A few readers took issue with my labeling health care practitioners as "laggards." In fact, argues Dr. Daniel Essin, former director of medical informatics at Los Angeles County + USC Medical Center, "physicians are, and have always been, early adopters of technology." Essin, who's now chairman of an electronic medical records vendor, ChartWare, says many physicians have made multiple attempts to implement EMRs but failed. He cites six main reasons:
- They can't articulate a set of requirements against which products can be judged.
- EMR systems aren't flexible enough, requiring workarounds even before their implementation is complete.
- There's a mismatch between the tasks products are expected to perform and the products' actual functionality.
- Some systems are conceived as a "simple" add-on to the billing system.
- System workflows consume way too much physician time and attention.
- There isn't adequate integration between internal and external systems.
Related to most of those obstacles is cost. One EMR kit at the entry level, offered by Wal-Mart's Sam's Club unit in partnership with Dell and eClinicalWorks, is priced at around $25,000 for the first physician and $10,000 for each additional one. After installation and training, annual maintenance and support costs are estimated at $4,000 to $6,500. That's still not chump change, especially for the smallest practices.
At the very high end, Essin estimates the full cost of one major health maintenance organization's EMR implementation to be more than $200,000 per physician when you take into account not only training (physicians as coders), customization, and upkeep, but also the two to four hours a day diligent doctors must spend finishing their electronic charting. (Essin insists that extra work isn't out of the ordinary.) Massive complexity.
Dr. Robert A. Bergamini, with the Pediatric Cancer and Hematology Center in Creve Coeur, Mo., offers some examples from his experience with EMRs. In pediatrics, most medication is weight-based, he says, yet finding the "last" weight on an EMR can take several minutes. More critically, he says, "issues like court orders, termination of parental rights, supervised visitation, orders of protection, or specialized emergency procedures disappear from the front of a chart to a line under a tab -- with no flag to say there is something crucial hiding there."
Bergamini compares EMR system rollouts to construction projects, which are often designed as they're being built to save money. "The difference is there are building codes in place that mandate certain minimum requirements," he says. "There are no such standards in place for electronic [medical] records. Unfortunately, I think that the standards will be set in and by the courts -- after someone has been hurt." And what if those standards are set after many doctors and hospitals have already deployed their systems? Retrofit or start over.
Another "big fear," says Bergamini, who was an early EMR adopter with a small practice, is if startup vendors of proprietary systems go out of business, making data "difficult to access or lost forever." There's also the huge question of data security, especially as patient records are passed from one provider to another and through the massive health care supply and payment chain. And, of course, there are privacy concerns: Even with HIPAA rules, could an EMR systems integrator, for instance, mine customers' data to peddle them other products?
Clearly, there's no shortage of obstacles to digitizing the health care industry -- mea culpa if my previous analysis oversimplified that effort. Nonetheless, the industry must march forward, as difficult as that will be.
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