Wednesday, November 24, 2010


EMR "meaningful use"

The Economic Recovery Act and The Affordable Health Care Act have mandated that all health care providers adopt electronic medical records (EMR). As proposed and mandated the EMR is a dangerous sham.

Nearly thirty years ago I began to design my ideal medical office computer system. When I began my solo family practice in 1983 I immediately designed and implemented some of the system. Over time I was able to understand the information management needs of my practice and by 1996 I was able to fully implement my ideal "paperless office".

In that year I integrated then shredded the thousands of paper charts, some dating back over fifty years to my predecessor doctor. I now had nearly instant access to my patients' entire medical record. In the subsequent fourteen years I have continued to develop the system. I have designed it for maximum efficiency and ease of use. It allows me with a small office staff (equivalent to only two full time employees) to take care of the primary care needs of over three thousand patents. They are very pleased with my care. I see patients more often than not within hours of their call. I take or return all calls daily, and the time in the waiting room is reliably less than ten minutes. I see about thirty patients daily, occasionally as many as fifty. The electronic medical record facilitates this efficiency.

The components of the system are fully integrated. They include:
1- Patient demographics
2- Appointment scheduling
3- Billing
4- Problem list
5- Office notes
6- Lab reports
7- EKGs
8- Medication lists
9- Immunization logs
10- Word processors
11- Filed external documents (scanned paper)

Every exam room has an identical terminal. The front desk has two and the work room and lab and my office each have terminals as well. For just one doc and a few office workers there are eleven computers: you are never more than a few steps away.

The speed of the system is such that any piece of information is no more than a dozen key clicks and a split second of processing away.

The database is fully relational and related elements are a key click away. The data is fully indexed and searchable. (Computer talk for it is easy to find out anything you want to know, even if you have not decided yet what that is).

The lab drawn by 5 PM and sent to two different clinical labs is filed in the patients' record by 8 AM in the morning the next day, ready and flagged for review. The office notes are dictated (full text detailed SOAP notes) then transcribed and automatically filed in the patients' record. Prescriptions are easily typed in the record and refills are a single key click. The prescriptions are legible: they are printed in full text, ready for my signature. The record is updated automatically. The patient's problem list is automatically updated from their check-out diagnoses. Their immunization log is automated and tracks the lot number of the vaccines administered. EKGs are never paper (unless they must be given to someone else): they are recorded directly into the patient's record. A wide variety of reports and notes and referrals are automatically printed. Scanned documents, filed by patient ID, date, and type (well over a quarter million pages so far) are retrieved with a maximum of a dozen key strokes, the first page on the screen within two seconds and subsequent pages in a fraction of a blink. There are lots of interesting bells and whistles (such as memo flags that appear when an appointment is scheduled or a patient is checking out). Check out and patient billing are simplified by fully searchable CPT and ICD9 codes, and simple two-letter "quick codes" for common procedures and diagnoses. No demographic information requires re-entry.

The system is designed for complete on-site security. There is no connection to the Internet. Links to laboratories are done through secure dedicated lines or via intra-office data transfer. The data is protected by on-site and off-site backup servers. Off-site access is secure: I carry a back-up of the entire system compressed in my pocket: any computer with a USB port becomes a terminal with all the data readily available!

All together it is a "way cool" system and it not only documents everything well, but frees me and my staff for the real game: taking care of people.

And yet, this system fulfills NONE of the governmental mandates for an EMR. The "meaningful use" minimal requirements are:
1- electronic prescribing
2 - sharing of records
3 - documentation of quality

Other criteria include demographic uniformity and standardized formatting.

Fully implemented, electronic prescribing may reduce prescription errors. It is, however, designed to limit the formulary, save insurers money, constrain and normalize prescribing patterns, and MONITOR WHAT DRUGS YOU GET. (Is that in caps?)

Electronic record sharing essentially means that any government agency has access to everything that was confidential. Since the Internet is the medium used to share the records, you can be assured of privacy and security -- NOT. (Oops - caps again?)

"Documentation of quality" is code for "practice according to governmental standards", with direct penalties and censure for doctors out of compliance.

There is nothing in the requirements for any real benefit to patients or physicians. As mandated it is a true threat, strike that, a true guarantee of loss of privacy.

And the cost of implementation? The Economic Recovery Act hinted at a rebate of over $40,000 per physician to implement the system. In reality, the amount is far less and is available only to those doctors who participate in Medicare. All pediatricians and over half of all other physicians will be excluded from any financial support. Full implementation will cost a lot more. And there is a financial penalty for not implementing an EMR with the above mentioned "meaningful use" criteria.

Wake up physicians: you are being forced to do things that are counter to your science, beliefs, and practices! Wake up people: your rights are about to be terminated. Wake up legislators: you are meddling in things of which you have no knowledge which will result in damages far beyond your imagination.

The mandate for EMR is directly related to people not taking responsibility for their own health care. In the end, it is driven by the fact that someone else is paying. It would be cheaper and more practical for me to be responsible for managing/controlling my own medical information rather than making the entire medical and government community responsible for keeping my 'secrets'. EMR is on a collision course with HIPA.
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