Saturday, March 14, 2009

EHR -- Electronic Health Records -- The Race is ON

Of all the acronyms polluting the mother tongue via texting, the one we all will soon know is EHR, electronic health record, since we all will have one in the next few years. Most of us already have the remnants of an electronic health record, scattered like DNA or fingerprints, as we contacted the health care system over the years. In most cases the only "electronic" part was the billing system because that has been the most important part of our care so far. All calls to a doctor, clinic or pharmacy are identified by an "account," identified by either a name or a number. Beyond that, most other records are in a folder, and whoever needs access gets a copy or the original. Once the bill is paid, the main record, like any other capital investment, depreciates to zero.

Health records are so important that they typically survive the subject. There is no way to know how many tons of manila folders, films, lab reports and notes are piling up as generations pass, but litigation and regulations aimed at protecting us have expanded over several decades. Fortunately, paper records don't take up too much space, so an entire human lifetime can fit into a few inches in one or two 9 by 12 folders. I recall going into a dental practice in the second generation and seeing an overwhelming number of dental records, more than I have ever imagined at one place. Five-foot, double-faced, six-foot-wide steel shelving units on tracks loaded with thousands of folders, all with color-coded tabs, took up nearly fifteen linear feet of the office. By rolling the shelves along the tracks, an office assistant could keep them stacked neatly together, opening up the collection like some gigantic book, walking into the opening to find a record. As I marveled at the collection, I had a flash of some forensic detective, way in the future, seeking the dental record of some long-dead former patient, waiting like a fossil, once again to see the light of day.

No one has brought this up as far as I have read, but the most important part of the health care debate involves a basic (love this buzzword) paradigm change in how we regard health records. The value of an individual's health record is not to discover whether or not the bill was paid or the individual should fall into this or than risk group, but instead What is the condition of the person's health? That question should be important to the individual and his family, but in many cases it is not. But when seen through the lens of costs the question becomes more important. Costs have always been important to providers because that's how they earn a living. If they don't know how much they spend on a patient there is no way to know how much to charge for that person's care. But from the patient's point of view, the day has past when true costs were their concern.

Thanks to insurance we can measure risks and share costs of a variety of misfortunes. A few people complain about the costs of home owners or auto insurance, but everyone eventually admits they would be worse off without them. Contrary to reason, we even purchase life insurance, naming beneficiaries to be compensated when we die, hoping to delay that day as long as possible. But in the case of health insurance we have been protected from knowing the real costs. Thanks to employer-paid or shared group insurance costs, then later to Medicare and other tax-funded insurance, the average American neither knows nor cares about his health care costs. All most of us care about is how it is received and how little of the cost we can get away with paying. For some the cost is nothing. For others a nominal "co-pay" or "deductible" is all they expect to pay out of pocket.

But there is a growing population for whom the costs of health care is a stark, shocking reality. The number of uninsured and under-insured people has finally grown to the point that their political influence is finally being felt. That is part of what the recent election was about. Although there were political differences, the need for health care reform was incorporated into both party platforms. A week ago I linked to an excellent, clear-eyed look at the messy state of health care costs as seen by a remarkably candid insurance broker.

...While the employee of a regional electric utility is complaining about monthly payroll deductions for his family that now exceed $500 or more on a $60,000 annual salary, the longtime employee of a local small electrician is looking at monthly payroll deductions for his family of $1,500 on a $35,000 annual salary. His apprentice is younger, and so is "fortunate" to have monthly deductions for his family of only $900 on a $20,000 annual salary. The electrician's helper making $9/hr can't afford even his half of the premium for just himself.

Individuals on personal health insurance policies are also feeling the "pinch." Most of my individual clients see increases of 18-25% a year.

It is all of these folks (and there are tens of millions of them), coupled with those who have already been priced out of the market altogether, who will fuel the fire for radical reform. It is these folks who complain - long, loud and bitterly - that the American dream is leaving them behind. It is these folks to whom the politicians will ultimately listen, because they're the ones making all the noise. It is these folks who will ultimately define what the next set of reforms looks like - and those reforms will NOT be confined only to the small group and individual markets - nor do these folks give a rat's rear end if the insurance industry is involved.

Enter Electronic Health Records.

My hope is that by seeing their medical records a growing number of people will face two questions:
  • What is the condition of my health? (And what, if anything, can I do about it?)
  • How much is it costing? (And who, other than me, is paying for it?)

My wife and I are keenly aware of what our medical challenges are and what we need to do to manage them. Like many people we do a lot of wrong stuff... overeat, exercise too little, yield to the temptations of special occasions, or stand in denial of some risks. But we know many people worse off than we who take pills without knowing why other than "the doctor gave me a prescription," or get tests without knowledge or even curiosity about why. We are looking forward to being able to see all our records at one place, at one time, with access to whatever physicians or others have noted along the way. Not right away, but in time, those who create records will do a better job for two reasons. First to communicate clearly with other professionals. And second, because the subject of those records might get in your face about something you did or failed to do. I suspect there may be reluctance on the part of some who would rather not reveal the full extent of their "practice" to the very people who depend on them, literally, in matters of life and death.So the first question carries a lot more implications than first meet the eye.

Electronic Medical Records should have two parts. The main record will be "read only" with no one able to make changes other than the individual or other provider representative authorized to do so. In addition, there must be a way that the subject or subject's legal representative must be able to include questions, notes or other information for all to read.

It is appropriate that every record reflect health care information:
1. Patient's complaint or medical problem presented, with a diagnosis, treatment plan and eventual outcome.
2. When and how well the individual was compliant with the plan.
3. Changes in (1) or (2), dated, by whom, and with explanation.
4. Well-care records, dated, by whom
5. Individual notes, questions and comments by the individual, for the record, dated.

In the matter of costs Electronic Health Records should show, in spreadsheet form, an easy to understand EOB, or costs information:
1. Billed amounts, itemized, with dates
2. Amounts paid, by whom and when
3. Adjustments, by whom, dated and reason
4. Cumulative amounts charged by type (services, fees, drug costs, etc.)
5. Cumulative amounts paid by source (insurance, tax money, out of pocket, etc)
6. Balances outstanding and dates due
7. Remarks or comments by the individual, dated.

These two standards, clearly described and available to every person, will go a long way toward lowering both costs and un-needed procedures and medications. I can forsee a time when at someone's request their EMR can be screened with their permisison for analysis. A growing data base of medical and financial data will point to ways to improve health and contain costs. Who knows: it may even do better than Dr. Phil or Oprah at changing behaviors for the better on the part of large numbers of people.



My vision is somewhat pie-in-the-sky. I ran it by Maggie Mahar and she was kind enough to email me these wise words:

A patient might well e-mail questions to his doctor after viewing the record. But I don't think we want people scribblng all over their permanent record.

One thing we have learned is that is essential that these records be as concise as possible. If a doctor writes very long notes, then ultimately the record becomes too long for any doctor to read. You need a record that a doctor can skim in an emergency, and even in a non-emergency, time is limited. No one has time to read a novel about your medical history.

Patients, on the other hand, tend to find themselves fascinating, and might well go on and on describing how they reacted to the first medication, what their brother-in-law said when he took it, etc.

Brevity is the soul of wit. Unfortunately, it's not my strong suit. Thank goodness for the Maggie Mahars of the world.

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