REMAKING THE ELECTRONIC HEALTH

RECORD

Response to the Broken Promises of the EHR

PETER N. MADRAS, MD

DISCLOSUREWHERE DID MY OPINIONS COME FROM?

DISCLOSUREWHERE DID MY OPINIONS COME FROM?

Asentral Inc Medical Record Bank

The Great Computerization FailureTHE UNFULFILLED PROMISES OF THE

EMR MAY BE THE GREATEST FAILURE IN COMPUTERIZATION HISTORY:◦ Adoption◦ Interoperability

Care Integration Cost ReductionCost Recovery

◦ Patient Safety◦ Practice Efficiency◦ Patient Engagement◦ Computerized Reports

Gingrich and KennedyNew York Times May 3, 2004

$7.3 Trillion over next decadePrevent half of 98,000 deaths from

errors

Kellerman and Jones: Rand Corporation 2005

Saving $81 Billion Annually

The Great EMR Promises: Cost Reduction

The Great EMR Failures: Savings

1. No change in the slope of the overall health cost curve2. Office of National CoordinatorBeaurocracy of HITECH, Meaningful Use4. Enormous Burden on Hospitalsand caregivers

The Great EMR Promises: Improved Quality and Safety

IOM 2001: Identified Communication between providers as a critical area in patient safety, and called for EMRs as means of achieving this goal.

◦General assumption that the EMR would

enhance communication and thereby agreement between providers.

The Great EMR Failure: Improved Quality and Safety

Reality: Decreased “Face to Face Time”Pre-post study of EPIC showed decreased face-to-face communication, worsened overall agreement. “.. (Online BMJ Quality and Safety from Tampa General Hospital April 2014)

The Great EMR Failure: Improved Quality and Safety

The Great EMR Promises: Adoption

1.Provider Adoption: Only 40% of MDs and 27% of hospitals are

using at least a basic EMR system, and

2. Patient Adoption:1. 90% Respond that they should have full access2. 42% Signed up when offered3. 20% viewed their records more than once.

What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology Kellerman and Jones of the RAND Corporation, HEALTH AFFAIRS 32, NO. 1 (2013): 63–68:

The Great EMR Failures: Adoption

The Great EMR Failures: Adoption

Physician Impression of Electronic Medical Record

Failure to Adopt: Physician Impressions of Electronic Medical Record

2012 2013

UnfavorableVery

Favorable UnfavorableVery

Favorable

12.4 5.4 16.1 3.3

PARTIAL LIST OF REASONS FOR POOR ADOPTION

Interference with the Practice of Medicine.Physician as a data-entry personProtocols and Algorithms.

Software StraightjacketComputerized Notes, Discharge Summaries, ConsultsPatient ResentmentRigid Algorithms, Standards of Care, Unfriendly SoftwareExcessive Training time for additional burdens

THE GREAT EMR PROMISES: INTEROPERABILITY

Many Definitions: ◦HAVING ALL NEEDED MEDICAL INFORMATION WHEREVER AND WHENEVER NEEDED

“Prime Directive” of computerizing medical records. All other functions are “nice to haves” but pale in importance.

TECHNOLOGY

THE PRIVACY - INTEROPERABILITY STANDOFF

PRIVACY

ASCENDANCY OF

PRIVACY

1890 - 1965

FROM The right to

privacy

TORIGHT OF PRIVACY

TOCAUSE OF PRIVACY

1965 - 2014 2003 -2014

From a Right to a Cause

“The increasing sophistication of information technology with its capacity to collect, analyze, and disseminate information on individuals has introduced a sense of urgency to the demand for legislation”.

TECHNOLOGY AND LIBERTYThe ACLU’s Project on Speech, Privacy and Technology

“One of the project’s major initiatives…is focused on updating and expanding privacy laws to include new developments in technology….”

Are New Technologies the Enemy of Privacy? ◦“Privacy always has been and needs to be

weighed against other goods (benefits) without an apriori assumption that privacy must trump all other considerations”

◦ Amital Etzioni Know Techn Pol (2007) 20:115-119

RESOLVING THE PRIVACY – INTEROPERABILITY STANDOFF

REMAKING THE EMR:A CLOUD BASED MEDICAL RECORD UNDER PATIENT CONTROL

Criteria for Success:◦Present all relevant Medical Information

wherever and whenever needed.◦Present such information in simple and

intuitive form. ◦Make no demands on physician practice

patterns Allow physician’s undivided attention to the patient

◦Devoid of extraneous features

REMAKING THE EMR:PATIENT CONTROL

Basis◦HIPAA states that patients own their

medical information, ◦A computer based system can guide the

patient, surrogate or counselor in: Every aspect of Health Data Collection,

Assembly, Storage Controlling access to maintain privacy

◦Patient, Surrogate, Caregiver, Family

COMPONENTS OF A PATIENT CONTROLLED MEDICAL RECORD 1. Software Driven, easily

understood and handled by the patient or surrogate.

2. Provides the Method for◦ Record Acquisition of Every Encounter◦ Assembly, classification and storage of every

record. ◦ Accessing record as allowed by the client.

3. Allows Diary entries related to status between visits.

ACCESS

GUIDANCE

EDUCATION

MOTI

VATION

Four Essentials

Remaking the Record

REMAKING THE EMR:USELESS EXTRANEOUS FEATURES

Digitized History and Physicals SchedulingBillingAutomated NotesConflating Hospital Records with Individual’s Health Record

REMAKING THE EMR:CONCLUSIONS.

The Patient Controlled Medical Record can be:

SimplerMore Comprehensive

No Demands on the physician Minimal, if any cost to the health care system.