Thank you for sponsoring The Wireless Future of Health IT. I realize it was a short forum but I think an important piece of any discussion on healthcare is security and privacy. The US Government in general has done a poor job of cybersecurity and there are almost daily reports of breaches of patient healthcare information.
The VA recently paid a multi-million dollar penalty for temporarily loosing a laptop full of patient information and the drug store chain CVS was fined under HIPAA several million dollars for their poor privacy practices.
I think before there are any massive amounts of money spent on electronic medical records there has to be a policy, framework, enforcement and penalties to secure patient information.
Thank you.

Regards,

David Frenkel
Reston, VA

This is a very interesting post onIT and health care joining together for maximum efficiency t. I still believe that our private info should not be transferred digitally, only stored digitally and not connected to the web in anyway.
Check this out , pretty disturbing already
http://www.nextgov.com/nextgov/ng_20090227_9147.php

Computerized Medicine

Electronic Medical Records (EMRs) are essentially digital treatment platforms that contain significant patient variables, such as the medical history of the patient, as well as existing medical conditions. This data as well as other relevant information assure to a higher degree that the treatment patients receive from their health care provider when it is needed is reasonable and necessary.
The first large demonstration of the effectiveness of EMRs was with the VA Hospital’s Vista System. The code was written by doctors for doctors, and has about 18000 pages within Vista. Author Phillip Longman wrote a book about this system and the quality it allowed for superior health care, which was entitled, “Best Care Anywhere.” The Vista is the largest EMR in the United States.
The first large demonstration of the effectiveness of EMRs was with the VA Hospital’s Vista System. The code was written by doctors for doctors, and has about 18000 pages within Vista. Author Phillip Longman wrote a book about this system and the quality it allowed for superior health care, which was entitled, “Best Care Anywhere.” The Vista is the largest EMR in the United States.
EMRs have the potential to prevent unfortunate medical errors that occur, which cause around 100 thousand deaths a year. For many other reasons beneficial for patients, EMRs are encouraged to be utilized within medical facilities. In fact, the U.S. government, starting in 2011, will pay doctors about 10 grand a year for 5 years to place an EMR in their clinic. Meanwhile, many are attempting to receive refundable federal tax credits for EMRs that they may purchase.
Present medical records on paper documents are digitized and integrated into the EMR easily. And EMRs are desirable in the medical community for a number of reasons because they potentially fill unmet needs to restore the health of others. These health care provider assets within EMRs provide evidence-based clinical information contained in this knowledge system.
In addition, EMRs provide additional patient safety in general, as well as regulatory and reporting needs. These needs, as well as confirming reimbursement requirements, provide a strong ROI for those medical facilities that have quality EMRs at their location. Wal Mart appears to see strong revenues with EMRs as well.
Their Sam’s club will offer their doctor members package deal EMR systems that will cost 25 thousand for the first doctor in a practice, and 10 thousand for each additional doctor. The computer maker will be Dell, and the EMR vendor will be eclinicalworks. With the Wal Mart venture, their limited EMR customization may be a concerning issue for some doctors.
In addition to EMRs storing patients’ medical history and present treatment regimens, EMRs make others aware when ordering ancillary testing for patients. The awareness is to make sure the testing ordered is not repeated, or does not already exist. In addition, and of particular importance to the health care provider, the need for transcription of patient notes is eliminated.
With some debate, there seems to be a good possibility for the development of increased profits for both health care providers and medical institutions. This is due to EMRs offering the most appropriate and accurate codes. These are diagnostic and procedural codes allowable for a particular patient as they are determined to be needed for this patient. These codes are used to seek reimbursement from health care payers, and are required for reimbursement from third party payers for certain patients.
The continuity of patient care improves the care of patients and reduces the need of additional patient staff that was needed before EMRs arrived at the medical facility. Historically, there is often a lack of needed staff at medical institutions due to the shortages of professions that exist in the health care field, such as nurses.
The EMR provides flexibility of architecture to meet individual workflow requirements at each location. Preventative medicine and compliance with treatment regimens are more assured with EMR utilization as well. Yet one does not have to begin with a complete EMR for their medical location. Many small offices acquire some automation that provides functionality that is beneficial, yet limited. This costs only 5 grand, instead of the full EMR package at over 40 grand. Such lightweight EMR versions include document management systems and electronic patient records.
Yet perhaps the essential stand-alone technology a medical clinic should acquire is eprescribing. When selecting eprescribing for your medical facility, assure that staff will be well-trained, any technological problems will be rapidly resolved, and that workflow remains adequate when selecting a vendor.
Again, evidence-based medicine as well as a higher degree of patient-centered healthcare is now possible and improved by EMRs. The many benefits perceived by others that are based on fact that has resulted in the utilization of EMRs by various managed care companies and pharmacy benefit management companies.
However, health care providers who are in solo practice are understandably reluctant to acquire EMRs because of cost. The cost of an EMR may approach 40 thousand dollars, as well as several thousands of dollars paid annually to maintain the EMR. A complete EMR package would include hardware, software, installation, maintenance, and training. The EMR hardware is typically replaced every 5 years.
One of the primary functions of EMRs often includes electronic prescribing, which is more reliable in reducing prescription errors. Prescribing errors are believed to cause over 5 thousand deaths a year. Electronic prescribing also lets the health care provider know if there is a generic version of the drug available, and if the patient’s pharmacy insurance benefit covers the drug chosen by the health care provider.
Additional functions of EMRs would include the ordering diagnostic tests, and retaining the results of these tests. Also, the documentation from the health care provider about the health and well-being of their patient after a visit with such a provider is placed directly upon direction from the provider into the EMR. This thankfully improves patient data availability for other health care professionals may have a need to retrieve regarding these patients.
Aside from having great ability to store information and data, as well as the EMR having user-friendly navigation, the EMR should have the following core functionalities: Health information and data about disease states and patients that have been treated, the, ability to manage results, the features to allow order entry, the ability to provide decision support, and the EMR should have good communication with other devices.
As far as the plan of implementing EMRs within a medical facility, this would involve the EMR’s hardware, software, EMR installation, maintenance of the EMRs as determined, and training of the medical staff. The EMR should have the ability to access the patient’s full medical history, and improve the quality and treatment regimens of those with various medical conditions. Also, the EMR should provide cost savings, and have the ability to promote research due to the data content of the EMR.
Selecting an EMR is a difficult decision at times. Tools to assist you with your decision are available at the Center for HIT website, as well as the American College of Physicians (www.acponline.org). The EMR format should have the ability to include critical data, and omissions due to interoperability should be limited. The EMR should be certified by the Certification Commission for HIT (www.cchit.org). Finally, many doctors and medical institutions are visiting locations with successful EMR implementation before they purchase this for themselves. Also, when you have chosen a vendor for your medical facility, make sure in the contract with the vendor contains a remedy if the vendor happens to go out of business, as such contracts may be for periods of 10 years or so.
Additional patient benefits because of the ability and function of EMRs is the reduction in mortality, according to some studies. Mortality has been concluded to be reduced by around 40 percent. Equally impressive is that the EMR makes patient care much more efficient, including where efficiency may be needed the most. That would be those many patients who have at least one chronic disease. Chronic diseases consume around 80 percent of health care spending. The EMR facilitates a medical home for those patients who are chronically ill.
Surveys have shown that most people surveyed favor EMRs more than they do a health care provider visit. The EMRs allow and encourage written dialogue between the health care provider and their patients. When this is done, visits between these patients and their providers are significantly decreased.
Presently, those who have access to EMRs range in ages of those in their late teens, to those in their early 90s. Utilization of EMRs by others is not limited because these records are very user-friendly for most people. And utilizing EMRs may also be used to enhance one’s medical knowledge regarding a particular topic or disease state. With those who are with medical problems, this knowledge often will improve their health and their medical issues because the patient is now an advocate in their own treatment of their medical problem.
EMRs are certainly not flawless, and there are those that oppose the integration of this digital advance into the U.S. Health Care System. There are privacy concerns, as well as more valid concerns about EMRs becoming dysfunctional without notice. Presently, those who make EMRs in this 20 billion dollar a year industry are not regulated, and no uniform standards regarding their durability have been established.
There are legal concerns as well regarding who owns the patient information stored within electronic medical records. Aside from privacy concerns, this information is encouraged by others to be used for research purposes. So EMRs are not without their issues. So likely, these issues will be resolved, and the EMRs that are the best for patients will eventually be identified,

Dan Abshear

I work with the Mayo Clinic Health Policy Center; we would agree that this is a critical time for deciding how to avoid "Door Number 2." Simply putting a computer on each physician's desk will not improve patient care, will not have a dramatic impact on safety, and will not advance medical practice as a discipline. A secure, interoperable health IT system is necessary to improve patient care, eliminate error and waste, and help advance research and best practices.

Privacy and security of information is a major concern, and we would agree that patients should own their information, deciding who should have access to it and when. And rigorous standards and safeguards should be in place. Having said that, the current paper records that some 80 percent of providers are still using have their own set of security issues. And patient care suffers because of the lack of information that providers have about their patients.

In August 2008, the Mayo Clinic Health Policy Center convened leaders from health care delivery (providers), health IT industry and privacy advocacy to discuss health IT and develop a set of principles, recommendations and action steps arrived at through a consensus process.

I offer these outcomes to whomever may be interested; they can be viewed at: http://www.mayoclinic.org/healthpolicycenter/it.html.

The future of medicine [also the name of my book] has some bright spots. One medical megatrend relates to the electronic health record. President Obama is aggressively pushing the electronic health record [EHR]. It will be a major improvement to medical care and to patient safety over time. But there are two major problems that need to be overcome before the EHR will ever be fully functional – interoperability and physician documentation. By interoperability I mean that each of the companies that produce the software do so in a proprietary manner. The result is that they cannot interact. So if a patient is discharged from one hospital today and goes to another hospital’s ER tomorrow, the information from the first hospital will likely not be accessible. This must change and it appears that the federal government is attempting to have standards established for all to follow. That will be a big improvement. There are issues however as to who should set the standards – government or a multidisciplinary working group. Either way, standards are needed. It is a problem that can be overcome, hopefully soon.
The second obstacle is that physicians find that most of the current systems actually impede productivity rather than enhance it. This is because the software creators have not spent the time necessary to understand how physician work and are intent on making the document easy to manipulate by the computer. Here is an example. Say a doctor admits a patient with pneumonia. He or she might want to insert the following into the chart: “55 year old nonsmoking male, sudden onset of high fever, shaking chills, productive cough and pain at left lower chest with inspiration. Temp 103, pulse 94, BP 128/74, abnormal breath sounds and dullness to percussion in left lower chest. Chest X-ray shows infiltrate in left lower lobe and sputum exam shows gram positive diplococcic. Diagnosis – pneumococcal pneumonia. Treatment – antibiotic.” Sorry for some “doctor speak” but in essence this is a fairly classical description of a pneumococcal pneumonia. It takes about 30 seconds to say, the same to dictate and perhaps 60 seconds to write or type these words. But to enter it into the chart as per the dictates of the software takes much longer because it requires following a long branching tree of choices. You might liken it to using Word for a document that can be read later versus Excel for a spreadsheet that can be manipulated. Physicians really dislike the extra time it takes and the fact that it is not consistent with the way they “think” about the patient and his or her problem. So they rebel and will not adopt. But this problem, like interoperability, can be overcome.
Once these two issues are resolved, the EHR can become a reality, but not before

The VA experience does not apply to how EMR's are being implemented in the private sector. The major flaw in the theory is that there are over a hundred EMR system few if any of which share a common format or are capable of exporting documents in a common format. The only way to transfer information between systems is to print a copy of the patient's record, scan the record, and then the information are stored as images which cannot be searched reviewed in an efficient manner. The print and scan time and manpower requirement is so high that for the most part the patients previous paper record is never entered into the electronic record.

If a patient is transferred from his private physicians office or from one hospital to another that utilizes a different EMR these factors make the transfer of information more cumbersome than without an EMR. When you print a hard copy of most EMR's you get endless pages of poorly organized information which is often redundant and full of information that does little to help the receiving physician evaluate and treat the patient.

The first step that should be taken before pouring billion of dollars into EMR's is making it mandatory that all EMR vendors include the ability to import and export in a common format.

In their NEJM article, Mandl and Isaac Kohane, MD, PhD, also of CHIP, propose for the government, through the Department of Health and Human Services (DHHS), to mandate the development of a platform that will support applications for clinical care, public health and research. Much like the software platform developed by Apple for the iPhone, or the Indivo platform created by CHIP researchers that has emerged as a model for personal health records, the co-authors encourage DHHS to mandate the creation of a platform that will support an ecosystem of applications (i.e. order entry systems, medication reconciliation systems, patient communication systems, etc.) which can be developed by existing vendors or new health IT developers. The platform they suggest would support: