I started my career in the area of Private Practice Administration and Health Care Information in 1987. When I started I was working for a Cardiology Program and a cardiologist at that time received approximately $1,000 to perform a Cardiac Catheterization on a patient. This procedure requires a physician to stick a guide wire and ultimately a catheter in your groin and push the wire through your body into your heart at which time he injects contrast material through the wire into your heart and then using an X-ray like device he takes X-Rays of your heart to look at the coronary artery tree. The procedure has not substantially changed. This is the same process and they use the same tools today as they did in 1987. The difference is the reimbursement rate is about $250 or one fifth of what it was back in 1987. The cost of living did not go down during this time and the cost of supplies did not go down. What was the rationale to lower the price? I can’t tell you. I can make some guesses. First, more people need caths now than in 1987; the population is aging so more patients are in need of the service. That means it costs the payers, of which the major payer in health care is the government, more money. In addition, the fees for certain services such as inpatient service have increased during the same time frame. You might ask why? Again, I don’t know. I do know that the hospital association has a pretty strong lobby in Washington while doctors are “like herding cats,” they don’t have a strong lobby. Since Medicare is “revenue neutral” if fees get increased in one area they have to be decreased in another area. Thus, if hospital fees go up, it is likely that some other fees like physician fees will go down.
Last year CMS reported that it was going to lower Medicare fees 10% across the board. This went all the way down to the wire and finally they decided not to decrease fees prior to the election, but fees are supposed to drop 20% the next go around. Again, why? Because health cost is going up. Why? We added a Part D medication benefit that increases fees which means other fees have to be reduced. The bottom line is that most of the reductions in Medicare spending have been on the backs of the providers of health care with little or no thought to the workload or the cost of the service. No one really knows what it costs to provide services. Why? Because most of that information is on paper, not digitized! Yet even though all of the medical cost reductions are little more than either decreasing the services that are covered or by arbitrarily lowering fees on providers, everyone expects the provider to pay for these sophisticated electronic health information systems at the upfront cost of between $40,000 and $60,000 per provider and ongoing costs of $7,200 to $10,800 per year per provider while at the same time getting their fees cut. This does not calculate!
The other problem is the business entity that most medical practices utilize. They often use a limited liability corporation or a partnership type of legal entity. The result is they zero out their income at the end of the year. This lowers the tax burden. Unlike companies that are incorporated and can carry “reserve capital” to purchase things, physicians typically have to pay cash or get loans or use a line of credit to purchase equipment. It is not unusual for a practice to 0 out at the end of the year (all leftover money gets distributed to the partners’ base salary). The practice has to take out a line of credit which they can use the first few months of the next year to pay staff salaries and operating expenses and as they begin to collect fees they pay off the line of credit and begin to acquire capital. It could be April before they are in the black again. It doesn’t matter if this is a one-physician office or a 40 physician office, it can work the same way. The problem is that doctors tend to think in 12-month cycles and they will often sit around a table and when presented with a $300,000 expenditure they take the number and divide it by the number of partners and figure out how much salary they will lose that year to purchase this item. If EMR adoption is to be increased, these factors have to be considered and there must be some way to ease the entry up front. Providing $40,000 over five years helps but is somewhat insignificant when typically you have to update your software and hardware within three years. If you go by my above rule of thumb, providing $40,000 over five years is equivalent to $8,000 per year which is a little more than their yearly support fee. Therefore, they still aren’t getting help with the initial start up cost. They truly need the money all at once or a dollar-for-dollar tax credit up to $40k per doctor for one year.
Tuesday, March 24, 2009
Monday, March 23, 2009
2. Create EMR systems that are so complicated that it takes years to achieve full integration into the practice
I spoke of regulation and certifications in previous posts. Again, I will say I am a proponent of the concepts. I am worried currently about the execution. Actually, one of the primary reasons why Providers currently purchase EMR’s isn’t because of benefits they perceive in the delivery of better patient care, it is the worry they have about meeting documentation and government and payer requirements. They are afraid that they can’t survive the increasing requirements for documentation in a paper world. That is very good news for EMR vendors, but it certainly isn’t why I got into this business. I saw that the only way to improve the quality of care while at the same time meeting requirements was to digitize information and make it available to multiple parties. When we first started building the product it was all about the provider and the practice. How can we improve workflow, increase efficiency, and improve patient care. We did a great deal of work with physicians and administrative staff. However, in the past 24 months all of our developmental work has been in response to Government and Certification Regulations and Mandates. E prescribing, CCHIT Certification, PQRI changes, “Red Flag” requirements, and in our case and additional American College of Cardiology IC3 quality initiatives have driven our product development. Instead of asking the question how can we improve quality of care and drive decision support tools, we are asking the question how can we support the “Red Flag” regulations with the least amount of additional effort on the part of the practice. I guess that is a form of improving efficiency, but it is kind of like I am going to give you a 2% incentive for e prescribing but I am cutting your diagnostic image fees by 22%.
My dad once said to me (I learned to drive a car when we still had manual steering), “It is easier to turn the car when you are driving than when you are standing still.” I think increasing regulations and tightening things down over time instead of during the adoption phase would be more conducive to enhancing adoption. However, everyone seems to think that the consequences of not having all these regulations in place are so severe that it is not worth having a digital system. That logic is preventing the adoption of EHR’s.
The other issue I raised in an earlier post was that of the generic nature of Health Care Information Systems. Clinical medicine is a vast enterprise; it incorporates an incredible amount of information. If you break it into functional areas, you would have to indicate that patient population (i.e., adult vs. child, men vs. women, etc.) is a vital area that needs to be considered. For example there are special needs for children that are different from adults and special needs for women versus men. Likewise, treatment location is also an area that has different requirements. Inpatient settings are different than ambulatory settings which are different than in-home treatment settings and require different tools to function effectively. Health care providers such as physicians, nurses, medical assistants, and physician extenders all have different capabilities and perform unique functions in the health care community. Then take one of those elements like Physicians and break that apart into specialties (cardiology, ophthalmology, pulmonologist, pediatric, etc.). These specialists use different diagnostic procedures, different treatments, different syntax to describe patient medical etiology and treatment. Anyone in this business who is honest with you will tell you that there is no one EHR system that can handle these issues. If you try to create one, the scope of the application and the functionality of it would be so complex that even if it could be built you would have to have a four year university degree to be trained in it. Even CCHIT decided to break certification into areas like general ambulatory, Cardiology, Children’s health, inpatient services, etc.
The general trend in the trade journals and the routine advice given by consultants in the area is to band together and use the community model and receive lower prices by getting everyone to purchase the same system and everything will connect. The long and short of it is that everything does not connect, that implementation takes years, and no one gets what they want or need because the scope is too big for one program to handle effectively. The internet didn’t get to be the incredible platform for everyone to use by waiting for someone to build the giant data warehouse that everyone could use. No, just the opposite; it became what it is because nodes of smaller computers systems all linked together to become the large platform that everyone could use. It still works that why. The problem with it is regulations are difficult because no one “owns” it and too many individuals contribute to it. “It is like herding cats.” There is a down side to that and that is for others to discuss; however, we are pretty familiar with the upside and most if not all would agree we are much better off with the internet than when we didn’t have it.
So, be careful of the all knowing all seeing all wondrous EHR that does everything for
My dad once said to me (I learned to drive a car when we still had manual steering), “It is easier to turn the car when you are driving than when you are standing still.” I think increasing regulations and tightening things down over time instead of during the adoption phase would be more conducive to enhancing adoption. However, everyone seems to think that the consequences of not having all these regulations in place are so severe that it is not worth having a digital system. That logic is preventing the adoption of EHR’s.
The other issue I raised in an earlier post was that of the generic nature of Health Care Information Systems. Clinical medicine is a vast enterprise; it incorporates an incredible amount of information. If you break it into functional areas, you would have to indicate that patient population (i.e., adult vs. child, men vs. women, etc.) is a vital area that needs to be considered. For example there are special needs for children that are different from adults and special needs for women versus men. Likewise, treatment location is also an area that has different requirements. Inpatient settings are different than ambulatory settings which are different than in-home treatment settings and require different tools to function effectively. Health care providers such as physicians, nurses, medical assistants, and physician extenders all have different capabilities and perform unique functions in the health care community. Then take one of those elements like Physicians and break that apart into specialties (cardiology, ophthalmology, pulmonologist, pediatric, etc.). These specialists use different diagnostic procedures, different treatments, different syntax to describe patient medical etiology and treatment. Anyone in this business who is honest with you will tell you that there is no one EHR system that can handle these issues. If you try to create one, the scope of the application and the functionality of it would be so complex that even if it could be built you would have to have a four year university degree to be trained in it. Even CCHIT decided to break certification into areas like general ambulatory, Cardiology, Children’s health, inpatient services, etc.
The general trend in the trade journals and the routine advice given by consultants in the area is to band together and use the community model and receive lower prices by getting everyone to purchase the same system and everything will connect. The long and short of it is that everything does not connect, that implementation takes years, and no one gets what they want or need because the scope is too big for one program to handle effectively. The internet didn’t get to be the incredible platform for everyone to use by waiting for someone to build the giant data warehouse that everyone could use. No, just the opposite; it became what it is because nodes of smaller computers systems all linked together to become the large platform that everyone could use. It still works that why. The problem with it is regulations are difficult because no one “owns” it and too many individuals contribute to it. “It is like herding cats.” There is a down side to that and that is for others to discuss; however, we are pretty familiar with the upside and most if not all would agree we are much better off with the internet than when we didn’t have it.
So, be careful of the all knowing all seeing all wondrous EHR that does everything for
Friday, March 6, 2009
3. Create a one size fits all EMR system
Here is another one of those statements that fly in the face of all the pundits out there who state they are experts on EMR. This also is in opposition to what the government is supporting. I understand the thinking. It goes something like this. EMR is an expensive proposition. We need to make these systems cheaper if we want adoption. How do we make t his digital conversion cheaper? One way is to have many physicians share the same system. Increase volume use can reduce prices. One method is using a SAS or ASP model. SAS stands for Software as Service (Wall Street Loves this) This is subscription based product that allows the provider to pay a monthly fee and reduces the overall entry cost to EMR by sharing hardware with others, not having to pay for on site IT support and only pays for what you need when you need it. ASP or Application Service provider is the same concept. It is a subscription based model where a provider pays monthly. The real savings for this type of service is in volume so it is important that you have many customers sharing the same data center, same applications etc. Obviously the assumption being made here is that it is possible to standardize the hardware, communications systems and the software that physicians use.
In my opinion that is where this concept breaks down. First, the most difficult EMR software to develop is primary care or internal medicine software. The reason for this is the breadth of services these professional have to offer. One patient could have ear infections and be 4 years old, the next could be a 55 y ear old with Angina and the next patient could be 80 years old with colon cancer. We worked on the knowledge base and workflow for Cardiology services for years before we got a comprehensive knowledge base and workflow tools. In my opinion that same process needs to take place for every single specialty in medicine (ie., pulmonary, Oncology, Orthopedic etc.) and then and only then will you be able to create a truly efficient EMR that reduces the physicians time to care for patients and increases their efficiency. I will also state categorically that I am biased because I sell a single specialty (Cardiology Specific) program. But I have some support for what I say. We are a small company, our product is arguably considered the premier product for Cardiology in country. We have sold more totally integrated Health information systems to Cardiologist then all our other competitors who are very very large companies with Market and selling budgets larger than our whole company. How can we do that? Our product is not cheaper then theirs? We have 1 sales person to 1000 of theirs. We can do it because our product works the best for Cardiologist. It is specialized for the Cardiologists. I dear say if I could solve the cost problem for them we could increase adoption tremendously. It is also why we don’t have large scale adoption because a general EMR does not make the physician more efficient it makes their job harder and requires the provider to customized the product to fit their knowledgebase and their workflow.
One interesting fact I discovered in two different EMR conferences was the length of time it took most practices to become fully implemented (every employee and every physician using the product). We went to two different national conferences where 4 of the top sellers in Cardiology EMR’s brought in two customers to present about how they selected their product, how they implemented their product and what kind of Return on Investment (ROI) they received. The interesting thing to note was that of 8 groups that presented only 2 (our customers) were fully implemented. Also interesting these groups all started the implementation at roughly the same time and it was three years later. It is hard to get an ROI when in less than 5 years when it takes over three to come up on the system. Why so long? There are lots of reasons. Some groups want to come up slowly because it takes internal resources, but a good deal of it is that the system is too generic and not specific enough for their workflow. Thus, they have to “build” their own version of the EMR with their language and workflow units and that takes a considerable amount of time just to get it so the practice can use it. Having a generic EMR is like saying I have a hammer and everything else must be a nail. Unfortunately it is not that simple.
In my opinion that is where this concept breaks down. First, the most difficult EMR software to develop is primary care or internal medicine software. The reason for this is the breadth of services these professional have to offer. One patient could have ear infections and be 4 years old, the next could be a 55 y ear old with Angina and the next patient could be 80 years old with colon cancer. We worked on the knowledge base and workflow for Cardiology services for years before we got a comprehensive knowledge base and workflow tools. In my opinion that same process needs to take place for every single specialty in medicine (ie., pulmonary, Oncology, Orthopedic etc.) and then and only then will you be able to create a truly efficient EMR that reduces the physicians time to care for patients and increases their efficiency. I will also state categorically that I am biased because I sell a single specialty (Cardiology Specific) program. But I have some support for what I say. We are a small company, our product is arguably considered the premier product for Cardiology in country. We have sold more totally integrated Health information systems to Cardiologist then all our other competitors who are very very large companies with Market and selling budgets larger than our whole company. How can we do that? Our product is not cheaper then theirs? We have 1 sales person to 1000 of theirs. We can do it because our product works the best for Cardiologist. It is specialized for the Cardiologists. I dear say if I could solve the cost problem for them we could increase adoption tremendously. It is also why we don’t have large scale adoption because a general EMR does not make the physician more efficient it makes their job harder and requires the provider to customized the product to fit their knowledgebase and their workflow.
One interesting fact I discovered in two different EMR conferences was the length of time it took most practices to become fully implemented (every employee and every physician using the product). We went to two different national conferences where 4 of the top sellers in Cardiology EMR’s brought in two customers to present about how they selected their product, how they implemented their product and what kind of Return on Investment (ROI) they received. The interesting thing to note was that of 8 groups that presented only 2 (our customers) were fully implemented. Also interesting these groups all started the implementation at roughly the same time and it was three years later. It is hard to get an ROI when in less than 5 years when it takes over three to come up on the system. Why so long? There are lots of reasons. Some groups want to come up slowly because it takes internal resources, but a good deal of it is that the system is too generic and not specific enough for their workflow. Thus, they have to “build” their own version of the EMR with their language and workflow units and that takes a considerable amount of time just to get it so the practice can use it. Having a generic EMR is like saying I have a hammer and everything else must be a nail. Unfortunately it is not that simple.
Thursday, March 5, 2009
4. Create standards that make the system cost more to purchase and more difficult to use.
When I first started the adventure we call EMR back in 1994 I looked at what some of the barriers to adoption might be. Back in the early days one of the most cited reasons that electronic EMR was not going to be successful was the notion that the Patients would not like it. They would feel it was impersonal and they would be afraid about security. I did a survey on 100 patients coming into our practice and asked a series of questions regarding their thoughts. The findings were surprising. First, the patients resounding love the concept. They thought it would improve health care immensely and they hoped they would not have to answer the same questions over and over again as they were currently doing. Second, they were adamant that they did not want their data stored or transmitted on the internet. This is particularly interesting since the health care information models being promoted today are dependent on the internet and third they did not want their clinical information going to their insurance company. The last one blew me away since all the patients sign an authorization form with the practice to provide all the information to the insurance company. What I found out after some additional interviews it was their Life Insurance carrier they were worried about. They were afraid they wouldn’t be able to get insurance or that their premiums would go way up.
I have provided this back ground for you to indicate that patients want their doctors to be digital and have every thing stored on computers, but they would prefer that the physician keep the information at their site. Most of the standards and regulations that are being promulgated are around sharing the patient information. These regulations include security, confidentiality, and identity theft, authentication of user or dispenser of treatment. Again, it is not that I am against these things I am all for them but they must be structured in a way that improves workflow instead of complicating it. In addition, these regulations are coming from everywhere. The federal government is a significant player, the State government has their own rules, and third party payers have rules and interesting enough they may conflict. Let’s look at a couple of examples.
As I mentioned before under the federal regulations for prescriptions the “dispenser” the person licensed or certified to prescribe medication must and authenticate the medication. In the terms of EMR authenticating is verifying that you as the prescriber are legally liable for the prescription and have the authority to prescribe it. Think about it as signing your name to a check. However, signing one’s name is more difficult in the technology field. Some programs use user name and then a personal identification number (PIN). For example when you go to an ATM machine to get your money you put your card in and you put in your PIN to verify its you. Well the regulations that are coming down with regard to authentication are requesting the same thing. The federal guidelines say that the “dispenser” must send the prescription. They must log on with their user id and they must somehow sign the prescription usually using a PIN number so the two forms of Identification are the Log in and PIN just like when you use the banking on line. However, I know of one state in particular that won’t allow that method. They want a physician to either have a smart card and a PIN (like a credit card and PIN) or they want to have the Dispenser to use biometric methods like a finger print or a retinal scan. Since there are few to no private physician groups that have biometric capabilities per prescription like they want they will allow for the following. A “paper” report gets developed each week that identifies every medication provide to patients on behalf of the physician. The physician must read and verify each one and then sign their name in “ink” on the paper and date it and store it for future verification if needed. So besides all the other checking that physicians have to do the mainstream methods for authenticating one self (User ID and PIN number or Password) are not acceptable. They must print out on paper a report and sign it and store it. It seems kind of odd to create paper to support a paper free electronic system. I already mentioned that e prescribing requires the physician to subscribe to data services to obtain up to date information prior to prescribing. This would be fine if the physician could charge a fee for this service but they can’t unless they make you come into the office. Oh and by the way providers are expecting another fee reduction from Medicare next year.
Recently, it was decided that everyone who allows customers or in this case patients to pay their bill on “account” or over time must follow the federal trade commission rules on “Red Flags” Red Flags are notifications that the practice identifies that may suggest there is a case of identity theft. The practice must but into place an anti identity theft program which should be as sophisticated as it needs to be based on the practice. No guidelines are given or what that means but in theory if you are a small program (defined by doctors and dollars generated I guess) your anti identity program doesn’t have to be that complicated but if you are a large program (20 physicians etc) then it must be more sophisticated. Here some things that the FTC would like to see happen. If someone calls up and wants to change their address you must verify who they are (they must have something like a PIN number that they give to you) prior to you changing their information in the system. It must be logged on what date, what time and who made the change. If someone comes to you for service you will need to check their government picture ID to verify the patient. Unlike the rules of almost every state that says you can never delete anything from a medical record that you have to draw a line through the data and indicate it is no longer valid (usually because if a treatment was given you want some idea of the data that was used to determine the treatment at the time) However, these rules state that if the data in a EMR was part of an identity theft you need to physically remove it from the record and store it in a Jane or John Doe folder tied to the record. (This is so that people don’t make a mistake and treat the real patient inappropriately because of fraudulent data) both reasonable approaches but they conflict so which one do you follow? There is a fair amount of programming that needs to take place that involves audit trails, setting up special screens for tracking, setting up alerts when demographic data does not match etc. The provider will end up paying for those changes in update fees. These FTC Red Flag mandates are on top of the already agreed upon and mandated HIPAA security and patient confidentiality requirements which also require the practice to set up a security program, including policy and procedures, auditing and monitoring program and someone designated on site as the Security Officer. The Red Flag rules state that a senior officer or Executive Level manager must over see the Red Flag program.
As soon as the Red Flag program was announced I was hit with phone calls from my customers asking when we were going to have the changes put in our program to automate these functions for them. Of course if you don’t have an EMR you are exempt from many of these regulations and don’t have to worry about them. Again, I don’t see these regulations as something that encourages adoption but something that slows the process down.
I have provided this back ground for you to indicate that patients want their doctors to be digital and have every thing stored on computers, but they would prefer that the physician keep the information at their site. Most of the standards and regulations that are being promulgated are around sharing the patient information. These regulations include security, confidentiality, and identity theft, authentication of user or dispenser of treatment. Again, it is not that I am against these things I am all for them but they must be structured in a way that improves workflow instead of complicating it. In addition, these regulations are coming from everywhere. The federal government is a significant player, the State government has their own rules, and third party payers have rules and interesting enough they may conflict. Let’s look at a couple of examples.
As I mentioned before under the federal regulations for prescriptions the “dispenser” the person licensed or certified to prescribe medication must and authenticate the medication. In the terms of EMR authenticating is verifying that you as the prescriber are legally liable for the prescription and have the authority to prescribe it. Think about it as signing your name to a check. However, signing one’s name is more difficult in the technology field. Some programs use user name and then a personal identification number (PIN). For example when you go to an ATM machine to get your money you put your card in and you put in your PIN to verify its you. Well the regulations that are coming down with regard to authentication are requesting the same thing. The federal guidelines say that the “dispenser” must send the prescription. They must log on with their user id and they must somehow sign the prescription usually using a PIN number so the two forms of Identification are the Log in and PIN just like when you use the banking on line. However, I know of one state in particular that won’t allow that method. They want a physician to either have a smart card and a PIN (like a credit card and PIN) or they want to have the Dispenser to use biometric methods like a finger print or a retinal scan. Since there are few to no private physician groups that have biometric capabilities per prescription like they want they will allow for the following. A “paper” report gets developed each week that identifies every medication provide to patients on behalf of the physician. The physician must read and verify each one and then sign their name in “ink” on the paper and date it and store it for future verification if needed. So besides all the other checking that physicians have to do the mainstream methods for authenticating one self (User ID and PIN number or Password) are not acceptable. They must print out on paper a report and sign it and store it. It seems kind of odd to create paper to support a paper free electronic system. I already mentioned that e prescribing requires the physician to subscribe to data services to obtain up to date information prior to prescribing. This would be fine if the physician could charge a fee for this service but they can’t unless they make you come into the office. Oh and by the way providers are expecting another fee reduction from Medicare next year.
Recently, it was decided that everyone who allows customers or in this case patients to pay their bill on “account” or over time must follow the federal trade commission rules on “Red Flags” Red Flags are notifications that the practice identifies that may suggest there is a case of identity theft. The practice must but into place an anti identity theft program which should be as sophisticated as it needs to be based on the practice. No guidelines are given or what that means but in theory if you are a small program (defined by doctors and dollars generated I guess) your anti identity program doesn’t have to be that complicated but if you are a large program (20 physicians etc) then it must be more sophisticated. Here some things that the FTC would like to see happen. If someone calls up and wants to change their address you must verify who they are (they must have something like a PIN number that they give to you) prior to you changing their information in the system. It must be logged on what date, what time and who made the change. If someone comes to you for service you will need to check their government picture ID to verify the patient. Unlike the rules of almost every state that says you can never delete anything from a medical record that you have to draw a line through the data and indicate it is no longer valid (usually because if a treatment was given you want some idea of the data that was used to determine the treatment at the time) However, these rules state that if the data in a EMR was part of an identity theft you need to physically remove it from the record and store it in a Jane or John Doe folder tied to the record. (This is so that people don’t make a mistake and treat the real patient inappropriately because of fraudulent data) both reasonable approaches but they conflict so which one do you follow? There is a fair amount of programming that needs to take place that involves audit trails, setting up special screens for tracking, setting up alerts when demographic data does not match etc. The provider will end up paying for those changes in update fees. These FTC Red Flag mandates are on top of the already agreed upon and mandated HIPAA security and patient confidentiality requirements which also require the practice to set up a security program, including policy and procedures, auditing and monitoring program and someone designated on site as the Security Officer. The Red Flag rules state that a senior officer or Executive Level manager must over see the Red Flag program.
As soon as the Red Flag program was announced I was hit with phone calls from my customers asking when we were going to have the changes put in our program to automate these functions for them. Of course if you don’t have an EMR you are exempt from many of these regulations and don’t have to worry about them. Again, I don’t see these regulations as something that encourages adoption but something that slows the process down.
Tuesday, March 3, 2009
5. Spend the money from the new stimulus package for a National Health Care Network and Health Care Exchanges and not Electronic Medical Record System
I have read in some recent publications that there is growing support to use the stimulus money earmarked for EMR adoption for the development of health care exchange networks both regionally and nationally. This is sort of like a highway to allow digital information to move from physician to physician from facility to facility from insurance companies to doctors and the like. Think of it as either a digital highway or a health care internet. Again, I don’t want to sound like I think health care data exchange is a bad idea. I wouldn’t be in this business if I did. Let me try to give you a couple of examples why I think the concept of health care exchange is putting the cart before the horse.
To further the analogue, let’s consider that the first automobile was created in Europe in the late 1800’s. We began automation of the automobile in the beginning of the 1900’s and assembly line production occurred prior to 1915. By 1920 Ford had produced over 18 million automobiles. Yet we did not get a National Highway system until the 1950’s, more than 50 years after the first car. Building a highway system sooner would have been a waste of money. There was not enough use to warrant it. The idea of “build it they will come” did not make sense.
We had personal computers in the early 1970’s; they became popular in the 1980’s. The internet became available in the late 1980’s and by the 1990’s some people had the idea that the internet was the next big thing. They put together business models for making money and everyone got excited in the late 1990’s (we had millions of personal computers in operation at the time); however, we had a technology bust in the marketplace due to the unrealized potential of the internet business models. In short, we had computers but not inexpensive internet communication technology. It took another 10 years for the internet to become viable. The business models that did not work in the late 90s are becoming main stream today.
There is real value in getting physicians to use digital information systems in their practice. It provides data to providers more quickly; errors are reduced by structuring the data collection process. The data can be accessed by multiple individuals simultaneously. The data can usually be printed and faxed more quickly, etc., etc. I have a problem when I hear “experts” in EMR’s say that EMR’s are not useful if they don’t interface to all other health systems and integrate all of the patient’s data in one spot. People forget that the current system of clinical data collection and reporting dates back to the 1700’s; we are using pen and ink on paper and storing this paper in folders and only one person can review the paper at a time. Single papers can be taken out of the folder and folders can be misfiled. Some practices order the folder by the alphabet and they are not even using a digital number sequence to insure proper filing. There are considerable benefits to EMR’s in their own right that are not connected to anything. To say that adoption would only occur rapidly if we have an easy way to exchange the data suggests that we have good data to exchange, and I would challenge that assumption in a paper world.
In summary, there must be a critical mass of users before data exchange and digital highways make sense. Data exchange is not the barrier to EMR adoption. Money and lack of efficiency for the physicians are the barriers. The stimulus money should be used to offset the cost to the physicians directly and products that increase the efficiency of the physicians should be encouraged.
To further the analogue, let’s consider that the first automobile was created in Europe in the late 1800’s. We began automation of the automobile in the beginning of the 1900’s and assembly line production occurred prior to 1915. By 1920 Ford had produced over 18 million automobiles. Yet we did not get a National Highway system until the 1950’s, more than 50 years after the first car. Building a highway system sooner would have been a waste of money. There was not enough use to warrant it. The idea of “build it they will come” did not make sense.
We had personal computers in the early 1970’s; they became popular in the 1980’s. The internet became available in the late 1980’s and by the 1990’s some people had the idea that the internet was the next big thing. They put together business models for making money and everyone got excited in the late 1990’s (we had millions of personal computers in operation at the time); however, we had a technology bust in the marketplace due to the unrealized potential of the internet business models. In short, we had computers but not inexpensive internet communication technology. It took another 10 years for the internet to become viable. The business models that did not work in the late 90s are becoming main stream today.
There is real value in getting physicians to use digital information systems in their practice. It provides data to providers more quickly; errors are reduced by structuring the data collection process. The data can be accessed by multiple individuals simultaneously. The data can usually be printed and faxed more quickly, etc., etc. I have a problem when I hear “experts” in EMR’s say that EMR’s are not useful if they don’t interface to all other health systems and integrate all of the patient’s data in one spot. People forget that the current system of clinical data collection and reporting dates back to the 1700’s; we are using pen and ink on paper and storing this paper in folders and only one person can review the paper at a time. Single papers can be taken out of the folder and folders can be misfiled. Some practices order the folder by the alphabet and they are not even using a digital number sequence to insure proper filing. There are considerable benefits to EMR’s in their own right that are not connected to anything. To say that adoption would only occur rapidly if we have an easy way to exchange the data suggests that we have good data to exchange, and I would challenge that assumption in a paper world.
In summary, there must be a critical mass of users before data exchange and digital highways make sense. Data exchange is not the barrier to EMR adoption. Money and lack of efficiency for the physicians are the barriers. The stimulus money should be used to offset the cost to the physicians directly and products that increase the efficiency of the physicians should be encouraged.
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