February 20, 2012

 To the Editor,

An Article from Information Week[1] states that only 47% of US doctors report that healthcare information technology (IT) has helped to improve the quality of treatment decisions, compared to 61% of doctors from a group of eight other countries. These countries not surprisingly include Australia, Canada, England, France, Germany, Spain and Singapore, all or most of which already have coherent, efficacious national medical systems. The US does not.

The main obstacle to US doctor acceptance is the large cost, due in no small part to the multitude of insurance forms, unique electronic access, and information requirements. Who in their right mind would want to gamble $20-40,000 of their own money for a program that might not interface with all the different vendors today, or, next week?

Patient acceptance of EHR’s is dependant on their perceived risk to the cost and availability of future medical coverage, life insurance, and job security (where companies may “let go” employees who have a larger apparent medical risk).

Adding another layer of cost in time or money are the built in “clinical support systems” and “external chart reviewers”, the federal, state and local information requirements. In the event of a data breach are you prepared to pay the average $200 cost per patient chart for notification, restitution and credit monitoring?[i]  Are you comforted by the fact that Department of Health and Human Services doesn’t require the reporting of breaches affecting fewer than 500 people?

The contribution of EHR’s to improvement of patient safety is primarily dependent on the ability to extract outcomes on populations utilizing various drugs,

procedures, medical devices and treatments. This will be resisted by the various economic interests threatened.

For myself, an acceptable EHR would have the following:

  1. Must be able to import my own Office Visit (OV) templates onto an electronic tablet.
  2. Carry forward Prior Medical and Surgical Histories, Meds and Allergies.
  3. Have a laser pencil attachment to the headpiece microphone that when shined on a particular blank space on my OV template will insert my spoken words in written form into that space: this also presumes a more highly functional voice-to-writing function than the last two versions of Dragon Naturally Speaking that we have tried.
  4. A program to keep score of any inputted data for the days OV to tally up whether enough “bullets” have been documented to satisfy the E & M level of care, 99213, 99214, 99215, etc.
  5. An updateable library of ICD-10 and Procedure codes.
  6. A feedback mechanism at the end of the OV template that automatically confirms or tells you how many more “bullets” you need for a particular level of services.
  7. Must be able to extract billing information to be automatically sent to the check out station, and sent out to the appropriate insurance vendor after appropriate review.
  8. Must be able to interface with all insurance carriers. This is a major stumbling block for EHR’s in the fractured, disjointed american system.
  9. Data encryption that does not require “a full time nanny”.
  10. Medical summary, labs and procedure reports must be transferable to a credit card size personal database.
  11. Must meet all HIPPA requirements, or coincide with the reduced need for them.
  12. Must be able to easily interface with laboratories, etc.
  13. Patient’s medical data must be in a searchable matrix form so that office, community and national outcome studies can be done, as they now are in parts of Scandinavia.
  14. The whole program cannot be cost prohibitive in terms of time and money.

The problem is not that US physicians do not know how to use their i-pads, PC’s and Blackberries. What US physicians smell is, that this boat isn’t ready to sail, except where large organizations have onsite IT staffs.

[i] Dolan, Pamela Lewis, Small practices are greatly at risk for data breaches, American Medical News, 1/30/2012