Small Dream

By: Dr. Jeffrey Kaufman
Baystate Vascular Services

To any observer of trends in the performance and finance of medicine in the US, the challenges are numerous and profound.  How physicians document and communicate information is a huge issue.  An all-digital health record is no panacea.  What matters is how that electronic health record (EHR) is used and shared.  So far, the benefit of EHR’s has been mixed across the whole spectrum of care.  Within individual practices and institutions, the benefits have been proven, but across communities, problems remain.

Having ruminated on this subject all too much, I have some modest proposals that should be shared with the larger medical community of western Massachusetts.  Our advantage is in our largely closed medical care system.  There are four counties, and our patients do not often leave the region for care.  There are twelve hospitals with one large integrated system (Baystate) and one smaller one (Berkshire).

The problem of information exchange among providers is not easily addressed.  There is a model regional health information organization (RHIO) in North Adams, but so far that has had no beneficial impact on any aspect of care I provide, and I see many people from that area.  RHIO's involve a great level of integration among providers, because everyone needs basically to work at the same level of hardware and software capability and computer literacy.  Our reality is that some offices in the region are still using handwritten notes, and others have formal EHR's.  Some are in the middle, with the capability of e-prescribing, for example.  Some have full document management capability (they can scan documents into their records), but some cannot.  Even some offices that are officially "electronic" maintain paper charts to be used by the provider at the same time as the computer is on.

I have a small proposal, a vision that will help all of us move ahead.  Recognizing that office EHR's are still not a settled issue, there is a level of integration that is possible that will expedite care and improve patient safety:  Give every provider in the region full access to the hospital and laboratory computer systems that service the region.  The problem is that medical care is balkanized, with data going into many different computers.  Clearly, despite HL7 and other standards, they are still not talking to each other.  What should be possible is that the provider should have access to all of them. 

If we examine our region, basically there are nine or ten computer systems serving those twelve hospitals, with the addition of two or three outside lab computer systems and two or three outside imaging vendors.  Why can’t any qualified provider in the region log on to any of those systems to obtain data on his or her patient?  In other words, when your patient indicates that there was a CT at Baystate later followed by an MRI at Cooley Dickinson, even later backed up by testing at North Adams, why are the data sequestered from you?  If the patient had a lab test sent to Quest after being ordered by another doctor, why is it difficult to see the data?

The barriers to this model are clear:  First is that such open sharing has not been the pattern in the past, so inertia to change is rampant.  Second, some people have cited HIPAA concerns as a barrier.  However, HIPAA was never designed to stop qualified practitioners to see data for health care reasons -- the barriers are to prevent breaches of privacy related to non-health-care issues.  In other words, one does not need to obtain consent to obtain information for a doctor's office.  Third, institutions have required medical staff membership for access electronically, but they have never stopped releasing data on paper or by cut film.  It would be a savings to the hospital to open the door directly, to avoid clerical costs.  Fourth, there has been the issue of "need to know" in terms of privacy, but all physicians are held to ethical standards regarding management of information, so it seems to me that they will understand that they cannot merely "surf" the database, invading privacy, without incurring sanctions and discipline.  Fifth is the reality that some physicians have trouble with computers, with either poor understanding of how to use a computer or inability to use a keyboard.  For those physicians, patience and good instruction sets will overcome hesitation to use the systems.

The larger barriers are technical:  how to apply for passwords, for example.  Even worse, it has been the custom to have the passwords lapse after 60 to 90 days if not activated in that time.  That means the passwords will need to be renewed, which is painful for the provider, unless the standards are changed such that they remain active longer.  HIPAA has been cited as the reason for this short life for passwords, but it seems to me that physicians can be given some sort of technical exemption to avoid the need to have their passwords lapse.  Otherwise, it should be a responsibility for the IT managers of those systems to manually restore those passwords automatically. 

What is the consequence of open architecture?  Huge savings in convenience and labor are potentially available.  Think of all the CT and MR scans that we can avoid repeating!  Consider the patient in the ER of hospital A, who was recently discharged from hospital B, and savings if the ER physicians can see the data from that first hospitalization.  How often has there been a complaint from a primary care provider that no one from hospital A bothered to send a discharge summary or any information about findings when a patient is seen after a serious hospitalization.  With an open architecture, all the data can be retrieved. 

Meaningful use is the current watchword regarding EHR's.  The problem with the regulations is that they still place barriers between the physician and the data.  It is clearly an improvement to require all the EHR vendors to have a system that will burn the entire patient's data on a disk, but that does not help the physician who is queried about a patient in the middle of the night.  There are systems being created to use the "cloud" of data storage as a means to share images, but that system does not work fast enough for many types of communication. 

This is not a vacuous dream.  There are systems that have opened their data, including the MRI Center in Springfield, the PACS for Cooley-Dickinson, and, most important, the CIS at Baystate.  Other systems need to be opened, especially that of Berkshire Medical Center, and others need some fixes, notably the Mercy system, which has log-on problems in my experience.  The point behind this is that open systems will save labor, frustration, and money.  We do not need fancy integrated systems to achieve this simple goal.  We need cooperation and an understanding by the computer mavens in our region that doctors need unfettered access to information in order to better serve their patients.
 
Disclaimer: The opinions are those of the author and not necessarily those of the Massachusetts Medical Society or the Hampden District Medical Society.

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