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This is Dr. Peter Madras' presentation that was given at the Health Innovators meeting on July 21st. For more information on Health Innovators, please visit us at http://www.healthinno.org
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REMAKING THE ELECTRONIC HEALTH
RECORD
Response to the Broken Promises of the EHR
PETER N. MADRAS, MD
DISCLOSUREWHERE DID MY OPINIONS COME FROM?
DISCLOSUREWHERE DID MY OPINIONS COME FROM?
Asentral Inc Medical Record Bank
The Great Computerization FailureTHE UNFULFILLED PROMISES OF THE
EMR MAY BE THE GREATEST FAILURE IN COMPUTERIZATION HISTORY:◦ Adoption◦ Interoperability
Care Integration Cost ReductionCost Recovery
◦ Patient Safety◦ Practice Efficiency◦ Patient Engagement◦ Computerized Reports
Gingrich and KennedyNew York Times May 3, 2004
$7.3 Trillion over next decadePrevent half of 98,000 deaths from
errors
Kellerman and Jones: Rand Corporation 2005
Saving $81 Billion Annually
The Great EMR Promises: Cost Reduction
The Great EMR Failures: Savings
1. No change in the slope of the overall health cost curve2. Office of National CoordinatorBeaurocracy of HITECH, Meaningful Use4. Enormous Burden on Hospitalsand caregivers
The Great EMR Promises: Improved Quality and Safety
IOM 2001: Identified Communication between providers as a critical area in patient safety, and called for EMRs as means of achieving this goal.
◦General assumption that the EMR would
enhance communication and thereby agreement between providers.
The Great EMR Failure: Improved Quality and Safety
Reality: Decreased “Face to Face Time”Pre-post study of EPIC showed decreased face-to-face communication, worsened overall agreement. “.. (Online BMJ Quality and Safety from Tampa General Hospital April 2014)
The Great EMR Failure: Improved Quality and Safety
The Great EMR Promises: Adoption
1.Provider Adoption: Only 40% of MDs and 27% of hospitals are
using at least a basic EMR system, and
2. Patient Adoption:1. 90% Respond that they should have full access2. 42% Signed up when offered3. 20% viewed their records more than once.
What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology Kellerman and Jones of the RAND Corporation, HEALTH AFFAIRS 32, NO. 1 (2013): 63–68:
The Great EMR Failures: Adoption
The Great EMR Failures: Adoption
Physician Impression of Electronic Medical Record
Failure to Adopt: Physician Impressions of Electronic Medical Record
2012 2013
UnfavorableVery
Favorable UnfavorableVery
Favorable
12.4 5.4 16.1 3.3
PARTIAL LIST OF REASONS FOR POOR ADOPTION
Interference with the Practice of Medicine.Physician as a data-entry personProtocols and Algorithms.
Software StraightjacketComputerized Notes, Discharge Summaries, ConsultsPatient ResentmentRigid Algorithms, Standards of Care, Unfriendly SoftwareExcessive Training time for additional burdens
THE GREAT EMR PROMISES: INTEROPERABILITY
Many Definitions: ◦HAVING ALL NEEDED MEDICAL INFORMATION WHEREVER AND WHENEVER NEEDED
“Prime Directive” of computerizing medical records. All other functions are “nice to haves” but pale in importance.
TECHNOLOGY
THE PRIVACY - INTEROPERABILITY STANDOFF
PRIVACY
ASCENDANCY OF
PRIVACY
1890 - 1965
FROM The right to
privacy
TORIGHT OF PRIVACY
TOCAUSE OF PRIVACY
1965 - 2014 2003 -2014
From a Right to a Cause
“The increasing sophistication of information technology with its capacity to collect, analyze, and disseminate information on individuals has introduced a sense of urgency to the demand for legislation”.
TECHNOLOGY AND LIBERTYThe ACLU’s Project on Speech, Privacy and Technology
“One of the project’s major initiatives…is focused on updating and expanding privacy laws to include new developments in technology….”
Are New Technologies the Enemy of Privacy? ◦“Privacy always has been and needs to be
weighed against other goods (benefits) without an apriori assumption that privacy must trump all other considerations”
◦ Amital Etzioni Know Techn Pol (2007) 20:115-119
RESOLVING THE PRIVACY – INTEROPERABILITY STANDOFF
REMAKING THE EMR:A CLOUD BASED MEDICAL RECORD UNDER PATIENT CONTROL
Criteria for Success:◦Present all relevant Medical Information
wherever and whenever needed.◦Present such information in simple and
intuitive form. ◦Make no demands on physician practice
patterns Allow physician’s undivided attention to the patient
◦Devoid of extraneous features
REMAKING THE EMR:PATIENT CONTROL
Basis◦HIPAA states that patients own their
medical information, ◦A computer based system can guide the
patient, surrogate or counselor in: Every aspect of Health Data Collection,
Assembly, Storage Controlling access to maintain privacy
◦Patient, Surrogate, Caregiver, Family
COMPONENTS OF A PATIENT CONTROLLED MEDICAL RECORD 1. Software Driven, easily
understood and handled by the patient or surrogate.
2. Provides the Method for◦ Record Acquisition of Every Encounter◦ Assembly, classification and storage of every
record. ◦ Accessing record as allowed by the client.
3. Allows Diary entries related to status between visits.
ACCESS
GUIDANCE
EDUCATION
MOTI
VATION
Four Essentials
Remaking the Record
REMAKING THE EMR:USELESS EXTRANEOUS FEATURES
Digitized History and Physicals SchedulingBillingAutomated NotesConflating Hospital Records with Individual’s Health Record
REMAKING THE EMR:CONCLUSIONS.
The Patient Controlled Medical Record can be:
SimplerMore Comprehensive
No Demands on the physician Minimal, if any cost to the health care system.
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