Monday, May 09, 2005

Presidential Executive Order 13335

More on this important order coming soon...... and here it is

A New Beemer: The Ultimate Charting Machine? by Dr. Tom Lee May 09, 2005

A little over a year ago, President Bush issued executive order 13335 calling for widespread adoption of interoperable electronic health records within 10 years. Since that order and the appointment of David Brailer as National Coordinator for Health Information Technology, the rise in national dialogue regarding EHR adoption and interoperability has been nothing but dramatic. Discussion about EHRs and their costs/benefits have permeated hospital cafeterias, state medical societies, national conferences, and even the public mass media. Suddenly, it's sexy to be doing EHRs. Electronic medical charting is no longer the moped with a flat tire, buried somewhere in your garage. It's the latest in high performance automobiles, arriving at your local dealer today.Small EHR vendors, once the ugly ducklings of medical conferences, are finding renewed interest from physicians. Large medical groups are feeling more confident about their current EHR implementation plans. And large health plan and vendor organizations are rethinking their strategies in a more interoperable environment. Yes, the intended effect has occurred. Momentum is building.But, for the growing number of physicians and administrators who are beginning to confront the practical realities of purchasing an EHR for their office-based practices, the momentum is short-lived. Costs remain prohibitive, product comparisons are cumbersome and the value proposition remains, at best, fuzzy. Sticker ShockAs is well known, costs [and their close cousin, time] still are some of the more daunting barriers to the widespread adoption of EHRs. Studies suggest that physicians are willing to spend only $100 per month for an EHR solution, but the vendor market continues to ask eight to 10 times that costs [with costs fully loaded and amortized over five years]. For many physicians in practice, that number is simply prohibitive.Physicians who work in large, shared-overhead practices or in procedure-based specialty groups may be most able to afford the time and money necessary to acquire an EHR. But with physicians' annual income varying by as much as $50-150K, one begins to wonder: Will there be a growing EHR "digital divide" between specialists and generalists? Between large and small group practices? Or will continued cost pressure make EHRs truly affordable to all?Income discrepancy is nothing new to medicine. As a physician in training, I spent weeks at a time rotating through a variety of community and academic hospitals. And it was hard not to notice a "ride divide" in the physician parking lot. Used white Volvo or Subaru? More likely driven by an underpaid generalist. New, black Beemer [BMW] or Lexus? Quite the contrary, probably a highly paid specialist. Is it just a matter of time until EMRs [or "Eeemers"] represent the next high-tech status symbol for well-paid physicians? Road TestingHigh costs may be the most noteworthy barrier to widespread adoption of EHRs, but other troublesome roadblocks stand in the way of purchase-minded physicians. When evaluating EHRs for my own medical practice, price was certainly a factor. But more importantly, I found it surprisingly difficult to rationally evaluate and compare product features among different EHRs. Does it have ABS? A sunroof? Power locks? In the world of EHRs, such a feature list was hard to find, not to mention define. How does one meaningfully convey a product's ability to quickly and accurately capture clinical symptoms in a granular, retrievable format to an interested physician prospect? Or the ability to export XML data for facilitating interoperability. Suddenly, the EHR doesn't sound as sexy.The lack of quantitative, comparative product metrics further adds to EHR feature ambiguity. What is the 0-60 for EHRs? The horsepower, torque, and fuel efficiency equivalents? There is no common basis for measurement and comparison. Even cost comparisons prove cumbersome with variable forms of modular pricing, licensing models and bundled hardware/support costs.Most of us at least have a shared experience when it comes to automobiles - either having been a passenger or driver. We know what the steering wheel does, what horsepower translates into, how a good brake feels. With EHRs, however, we're talking about a totally new and different driving experience. What kind of MHz do you seek to exhibit the full power of clinical data capture? How much RAM do you need to feel in total multi-threaded control? The experience is totally unfamiliar to most purchasers, and it's not surprising that there's inherent reluctance to shell out 5% of one's income annually for such intangibles. Rand McNallyCongratulations. You're now the proud owner of a new EHR. No, you don't quite know what the product does and, yes, you paid the steep price that all the vendors seem to be asking for. So, where do you want to go now?Unfortunately, amid all the hype of improving, standardizing, "interoperating" and adopting EHRs, there's a missing dialogue about where we're going with all this new equipment. Yes, you can now record your clinical encounters electronically. And, yes you can view the records from home. But so what? You also now spend a few extra minutes per visit documenting items through a clunky interface. And you need to see a few extra patients per week to make up for the added overhead. Remind me where we're headed again?What's lacking is a roadmap of EHR benefits and their associated features. We should be able to perform [fill in the blank]) functions today, and it will give physicians and patients these [fill in the blank] benefits. Without clear, compelling and realizable benefits, the adoption of EHRs will be significantly hampered. At an even higher level, we need a common vision and articulated plan for improving our current health care system - making it more cost effective and quality-focused. Yes, information technology will help. But how? And what do we need to get there: an SUV, Beemer, or bicycle?Today, it's unclear who's driving this vision for improving health care in America. Is it your doctor? The AMA? HHS? President Bush? Without a unified vision and plan for how we can cover the uninsured, lower costs for employers and their workers and ultimately increase the transparency of health care, the adoption of EHRs will occur without a higher purpose - adopting for adoption's sake. Even worse, we may be implementing an infrastructure that can't take us where we ultimately want to go. Driving AheadA successful product marketing campaign is often able to convey three important messages to its target audience: the benefits to the purchaser, the features of the product, and the price - usually in that order. With EHRs, that clarity is severely lacking.We need a roadmap. How will we improve our fragmented, inefficient health care system and how will interoperable EHRs play a role? What benefits should EHRs convey directly to physicians and patients? And what product features and functions will create those benefits?We need a common set of product features and definitions. What physicians need is something they can readily understand and use to compare different EHR products. Certainly, EHR certification will help, but we need to be able to "productize" the core set of functions that create benefits for physicians and patients.We need competition. When it comes to EHRs, there's plenty of room for more innovation, creativity and competition to meet the complex needs of the marketplace. Simply asking for lower prices won't get us there. By creating benefits and features that are valuable enough to physicians, we hopefully won't need to get as low as $100 per month. But, after having reviewed most of the leading products for my own practice, we still have a ways to go.Information technology has the potential to automate processes and reduce search costs. And yes, interoperable EHRs may facilitate more efficient care. But, before we embark on encouraging physicians to purchase en masse the next best EHR, we should be able to tell them where we're going and how to select the best vehicle for the job. About the author:Dr. Lee is a physician entrepreneur who builds innovative software systems and practice organizations that better meet the needs of physicians in practice. He can be reached at tlee@metropolitan.md.The views expressed in this column are those of the author and do not represent the views of the California HealthCare Foundation or the Advisory Board Company.

iHealthBeat is published daily for the California HealthCare Foundation by the Advisory Board Company. © 2005 The Advisory Board Company. All Rights Reserved. -->

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