If you've been having trouble reaching your doctor lately, maybe you should try hanging out in the blogosphere. The prospect of a $19.2 billion investment in electronic medical records (EMRs) — the always controversial, not-so-new thing that is supposed to deliver better health care and lower costs — has driven docs to step into a new digital divide. Some lament product features about EMRs they've known (It won't print. I have to constantly reboot); others get philosophical about the future of medicine (What about privacy?).
Doctors can debate, but it looks as if EMRs are here to stay. The American Recovery and Reinvestment Act states that every American should be provided an electronic medical record by 2014. The Obama administration is looking to speed the transition by providing financial incentives, up to $65,000 apiece to eligible physicians, starting in 2011.
At the most basic, EMRs are digital documentation of a doctor's visit, including patient histories, exam notes, tests ordered, drugs prescribed, and any results. Some systems check for drug interactions, access X-rays, or deliver a prompt when a patient has not had a flu shot. "The preventive aspects alone have saved millions of dollars and thousands of hospitalizations," says Dr. Steve Zeitzew, an orthopedic surgeon at the Veterans Administration West Los Angeles Healthcare Center.
So far, only 17% of doctors use even a basic EMR, and so far, most have had little reason to try. The average primary-care physician, earning, say, $110,000 a year, has no time to research the right EMR system from the 160 certified products out there, and less time to learn how to use it. "The hardware and software will cost you some $50,000," says health-care-IT guru Dr. John Halamka — he's CIO and dean for technology at Harvard Medical School and chairman of the New England Health Electronic Data Interchange Network, among other roles — "then 25% of your productivity will disappear as you implement it, patients will complain, and half your office will quit." Worse, if the system does work, the doctor makes less money. "A doctor doesn't get paid for illness she prevents," says Halamka. Cough up money for an MRI machine and the first time you use it, "you get $1,000." Cough up the $50,000 for an EMR system and you get nothing but headaches.
The dream of interoperable EMRs, which would create a mass database where we can detect epidemics and study drug interactions, has yet to be realized. Financial incentives from the government and private insurers may help, but there are other hurdles to overcome. Here are three places to begin.
TEACH THE DOCTORS WELL
Asking doctors to do this on their own is a recipe for disaster. Halamka applauds the regional health-care-IT centers that are outlined in the stimulus bill — "SWAT teams," as he calls them. "Vendors," he says, "are good at creating products, but not good at implementation, or workflow, or practice reengineering." He cites regional public-private hybrids in Massachusetts and in New York City that have helped deploy hundreds of EMRs.
TAKE OPEN SOURCE SERIOUSLY
The VA's VistA clinical software system, available for free under the Freedom of Information Act, has been a shining example of how EMRs can work. The VA relies on technology developed in-house, so iteration can be slow, but several modified versions exist for non-VA applications. A faster-track solution may be on the horizon. A recent meeting of WorldVistA, a not-for-profit group of VistA developers and fans, focused on creating an open-source collaboration model — think Mozilla's Firefox — to make the platform a real alternative to privately developed systems, one to be shared freely.
The fundamental problem is that doctors get paid for service, not wellness. The ideal is to find real patterns in health, safety, and wellness in EMRs, and reward accordingly. That requires the widespread adoption of a truly interconnected system that doesn't quite exist yet. Even in the widely used VA EMR system, some data are recorded and shared, and some aren't. Once we solve that problem, it will take the determination of all parties — including the government, through reform to Medicare and Medicaid — to put in place a new way of paying doctors and health systems.