Monday, May 25, 2009

Optimism, opportunity abound via cash for EHR fixes

The Modern Healthcare article I mentioned in a previous post quoted me as saying that for $36 billion of incentives, the government better make sure they are paying for improved quality and value, not simply for the use of present-day EMRs which do not automatically equate with clinical improvements. There were many letters to the editor about that article- most agreeing with this underlying premise.

Of course, there was one confused writer who actually said that EMRs must be fine since the vendors employ physicians... well, it is a nice thought, but basically that's the same as saying the banking industry must be fine since they employ MBAs - and we know that's not the case! The reality is that there are two flaws with this arrangement:

1. The physicians are not IT/Informatics savvy and/or the IT people are not clinical savvy. The problem is that the vision is wrong (eg "let's try and create an EMR that looks/acts like paper"), or the interpretation of the vision is wrong (we can't expect 20somthing year old IT programmers to understand how to model complex healthcare workflows without very deep guidance).

2. Even if you have a sophisticated informatics, future thinking Physician Executive who figures it all out - the marketing/sales team at the EMR vendor usually has a bigger say in development. Why? Because they are more concerned with selling to the "new customer" - and the "new customer" is usually naive about EMRs and thus they want a demo that looks/acts like the paper based system they currently use. It's definitely a catch-22...

So, here is the "reply" I sent in to clarify and expand on some of the things I said earlier:

Optimism, opportunity abound via cash for EHR fixes
In response to reader commentary on Joseph Conn’s “Rush for EHRs could ‘stick docs with bad systems’ ":

I am certainly pleased to see that this article has sparked so many great comments and responses. Of course, it is interesting to observe how different people have interpreted it through their own lenses, so I thought I would add a few more thoughts to the discussion.

First, I certainly think the American Recovery and Reinvestment Act of 2009 incentives for electronic health records are a good idea. I simply expressed my hope about how those monies would be distributed—specifically, that the government would define “meaningful use” based upon improvements in quality and efficiency (and not on just using a keyboard in an exam room). As it turns out, it appears that things are headed that way, and so I hope it continues in that direction.

Second, I’ll put on my primary-care physician hat and point out that while the incentives are a nice start, they are not enough. The government (and other payers) really need to change the whole healthcare reimbursement model to reward quality and value over quantity and volume. Once that occurs, we will see some true innovation in healthcare process and delivery that will certainly include robust adoption of EHR systems as an important tool to improve quality and value.

Third, I stand by my premise that current EHR systems need to do better with a lot of emphasis on improving their user interfaces, which need to be more intuitive and workflow-savvy. This problem with EHRs has been confirmed by recent studies showing both poor adoption rates as well as poor benefit realization in healthcare systems with mature EHR implementations. And while there are also some excellent implementations of EHRs throughout the nation, they usually require a huge amount of time, effort and money, factors we honestly can’t count on in the majority of locations.

Fourth, I am not saying to throw the baby out with the bathwater, but that baby has to start growing up. So how can EHRs improve? I think there are two critical components: incentives and usability. The more healthcare reimbursement incentives reflects the importance of features like quality reporting, registries, chronic disease management and virtual care, the more EHRs will move in that direction.

But that has to be paired with better usability that is very dependent on obtaining better physician input. While having physicians employed by vendors is a nice start, experience shows us that is certainly not enough. Rather, vendors need to start spending a lot more time with their actual users—physicians and other clinicians in the trenches. They should make their programmers go out and observe physicians using the systems they are creating, as well as use formal usability techniques to better understand how to improve their systems—the synergies and learning will be critical all the way around.

But be aware, if EHR vendors don’t start improving, and if there is not better adoption and better care, then the government may wind up using that money to instead create their own “iEHR” platform, which allows developers all over the world to create apps and widgets that meet every niche physicians’ need.

Finally, the title of the article was a warning, but one that can hopefully be averted—the overall message should be viewed as one of optimism and potential. At this moment of time, we have a very big opportunity, but with that comes a responsibility to make sure the physician’s voice is heard loud and clear as we move forward. Fortunately, we just have a very simple message: “Give us highly usable EHR systems paired with well-aligned reimbursement philosophies, and we will give you the best healthcare system ever.” - Lyle Berkowitz, M.D.

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