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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Pitiful: Contrasting Studies of EHR Adoptions

Pitiful (pĭt’ĭ-fəl) adj.

  1. Inspiring or deserving pity.
  2. Arousing contemptuous pity, as through ineptitude or inadequacy.

There have been several interesting reports that have recently been published regarding the adoption and use of Electronic Health Records (EHR) by our health care system. The articles provide an interesting contrast into the promise and potential of EHR’s but also the pitiful progress that we have made as a country in utilizing these tools.

First the good news. The most recent issue of Health Affairs higlights Kaiser Permanente’s experience with the largest civilian EHR implementation ever and the corrolating impact of extending that technology to its members.The article is impressive, and highlights the amazing work that Kaiser has done in impacting the clincial, financial, and administrative inefficiencies in their own system through the implementation of an comprehensive EHR. All the typical advantages that you would expect are highlighted but perhaps most interesting to me was the common theme of how effective and efficient the comprehensive system made the organization in delivery high quality care to everyone everywhere along the continuum. The relationship between physicians and patients was dramatically altered for the better, communication and trust improved, and overall satisifcation enhanced by both parties.

Kaiser is not alone in this, as other integrated delivery networks such as Geisinger and Intermountain have reported the same benefits. Kaiser to its credit, demurers their success by stating their efforts are “still in progress”. Furthermore, the highlight the unique aligned environment in which their integrated delivery network is optimized for effective and efficient care  regardless of how the care is delivered. Therefore, for them, there is no economic disincentive to perform an email consult as opposed to an in person visit. The CBO has previously highlighted this key point by stating, “How well health IT lives up to its potential depends in part on how effectively financial incentive can be realigned to encourage the optimal use of the technology’s capabilities.”

Now the bad news. The august New England Journal of Medicine reports in their March 25 issue that less than 2% of US have a comprehensive EHR (defined clinical documentation, test and imaging results, computerized provider order entry, and decision support).  Read that again – less than 2% of US hospitals have the essential tool that is required to practice best evidence, most efficient, and most effective health care. Is it any wonder that we have the level of errors, the lack of information, and the woeful inefficiencies in our health care system. Can you imagine any of our large retailers, financial institutions, or shipping companies having a 2% adoption rate of the systems absolutely required for them to compete? It is literally unbelievable.

Drilling down one layer, the reasons for lack of adoption were the common ones:

  1. Inadequate capital for licensing and implementation
  2. Inadequate capital for maintenance
  3. Physician resistance
  4. Unclear return on investment
  5. Lack of trained technical staff for ongoing system support

I could spend alot of time commenting on the above, particularly #3 and #4, which are completely unacceptable in my opinion. We certainly don’t see physicians resisting the latest CT, the latest surgical tool, or the most advanced pharmacologic agents in their management of patients. In fact, given the reimbursement system, we see their overutilization of these tools because they are paid to use them.

The article reaches this same conclusion and states that the health care financing system needs to reward hospitals and physicians for actually using these tools. This can be accomplished by incentives to implement, to report back on usage, and to receive higher compensation for managing populations effectively (most readily acheived by using the tool). Strong disincentives also need to be put in place for individuals not using these tools in the form of lower reimbursement and ultimately penalties for non-use.

While I cheer for the Kaisers of the world and all the other brave souls who have implemented comprehensive EHR’s, I also castigate the sloths who have failed to implement the tools and technology that are required to transition to high performing health care delivery organizations. I am hopeful that the TARP / ARRA pig trough can create the finanical realignment required to create the breakthroughs in health IT adoption that are so desperately needed.

2 comments on “Pitiful: Contrasting Studies of EHR Adoptions

  1. Dan says:

    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.

    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- containing some of the possible 32 EMR possible functionalities. 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 the over thirty functions available with 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 ( 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 ( 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. The medical facility is liable for any medical errors that may occur due to an EMR, and not the EMR vendor.

    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. So EMRs are asssigning diagnostic codes typically assigned by the health care provider, historically.

    Also, EMRs are preloading documentation on a patient encounter by a health care provider, when the provider has historically either dictated or annotated such documentation themselves. There is risk with this procedure from a malpractice paradigm.

    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

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