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.
