorts of tax payer monies. The goals may be different and the rules of engagement are certainly different, but these arrangements have one thing in common. They all prefer that you generate and consume large amounts of clinical data in electronic format. You will need an EHR for that.

Treatment – A physician-centered approach to the problem suggests that you should be informed of your options and allowed to make a decision based on your personal and cultural preferences. Since medical practices are not people, you may choose to euthanize your practice. This may make perfect sense if your practice had a long and productive life and your medical career is in its twilight years anyway. A less terminal option would be to allow your practice to be hooked up to the machinery available in large health systems. You will still have to use an EHR, but your new employer will undertake the mitigation of most side effects. There is a slim chance that someday you may be able to remove the tubes and resume private practice, but while your medical career can survive indefinitely, your practice as you know it now is not likely to recover. Or you could make a stand and fight for your independence.

Prognosis – By definition there could be no blinded trials for EHR utilization, and by omission there are no randomized control trial results to learn from. The anecdotal evidence suggests that many thousands of physicians in independent practice are surviving just fine after EHR implementation. Some would say that they are doing better than ever now, and others have resigned to the new ways of doing business. For most, the life threatening problem has been transformed into a manageable chronic condition. It must be noted however, that a significant number of physicians is currently in need of life-support from health systems and hospitals, and many of these are post EHR implementation. We cannot be certain, since there is almost no literature on the subject, but it is highly probable that practices suffering from a relapse have had multiple comorbidities to start with and/or developed other life threatening conditions since. There are no guarantees of course, but if you have an otherwise healthy practice, a positive outlook and a supportive environment, chances are good that transition to EHR now will enable your independent practice to survive and thrive for many years to come. And the opposite is also true.

EHR Bargains Review – Practice Fusion

(Survival Tips for Small Practices)

If you subscribe to Prof. Clayton Christensen’s theories of innovation, Practice Fusion is to the EHR industry what Southwest Airlines was to the air travel industry, ad extremis, with no thrills, no frills and no peanuts. Practice Fusion is completely and truly free to users, and it will take you from point A to point B in a straight and short line, with point A being paper charts and point B being a Meaningful Use incentive check.

The Model

Practice Fusion is a web-based EHR and it is free to use no matter who you are. The company website has a self-provisioning button where any visitor can sign up for a free account and immediately start using the software. All you need is a valid email address. The company prides itself in taking users live on the EHR in 5 minutes. It actually takes much less than 5 minutes to get to a point where you can begin charting, but it takes a week or more to hook up to electronic prescribing and lab interfaces, and this is very much in line with industry practice. Practice Fusion offers free connectivity to national reference labs and a handful of regional ones as well. Just like there are no charges for electronic prescribing, there are no interface fees for the currently available lab connections and no mention of “custom” interfaces built for a fee. You get only what you see.

Since we all know that there is no free lunch, how is it possible to get a free EHR, including significant interoperability? The standard answer to this is that Practice Fusion is ad supported. Just like you get free email services from Google in return for agreeing to see ads on every email page, when you sign up for Practice Fusion, you are agreeing to see ads on every EHR page. To my pleasant surprise, the ads are mostly limited to about one inch of space at the bottom of the screen, and are not at all intrusive in the workflow. I actually don’t quite see how these ads support anything, since with the exception of one Dell advertisement they all seem to be Practice Fusion self-promotions. Furthermore, the fairly new Patient Fusion portal displays no ads at all. Similar to most other EHRs, the Practice Fusion end user agreement reserves the right for the vendor to aggregate and monetize EHR data, and perhaps this is a possible explanation for this free lunch.

Functionality

The best description for Practice Fusion’s functionality is bare-bones. There is no fluff, no bells and no whistles to be found in the very simple, very clean user interface. After muddling through a variety of top-shelf EHRs with double and triple menu-bars and icon studded task-bars on every page, the Spartan look & feel of Practice Fusion is quite refreshing. Although there are multiple training aids in the system, if you are an average computer user (e.g. email, Word), you should not need much coaching to become productive at very short notice. This of course eliminates another hefty expense associated with EHR adoption: training.

Whatever free-form stuff you are now doing on paper, you can do in Practice Fusion, pretty much the same way. It comes with a simple set of SOAP templates consisting mostly of questions where you get to type in the free text response. You can also type directly into the note and probably use Dragon as well. You can create your own sets of questions, or add to existing ones. You can order meds, labs and imaging and print those, or send electronically if connected. Scanned documents can be uploaded to any particular chart. There is no clinical content available for decision support, at this time. Registry functions are in their infancy and the handful of available reports is very simplistic. Disappointingly, the Meaningful Use report does not automatically calculate numerators and denominators for core and menu items, but clinical quality reporting is automated. There is very little customization possible and none is required.

For patients, there is Patient Fusion, a simple web-based portal that allows patients to see appointments, meds, allergies, immunizations and labs. It also provides some links to medical content on the web. It seems that the portal is very much a work in progress, but just like the EHR, its user interface is clean, simple and appealing. Unlike the EHR, which is Flash based and therefore unavailable for use on Apple mobile devices, the portal is accessible from an iPhone or an iPad. Practice Fusion did announce recently that a native version of its EHR for the iPhone is due to be released soon. 

Viability

Practice Fusion is privately owned and has been around since 2005, but started taking off in earnest around 2009. Its recent growth coincides with the HITECH act and the advent of Meaningful Use. Although it is possible that it will follow a trajectory similar to Southwest Airlines and blossom into a major EHR vendor, it is also possible that it would make a rather attractive acquisition target for one of the much bigger fish circling health care IT right now. Will it remain free to end users? There seems to be no current intent to charge customers for software usage, but Practice Fusion received over $36 million in venture capital, which usually comes with expectations of short term spectacular returns. Time will tell.

Bottom Line

Practice Fusion is currently certified for Meaningful use as a Complete EHR, which means that you don’t have to buy additional software in order to achieve Meaningful Use requirements. As is the case with all web-based EHRs, you will have to buy desktop (or mobile) hardware, internet services and networking hardware. You will still need to pay for a Practice Management system and billing, and unless you choose to utilize the sole Practice Fusion partner for these activities, you will need to budget staff time for double data entry. You will not need to pay for the EHR, its server and its maintenance. If you are interested in Meaningful Use incentives, and if you practice in a small group, and if the cost of EHR seems prohibitive (or a waste of good money), and if you have no use for bells and whistles above and beyond a paper chart, then by all means, go ahead and try it out. It’s free.

Occupy Health Care

Earlier this year, in the midst of the civil unrest in Egypt, Michael Millenson pondered about the passive attitude of those lacking health care insurance and their failure to organize and “take to the streets”. Well, unless you are living under a rock, or are really busy seeing patients, you know that we have quite a few people “taking to the streets” nowadays. They call themselves the 99% and they are set to Occupy Wall Street along with a bunch of other cities across the country. They have been called everything from “the rise of a popular movement” to “anti-American”. Are these Michael Millenson’s uninsured finally standing up for themselves? Judging from the stories they write on the placards covering their faces, which look eerily similar to what you see at busy urban intersections (e.g. “Lost home and job, will work for food”), lack of health insurance is often cited as a source of misery, but so are student loans, lost savings and inability to find work. Although this peaceful movement of folks camping out in parks and marching down streets has no coherent message, their grievances are casting a large net directed at the destructive influence of Wall Street, big corporations and consumerism in general. Michael Millenson should be satisfied, since health care is most definitely included in this all-encompassing indictment of an unjust society, and here is why.

But first a little detour into terminology. The word “care” originates from the Old English caru, cearu "sorrow, anxiety, grief," also "serious mental attention" for the noun, and carian, cearian "be anxious, grieve; to feel concern or interest" for the verb. When it comes to one’s health, with the exception of patients, their loved ones and increasingly fewer and fewer doctors, nobody in the medical complex experiences any feelings of anxiety, grief or even true interest or concern for the sick, although they may experience all of the above for the cash flow associated with treating sick people. The term health care is an anachronism from a bygone era and it needs to be changed. Health Services seems a much better fit with the prevailing consumer philosophy, which brings us to the next point.

Ever so gradually and insidiously, the term consumer is replacing the term patient in health services contexts, just like it replaced the term people in larger contexts. The etymology for the word consumer dates back to the early 15th century as "one who squanders or wastes", and in economic sense, "one who uses up goods or articles (opposite of producer) from 1745”. Interestingly enough those who presumably advocate for poor and vulnerable populations and even our own government are enthusiastically standing up for their constituencies of squanderers and wasters. Sometimes terminology describes existing realities and sometimes carefully chosen terminology shapes reality. We are witnessing the latter. The big corporations being targeted by those who Occupy Wall Street, have a long, and productive, history of manipulating the 99% into using up as many goods and articles as possible, and then some (i.e. debt), while extracting both profit and power from an increasingly impoverished society. Squandering and wasting is the secret sauce for a consumerist world order, and the medical complex is no different. According to Forbes, in the midst of a recession, CEO pay has increased in 2011 by 28% compared to 2010. The highest paid CEO in America, at $131 million per year (twice as much as the second CEO on the list), is running a health services company. Makes perfect sense. After all health services are quickly approaching 20% of a successful wasting and squandering economy. $131 million is peanuts by comparison.

But here the big corporations are encountering a big problem. The U.S. government, that is supporting a large portion of the waste and squander in the health services sector, is running out of money, and the squanderers themselves seem unwilling to waste their own money on health services. They much rather debt finance homes, cars and iPhones than, say, colonoscopies and designer drugs. The solution to this quandary is a brilliant one-two punch. First we use the bought and paid for government to educate consumers that in a world of finite resources, after skimming the $131 million type “compensations” from the top, only those who have their own resources (i.e. cash) should expect to continue wasting and squandering health services. Second, to compensate for lost revenue from government’s support of health services consumption, we employ two, time tested, strategies. We convert non-consumers to consumers by giving them free small things to lure them into buying more expensive items. For example, we give out free cholesterol screenings so we can create a recurring revenue stream from statins and hopefully more expensive interventions down the road. After all there is a huge untapped market of 50% of Americans who barely use any health services.  Then we increase the prices of everything from health insurance to direct services, by eliminate those obnoxious small businesses floundering in this space and fragmenting our ability to negotiate higher prices. The government is of course expected to help with the necessary laws and regulations, and so far, keep your fingers crossed, it’s going rather well. With a little bit of luck, smart consumers will soon realize that it is in their best interest to spend money they don’t have on the medical complex rather than the real estate market, which has gotten more than its share already, or the high tech gadget market which is booming, or the automotive market which is dead anyway (except for Audi who is selling cars for a crumbling infrastructure littered with trash). It’s all about reallocating extortion revenue and nobody is in a better position to do that than the medical complex. Brilliant indeed.

As the ancient prophet said “What has been will be again, what has been done will be done again; there is nothing new under the sun” [Ecclesiastes 1:9], all of the above has been tried before, in this case by the legendary Mullah Nasreddin, and we know how it ends:

One winter Nasreddin had very little money. His crops had been very bad that year, and he had to live very cheaply. He gave his donkey less food, and when after two days the donkey looked just the same, he said to himself, "The donkey was used to eating a lot. Now he is quickly getting used to eating less; and soon he will get used to living on almost nothing."
Each day Nasreddin gave the donkey a little less food, until it was hardly eating anything. Then one day, when the donkey was going to market with a loan[sic] of wood on its back, it suddenly died. "How unlucky I am," said Nasreddin. "Just when my donkey had got used to eating hardly anything, it came to the end of its days in this world."

To the 99% of us donkeys out there: Occupy Health Care Now!

The Rise of Big Data

Health care is in the process of getting itself computerized. Fashionably late to the party, health care is making a big entrance into the information age, because health care is well positioned to become a big player in the ongoing Big Data game. In case you haven’t noticed computerized health care, which used to be the realm of obscure and mostly small companies, is now attracting interest from household names such as IBM, Google, AT&T, Verizon and Microsoft, just to name a few. The amount and quality of Big Data that health care can bring to the table is tremendous and it complements the business activities of many large technology players. We all know about paper charts currently being transformed via electronic medical records to computerized data, but what exactly is Big Data? Is it lots and lots of data? Yes, but that’s not all it is.

Americans live for approximately 78 years. They see a doctor about 4 times per year and spend on average 0.6 days each year in a hospital. To keep a life time record of blood pressure readings for all Americans, including metadata (date/time of reading, who recorded the measure and where, etc.) takes approximately 6 TB (terabytes) of storage space, or about 12 laptops with standard 600 GB hard drives. Not too big. What if we start using mobile wearable devices to quantify ourselves, as some folks already do, and we record blood pressure, say, every hour? We will require 1460 TB of storage, or almost 3000 laptops, or the equivalent of 6 times the digitized contents of the Library of Congress, and this is for blood pressure monitoring only. Adding in the remaining 99.9% of the medical record, including large imaging files, hospital monitoring devices, pharmacy data, insurer data, telehealth sessions and other personal health sensors, and keeping in mind that all these data are meant to be exchanged freely over the Internet, we are approaching a data tsunami of biblical proportions. And we are not done just yet. Once health care’s Big Data is released into the mainstream Internet, it will initiate secondary and tertiary waves of new data created by consumers addressing their newly found health care data on social media venues, specialty forums, blogs and commercial sites offering services for health data. Big Data is the fluid combination of the ever increasing real-time data streams created by everything from government to businesses to Facebook, Twitter, Geo-locators, mobile devices and connected sensors everywhere. Big Data is as much about size as it is about cross pollination of data from disparate sources.

A fascinating June 2011, McKinsey report predicts that Big Data is the “next frontier for innovation, competition, and productivity” and that Big Data will become equal to labor and capital in its importance to production. For U.S. health care, the report is predicting $300 billion per year in savings due to utilization of Big Data to drive the execution of strategies proposed by health care experts. In the area of clinical operations, the report lists projected savings from Comparative Effectiveness Research (CER) when tied to insurance coverage, Clinical Decision Support (CDS) savings derived from delegating work to lower paid resources and from reductions in adverse events, transparency for consumers in the form of quality reports for physicians and hospitals, home monitoring devices including pills that report back when they are ingested, and profiling patients for managed care interventions. Administrative savings are projected from automated systems to detect and reduce fraud and from shifting to outcomes based reimbursement for providers and, interestingly, for drug manufacturers through collective bargaining by insurers. Most savings listed under research and development opportunities from Big Data seem to accrue to pharmaceutical and device manufacturers. There is nothing to suggest that Big Data will somehow reduce unit prices of products or services.

To be honest, I don’t quite understand where the $300 billion in savings come from as there are no actual itemized numbers to support this prediction. In addition to stated reliance on individual studies and expert interviews, there are many structural assumptions regarding massive provider consolidation, proliferation of Accountable Care Organizations, technology adoption rates of 90% across the industry and data sharing amongst all stakeholders, at which point Big Data will come in and do its thing. The costs for generating, storing and analyzing Big Data which include emerging data storage technologies and analytical expertise are factored in, with the costs of national deployment of EHRs alone “estimated at around $20 billion a year, after initial deployment (estimated at up to $200 billion)”.

Most people, including doctors, will probably agree that pertinent data, big or small, can be transformed into pertinent information, and pertinent information is vital to good decision making. But is Big Data pertinent? Are all those petabytes of minute details about everything and everybody really useful, or are we just mixing a little wheat with a lot of chaff? There are various opinions on this, but the prevailing wisdom seems to be that the more data you have, the more likely you are to be able to extract something useful out of it. By observing patterns and correlations in this ocean of information you may discover answers to questions you wouldn’t have known to ask in the first place. There is much power in Big Data, but there is also danger. As big as Big Data may be, it does not guarantee that it is complete or accurate, which may lead to equally incomplete and inaccurate observations. Big Data is not available to all and is not created by all in equal amounts, which may lead to undue power for Big Data holders and misrepresentation of interests for those who do not generate enough Big Data. Collection and analysis of Big Data has obvious implications to privacy and human rights. But the biggest danger of all, in my opinion, is the forthcoming relaxations in the rigors of accepted scientific methods, and none seems bigger than the temptation to infer causality from correlation.

We’ve been there before. When humanity dwelt in caves and villages, correlation was enough to establish causality. We’ve come a long way since, but the global village we are creating today seems tempted to go back to observation as the main way of gaining understanding. Just like the historic villagers, we are now convinced that we can see everything there is to be seen; therefore the answers to all our questions must be found in the Big Data mirror we placed in front of us. All we have to do is stare at it long enough and the patterns will emerge. The sheer size and variety of Big Data will make it much easier to reject the null hypothesis and see patterns where none exist. On the other hand, if we keep staring at our digital selves in the eye for long enough, perhaps we will achieve the most coveted observation of all: a glimpse through the windows to our digitized soul.

Who Should Pay for EHRs?

During the 2008 Presidential campaign, Candidate Obama promised an EHR for every American by 2014. The goal was to improve quality of care, reduce disparities and contain costs of health care. When the HITECH act became law in 2009, physicians found themselves under increased pressure to purchase an EHR. Many took action, went out and bought an EHR for their practice, and these are now well positioned to collect the financial incentives put forward by the HITECH act. Many more did not. EHRs are by and large a complex and expensive proposition and the HITECH incentives are not covering the average cost of purchasing and maintaining an EHR. In survey after survey, physicians consistently rank cost associated with EHRs as their top concern when considering transition from paper charts to electronic medical records. This is a bit disconcerting, since physicians have no problem buying other expensive tools and paying for human resources in their practices. How are EHRs any different?

Non physicians usually attribute this reluctance to computerize medical records to technophobia or a perverse need to keep patients uninformed in order to maintain power and perhaps even financial advantages. Physicians on the other hand, mostly argue that EHRs do not benefit them directly and therefore they should not be expected to use them, let alone pay for them. Since there is no evidence of physician technophobia in any other areas of medicine (or private life) and since there is no measurable benefit to doctors in keeping their patients in a subservient position, the question then becomes: who is benefiting from EHRs?

There are three primary stakeholders in health care: those who receive care, those who provide care and those who manage the financial aspects of health care, and no, we are not getting into the quintessential argument of whether there should be only two primary stakeholders. There are several secondary stakeholders as well: those who manufacture medical goods, those who provide ancillary services and those engaged in medical research.

Historically, an EHR has been defined as a software tool, used by health care providers to collect, analyze, display and exchange clinical information with others. The content collected in an EHR was exclusively generated by health care providers or by traditional ancillary service providers (e.g. labs, imaging, etc.). There is however a new type of ancillary service providers aiming to provide services directly to patients, mostly through mobile devices, who are clamoring for the right to become an accepted partner to the EHR clinical information exchange network. And of course patients, whether through these new ancillary service providers or directly, are also increasingly voicing a desire to be included in clinical information exchange. These developments are altering the classic definition of an EHR and changing the focus from tools to provide care to broad content management, which is more in line with Candidate Obama’s vision. In reality all these functions are still in their infancy, but the direction is fairly clear, and it is worth noting that unless all functions are optimally performed, there is not much benefit accruing to any stakeholder. Various constituencies may derive more value from one particular function rather than the others, but as long as that value exceeds what is made available by a paper system, someone should be willing to pay for it. Let’s examine our stakeholders, and their willingness to pay, from the bottom up.

Secondary Stakeholders – Here we find the drug and device manufacturers and the bewildering array of diagnostic facilities. Most of these companies are largely indifferent to what EHRs do and some stand to lose revenue when EHRs shine bright lights on spending patterns. They are not likely to consider paying anything for widespread EHR adoption. On the other hand, the mushrooming mobile health and personal health application providers, who base their entire existence on the availability and successful use of EHRs, show no willingness to share in the cost of computerizing medical records. Needless to say that medical research centers which have been habituated to mostly free access to data sources, may be willing to pay data aggregators, but would never consider participation in infrastructure investments.

Health Insurance Providers – The largest health insurance provider in this country is the Federal Government through the Centers for Medicare and Medicaid Services (CMS), and CMS is proposing to bear a rather hefty portion of the costs of EHR deployments. Obviously CMS is expecting to see great financial rewards from a fully functional EHR network. Whether CMS is placing onerous or misguided requirements on the technology is a completely different question and one has to keep in mind that CMS is primarily a payer and its primary concern must be proper stewardship of tax payer funds. To do that, CMS needs data, and lots of it. You don’t usually pay a mechanic to take a look at your car – you pay him to fix it. CMS is now paying health care providers to treat people and it would much rather pay them to fix people and keep them under warranty, and it would also prefer that this is done via a fixed price contract, instead of the current time & materials model. EHRs are the tools by which quality assurance is performed and deliverables are accounted for and measured.

What’s good for the goose should be good for the gander, and private insurers figured out that paying for EHRs may not be such a bad idea after all. I am not 100% certain, but I would suspect that financing EHRs for physicians in order to improve quality of care falls under the medical expenditures rubric and can be deducted from the federally imposed Medical Loss Ratios (MLR). Since private insurers have historically ran much tighter ships than CMS, I would expect that in return for their Stark exempt contribution to EHR expenses, private insurers will ask for at least as much data as CMS and probably a lot more.

Health Care Providers – These folks are as diverse as the patients they serve, but their interests in EHR are most closely correlated to their size, which ranges from the solo doc in a micro practice to integrated delivery networks serving millions of patients. For large providers who operate multiple and varied facilities of care, EHRs are a tool to effectively manage their business. They were always willing to pay for them and they are continuing to do so now, in spite of the constant rumbling about CMS regulations. At the other end of the spectrum, the small providers, mainly physicians in private practice, who are more financially strapped than ever, see no good reason to take on debt and pay for tools with no demonstrated ability to provide tangible returns. Keep in mind that using paper-based tools to manage a few hundred customers who purchase one of a handful of services between 9 and 5 four days a week, is not nearly as onerous as managing millions of customers purchasing thousands of different services around the clock all day every day. Nevertheless, even these small providers are starting to buy EHRs. As EHR software gets better, some manage to find efficiencies never before contemplated and others are just trying to keep up with the Joneses and survive. Reluctantly and grudgingly, with lots of hard feelings building up, they too are willing to pay.

Patients – All stated goals of EHR adoption ultimately benefit patients. Some may stand to benefit more than others, but in aggregate we will all benefit from improved quality, reduction in disparities and cost containment of medical services. Whether directly or indirectly, through taxation, premiums, wage reduction, increased prices of goods and plain old cash, patients pay for the entire enormity we call health care costs, which includes cost of actual care delivery, overhead and profit margins for all other stakeholders. EHR software is part of that overhead and so are the costs of analyzing, displaying and exchanging information collected by EHR software. When CMS and private insurers and even health care providers write checks for EHR software vendors, somewhere down the line this translates into a little bit less health care for each patient and/or a little more money needed to obtain care. So although we pay for all EHR expenses, we as patients, find ourselves in the perplexing situation where we are forced to lobby, argue, advocate and practically beg for access to the work product of EHR software. And that work product is our life story. It is the record of our birth, the narrative of our childhood successes and mishaps, a document of our education, sexual activity, fears, hopes, marriages, new children, career choices, residence, divorce, widowhood, disease, death and everything in between. In other words: Data. We are paying for this data to be collected, exchanged and analyzed. We are paying for people to decide if we should have a right to opt-in or opt-out of such activities. We are paying for media campaigns to convince us that what we are already paying for is worthwhile.

So here is one suggestion: instead of paying for EHRs indirectly, while allowing all stakeholders to complain about the expenses as if the fees came out of their own pockets, how about patients paying for EHRs directly? There is no difference in aggregate and we are not talking about a lot of money for each individual patient. A yearly fee of something between $5 and $10 per patient, per facility, should suffice. Call it EHR fee, or EHR subscription. Once we explicitly pay for it, we own it; not the software, not the hardware, but the Data itself. And this is how it should be.

Road Trip to Meaningful Use Land

The voice on the phone seemed genuinely amused, “Let me see, the GPS can’t find our location, right?” Right. One U-turn by the burnt barn, a right after the Conoco station, another right at the end of the road, a left across the John Deere and two and a half hours from the city on highway W, brought me to a small and very white store front, housing a nail salon and a busy family physician practice. If I stretched out both arms, I could put one hand on the front desk, and place the other hand on the back of a waiting room chair. There were six chairs separated by small tables adorned with yellow silk flowers. A texting young man in jeans and baseball cap and a middle aged woman clad in floral attire and a big green purse, occupied two of those chairs. And then Bessie walked out the doctor’s office behind the usual and customary tennis ball footed aluminum walker which was almost as tall as her, and helped by the front desk lady made a slow trek to the one chair with arms on both sides. They were calling Joe to come pick her up. Joe was going to be there in ten, fifteen minutes, tops. It was 4 PM and they were running behind.

Looks can be deceiving though. This practice is an anomaly in the rural health continuum. There are computers in every room and not even a trace of paper charts. They’ve been on a top of the line Cadillac EMR since 2005, paying a small fortune every year for the privilege and for IT guys to support it. They kept up with all the upgrades and are on the latest and greatest certified version and would very much like to get the Meaningful Use incentive that will cover about three quarters of what they spent on EMR maintenance this year. The doctor would even like to try the patient portal. He thinks it could make him more efficient. They were all ready to go on October 1st, but then something happened. They started getting solicitation emails from their EHR vendor informing the doctor that there are several accessories that he must purchase in addition to his fully certified EHR, if he wants to qualify for Meaningful Use incentives, and of course, the Cadillac vendor has a special sale on accessories this month. Confusion and frustration were palpable around the huge, and completely out of place, formal pedestal dining table in the break room.

I’ve been to this movie before, and I never had any luck convincing this particular vendor that a certified complete EHR should allow the user to achieve Meaningful Use with no need for other bits and pieces that were not mentioned anywhere during the certification process. Unfortunately, those who certify EHRs and those who supervise the certifiers are turning a blind eye and a deaf ear to what is essentially a regulatory issue. In the break room the confusion and frustration were slowly changing to anger and the big plastic QT cups of pink lemonade that were brought in by someone didn’t help much. The conversation shifted to the various Meaningful Use measures and by now I wasn’t surprised to hear that they are doing rather well on most, from electronically prescribing everything to recording race and ethnicity and generating beautiful CCD clinical summaries. They weren’t sure how to give folks electronic copies of their medical records, but nobody ever asked for that and it’s highly unlikely that anyone will in the next three months. That should be good enough.

“Am I also good on immunizations? I don’t do many of those either… maybe a few HPV and some flu shots for elderly patients to save them a trip to the pharmacy. I shouldn’t have to report anything, right?” Eh… wrong, doc. Even if you only do one immunization in the next three months, you would have to test an immunization interface with the State registry, and your Cadillac EHR can’t generate the test file at this time although it is fully certified for Meaningful Use. I’ve been trying to get an answer from this vendor for months. I’ve asked CMS for a solution over a month and a half ago. I have written a blog post that got more page visits than anything I ever wrote before, and came up empty on all fronts. But the doctor seemed to be working his way to an innovative solution all by himself.

“So if I don’t give any shots after October 1st, I should be OK…. We have one bottle of HPV left anyway and Marcie needs her shot… I have a week to do that… They pay peanuts for shots, you know…. They’ll just have to go to the pharmacy…. It’s not that far…. I really don’t give many shots anyway… Yep. It should work… “. October is flu season, and I was wondering if Joe picked up Bessie by now and if the pharmacy is on their way home. I wanted to know if the pharmacy had a chair with arms for Bessie and if the pharmacy folks would also call Joe to pick her up after waiting in line for her flu shot. But instead, I just found myself mumbling that this wasn’t really the intent, but yeah, this should work.

A couple of months ago, I heard a story about a geriatrician who chose to stop giving courtesy flu shots to his patients because of Meaningful Use. I found it hard to believe then. Needless to say, I believe it now. I am certain this was not the intent at CMS and I am pretty sure this was not on the Meaningful Use roadmap at ONC. I am not in the habit of pleading and begging the powers to be to do the right thing, but I will make an exception this once. This unremarkable little practice in the middle of nowhere could have been the poster child for successful EHR adoption. Can somebody at HHS, CMS or ONC help these small practices stand up to the greedy whims of a powerful EHR vendor? And above all, can we do something to help Bessie keep her “I” in Health IT, please?

Disclaimer: In order to protect their privacy, the names of all people and locations mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.

The Power of Empowerment

Grant Wood, American Gothic (1930)

Housing is expensive if you want to live in a Tudor style mansion on a half-acre wooded lot. Housing is a lot cheaper if you choose to rent a two-bedroom apartment on the fourth floor of a square building with no elevator, 45 minutes away from your workplace. And it won’t kill you to rent. Food is also very expensive if you want a varied, fresh and gourmet diet, but food can be cheap, and it won’t kill you to cook your own food and stick to a diet of mashed potatoes and boiled cabbage, with an occasional bit of tripe. Health insurance is very expensive if you insist on having all your medical needs covered by an insurance policy. Health insurance can be a lot cheaper if you pay for most of your medical care yourself and if you only buy limited coverage for the eventuality of falling off your dressage horse, and cheaper still if you promise to drop dead shortly thereafter.  Health care itself is very expensive if you insist on receiving medical care from highly trained professionals, using cutting edge technology in state of the art facilities. Health care can be a lot cheaper if you find a way to take care of your health without involving doctors and hospitals and their overpriced opinions, chemicals, machines and unnecessary procedures. It’s all about consumers empowered to freely make their own choices: mansion or rented apartment, steak or tripe, Cadillac or catastrophic health insurance, ICU or alcohol rub…..

The Consumer Empowerment terminology originated in the health insurance industry to mark the transition from having insurers pay for every cut, bruise and sniffle, to the more responsible way of paying for much of your health care directly out of your own pocket leaving the insurer responsible for rarely incurred catastrophic expenditures. The newly empowered consumers discovered that health insurance is now much more affordable, and perhaps even unnecessary, while health insurers discovered that magically, their profits are also improving, probably because empowered consumers seem to generate significantly less reimbursement claims, than the irresponsible and unempowered crowd served by public entitlements.

Although empowering consumers to pay for their own health care proved to be a stroke of genius, we have a long way to go before the overall cost of health care is contained. The problem here is that over the years Americans figured out that staying healthy doesn’t really pay off and quite the opposite is true, because once you get really sick there are all sorts of freebies made available to you, from amputations to chemotherapy to mastectomy to castration - a veritable smorgasbord to choose from, and the temptation is huge since the monetary value of these free goodies can add up to more than many people make in a lifetime of hard work. Not to mention the fatherly physician figures busy offering you helping after helping of a carefully selected array of the most expensive fare available. And then an innovative idea was put forward by selfless luminaries, and is catching on like brushfire after a long global warming induced drought. If health care insurers were able to cut costs and increase profit by empowering consumers to insure themselves, could health care providers achieve the same spectacular success by empowering consumers to care for themselves?

Empowering consumers to engage in their own health care may rank up there with cold fusion and perpetuum mobile in its transformational potential for humanity. Empowering millions of people to actively manage their medical care, by making their own medical decisions, breaking free of the old-fashioned paternalistic directives of financially conflicted physicians, and restoring the nineteenth century self-reliant approach to health care, will slash costs, improve quality and eliminate disparities in health and health care in one patient-centered fell swoop. And how do we accomplish such monumental task? We harness the unlimited power of the Internet. This is the Information age, and just like the Industrial age brought a car and a television set to every home, the Internet puts the entire world’s knowledge at the fingertips of all humanity with astounding effects already visible in the education attainment of our children. But the world’s knowledge is missing a vital piece of information pertinent to our goals in health care.

Enter Health Information Technology (HIT). HIT will pry loose the last piece of the puzzle – the secretive documentation amassed and jealously guarded by doctors in their offices. Information kept in detailed color coded charts and recorded in strange cult-like symbols that prevent anybody but doctors from understanding the contents. Once that information is made available to computers and the thousands of new high tech tools chomping at the bit to translate, analyze and recommend what you should buy to treat any ailment ever recorded, the Internet will bring this knowledge to every hamlet and fuel a renaissance of rugged Americanism where every man woman and child will be empowered to manage his or her own health care. The amount of money spent on health care will decrease sharply since the time people spend researching, diagnosing and treating themselves at home, and the cost of technology tools and over the counter remedies to facilitate these activities are not considered health care expenses. The quality of such care will be exponentially improved by harnessing the knowledge and insights of millions, instead of just one medical school graduate. And by definition, the Internet eliminates all disparities, as evidenced by the blossoming democracy in Egypt.

So much empowerment may seem a bit daunting to some who grew accustomed to getting advice from doctors. No need to worry though because this will be a gradual and gentle process. It’s not like you will have to perform an appendectomy on yourself come Monday morning, although it wouldn’t hurt to start practicing simple things like freezing warts at home and researching minor chest pain on Internet boards. When you finally keel over in pain, or are otherwise ready to confront a doctor, you must prepare yourself mentally to act as empowered as possible. While the civic minded insurers have been happy to empower people and let them spend their own money any way they saw fit, doctors find it much harder to relinquish control of their patients. You need to come in with all your symptoms researched, a tentative diagnosis formulated and most important, a preferred course of treatment that fits your cultural values and preferences. You need to resist your doctor’s efforts to tempt you into partaking in the smorgasbord of free tests and procedures, some of which will be harmful to you and others will be very unpleasant for your friendly insurer. If you concur with your doctor’s opinion and have some tests done, make sure you understand WBCs and RBCs, units and normal ranges for the lab you are going to use after shopping around for a good price, and be sure to validate whether you need a differential count or not. The Internet is your friend and all this information is available online. But whatever you do, don’t leave your doctor’s office without an electronic copy of your medical records in a computable format, because any day now, there will be a free app for all these decisions and iWatson will empower you to care for yourself and your loved ones in ways that the log-cabin pioneers couldn’t even dream about. Better, faster and infinitely cheaper.