The following two blog posts are well worth a careful read as they point out some serious issues that need to be addressed as the Obama administration plans the details of its Health IT initiative.
January 05, 2009
Let's Reboot America's HIT Conversation Part 1: Putting EHRs in Context
Kibbe & Klepper are back with an update to their pre-Christmas piece on EHRs and the forthcoming Obama Administration's investment policy towards them. Lest you think that this is just a small group here on THCB and fellow traveler blogs shouting to each other, I'd point you towards the Boston Globe article about their previous "Open Letter," which shows that this discussion (and a similar piece on THCB from Rick Peters) appears to be being taken very seriously. As it should--Matthew Holt
On Dec. 19, we published an Open Letter to the Obama Health Team, cautioning the incoming Administration against limiting its Health Information Technology (IT) investments to Electronic Health Records (EHRs). Instead, we recommended that their health IT plan be rethought to favor a large array of innovative applications that can be easily adopted to result in more effective, less expensive care.
The response to that post was vigorous. We received many comments and inquiries from the health care vendor, professional and policy communities - urging us to provide more clarity. One prominent commentator called to ask whether we, in fact, supported the use of EHRs. We both have been active EMR and health IT supporters for many years. Dr. Kibbe was a developer of the Continuity of Care Record (CCR), a de facto standard format for Electronic Medical Records (EMRs), and has assisted hundreds of medical practices to adopt EHRs. Dr. Klepper has been involved in EMR projects for the last 15 years, and the onsite clinic firm he works with provides every clinician with a range of health IT tools, including EMRs.
That said, we are realistic about the problems that exist with health information technologies as they are currently constituted. As we described in our previous post (and contrary to some recent claims), most products are NOT interoperable, meaning licensees of different commercial systems - each using different proprietary formats - often find it difficult to exchange even basic health care information.
Most EHRs are bloated with functions that often are turned off by practitioners, that are promoted politically through the current CCHIT certification process, and that drive up costs of purchase, implementation and maintenance. Despite moving toward Web-based delivery models that have MUCH lower transactional costs than old-fashioned client/server approaches, most commercial offerings are still extremely expensive, especially compared to the revenue flows of the relatively small operations they support. (Dr. John Halamka's recent recommendation that the Fed invest $50,000 per clinician for rapid implementation of "interoperable CCHIT certified electronic records with built in decision support, clinical data exchange, and quality reporting" provides an idea of the resource allocations that are on the table.) The very wide range of choices in the market currently raises the question of whether the implementation of a national EHR infrastructure MUST be so costly.
Much more here:
http://www.thehealthcareblog.com/the_health_care_blog/2009/01/lets-reboot-ame.html#more
The second part is here:
January 06, 2009
Let's Reboot America's Health IT Conversation Part 2: Beyond EHRs
Yesterday we tried to put EHRs into perspective. They're important, and we can't effectively move health care forward without them. But they're only one of many important health IT functions. EHRs and health IT alone won't fix health care. So developing a comprehensive but effective national health IT plan is a huge undertaking that requires broad, non-ideological thinking.
As we've learned so painfully elsewhere in the economy, the danger we face now in developing health care solutions is throwing good money after bad. We don't merely need a readjustment of how health IT dollars are spent. We need to reboot the entire conversation about how health IT relates to health, health care, and health care reform. To get there, we need to take a deep breath and start from well-established and agreed-upon principles.
Most of us want a health system that, whenever possible, bases care on knowledge of what does and doesn't work - i.e., evidence. We want care that is coordinated, not fragmented, across the continuum of settings, visits and events. And we want care that is personal, affordable and increasingly convenient.
Most of us also agree that, so far, we have not achieved these ideals. In fact, health care continues to become costlier, quality is spotty, and the gap between the health care we believe possible and the current system is widening.
We believe that most health care professionals are acutely aware that more health IT alone cannot resolve these problems. Despite billions of dollars in health IT investments by health care professionals and organizations, the gap persists and is widening. Many physician practices have expanded their health IT functions, moving beyond electronic billing systems - a necessary asset to be paid by Medicare - toward EMRs and from paper to software systems. About a quarter of US physicians use EHRs from commercial vendors. Hospitals and health plans - larger, corporate organizations with more dedicated capital resources - have implemented health IT more quickly. Even so, the tools implemented have typically been focused on record-keeping and transactional processing, not decision-support. Health care clinical and administrative decisions have not yet become more rational, less tolerant of waste and duplication, or more congruent with evidence.
We don't need simply more health health IT; instead, we need an array of specific health IT functions and capabilities that can facilitate better care at lower cost, and the adherence to evidence-based rules.
What would those empowering health IT products look like, and what would they do?
Focusing on Decision Support
ost important, new health IT would help patients, clinicians, managers and purchasers make the best possible clinical and administrative decisions. This includes identifying risks and following the best path to lowering them whenever possible. Health IT should help people stay healthy and avoid illness through active clinical decision support, and make sure that the system recognizes value. Which patients, according to past data, have acute or chronic conditions that need care? Which, do the data show, are the most effective (or high value) doctors, hospital services, treatments and interventions - so that the market can work to drive efficiency. Given a particular set of signs or symptoms, lab test results, or genetic test, what is the best next step in care?
Technology and information engineering is readily available to do this. Car technologies now help drivers understand when a problem is occurring, or is likely to occur, monitoring and communicating fluid levels, tire pressure, maintenance appointments, and location in case of emergency. Banking technologies can flag suspicious credit card purchases and can instantly invalidate charge cards. Recently, Google trended flu searches to help estimate regional flu activity; their estimates have been consistent with the CDC's weekly provider surveillance network reports.
By comparison, most health IT is relatively unsophisticated. In general, the prevailing front line tools do not yet help clinicians identify individual- or population-level health risks. They do not yet provide guidance with evidence-based approaches that can best mitigate those risks, create alerts and reminders, or help monitor adherence to care plans, even though the data are now clear that most Americans die and we pay the most money due to easily preventable and managed conditions.
In short, we monitor our cars and bank accounts better than we do our health. We can change this.
Much more good stuff with lots of comments here:
http://www.thehealthcareblog.com/the_health_care_blog/2009/01/lets-reboot-a-1.html
Browsing these two posts and the associated comments is a very interesting exercise indeed and to be commended to all. The approach suggested seems pretty sensible to me!
David.
Unfortunately the writers of these articles appear confused about the definitions of EHRs and EMRs and use the terms interchangeably. This is evidenced by their reference to the CCR document as part of the EMR.
ReplyDeleteThe Continuity of Care Record (CCR) is used for cross-practice communication. It does not live in a single EMR, nor should it. It is either sent as a message or lives in a SEHR.
There are two quite separate concepts:
- the records a practice keeps (often called EMR)
- a cross-practice record of health care (called variously SEHR, IEHR, RHIO, etc)
EHR is an ambuguous term and should only be used after defining it, or preferably not at all.
"EHR is an ambiguous term and should only be used after defining it, or preferably not at all."
ReplyDeleteAgree - and if you are using it to refer to a system as opposed to a specific electronic patient record, do everyone a favour and strap an 'S' to the end.