Increasingly, the many difficulties created by electronic health records (EHRs) are a focus of discussion within the healthcare industry. As reforms for improved physician usability are debated, it’s potentially valuable to recognize that the records systems employed by telemedicine providers may provide useful lessons into how EHR systems can be re-created, to enhance, rather than hinder, healthcare.
Background: First Stop Health Telemedicine and The Dysfunctional State of EHR’s
As the Chief Medical Officer and co-founder of First Stop Health’s telemedicine service, one of my first responsibilities was to work with our launch team to set up our EHR. As the CMO, my central objective was to ensure that our systems supported our physicians in delivering convenient, high quality care.
We formally assessed existing systems. Sadly, I knew the likely outcome of this effort: EHRs have become cumbersome labyrinths that hamstring the practice of medicine. Consequently, we designed an entirely new system, as discussed below, that we have successfully deployed. It’s served us well as our business and volume of consultations have tripled or more, in each of the past several years.
To understand the problems associated with EHRs today, it’s essential to understand how our current system evolved.
The effort to computerize medical records began at the dawn of the computer era in medicine. Like many physicians, I was initially excited by the prospect, and potential utility, of electronic access to patient medical records, and I was involved in some of the earliest efforts to create EHRs. In the mid ‘80s, we started work on computerized voice dictation systems and the development of information input systems. These systems were designed (by physicians) to make charting, easier, faster, legible, accurate, and more convenient. The promise of our work was that errors would be eliminated, and records would be accessible 24 /7 from anywhere a physician had a computer. In fact, as I prepared this article, I came across the picture below (circa 1987) which shows me, 30 years ago, talking into a computer-based Kurzweil dictation machine:
The Hijacking of HIPAA
Unfortunately, the evolution of EHRs reflect a dynamic that seems to have repeated many times over the past 30 years in the healthcare industry: Businesses create systems that become the industry standard; create barriers to change through complexity; and create frustrating time-consuming issues for doctors. Ultimately, this dynamic raises the cost of care while reducing the quality of care delivered.
A recent study by the American Medical Association found that primary care doctors spend more than 50% of their time on EHR related tasks. The result: Doctors are forced to charge more for every patient they treat—as their practice time is limited by the demands of EHR systems. At the same time, it’s far from clear that these systems support easy access to patient records by physicians in different stages of care, which is essential to delivering optimum healthcare.
A central cause of this dysfunction has been the hijacking of medical records by HIPAA and related legislation. Congress determined that patient records needed to be protected, and HIPAA (the Health Insurance Portability and Accountability Act of 1996), was enacted. Subsequently, the Health Information Technology for Economic and Clinical Health (HITECH) Act, was enacted to promote the adoption and meaningful use of health information technology. This Act provided incentives for the use of EHRs, while also strengthening the civil and criminal enforcement of HIPAA rules.
HIPAA's purporse, in part, is to preserve doctor-patient confidentiality. However, the actual implementation of HIPAA and related legislation create burdens that are not necessary for the essential protection of patient privacy.
In practice, EHR firms hijacked HIPAA to meet their business objectives. HIPAA and related legislation have become a poor excuse for systems that make access to medical records unnecessarily burdensome, prevent vital, fast access to these records (such as when they are needed in an emergency), and prevent patients from easily accessing their personal medical records.
EHR companies have developed monstrously complex products, asserting that they were mandated by HIPAA requirements. I struggle to see the connection. EHR companies have, to my knowledge, never been called upon to address the many glaring disconnects between their products and the actual requirements of HIPAA and related legislation.
Nonetheless, this complexity has served the needs of these software companies (at the expense of the more effective practice of medicine) and to some extent the worst instincts of healthcare systems and providers seeking to prevent the loss of patients.
EHR Systems and the Problem of Complexity
Today, some of the many problems associated with overly complex electronic health record (EHR) systems include:
- Existing EHR systems were designed by IT people for purposes of medical billing – not by doctors for medical care. As noted by a recent PBS report, the management of the healthcare system is governed by a billing system, rather than a patient care system.
- These proprietary systems are not interoperable: They don’t talk to each other. Separate systems for hospitals, doctors, radiology, labs, and data from emerging connected care devices don’t communicate with each other. As a result, the collection and transfer of records is even more difficult. Indeed, many health records are still sent by fax (a “HIPAA secure” method) from one department to the next within a health care system, and from the offices of one doctor to the next.
- The recording requirements of EHR systems have become even more complex. The ICD-10 (international classification of disease-10th edition) was introduced as the new “standard” for medical records. This shift added significantly to the costs of EHR systems, while making medical billing and coding so difficult that few doctors use this system properly.
- Healthcare systems deploy HIPAA as the first line of an indefensible defense to prevent patients from switching providers: The difficulty and cost of transferring HIPAA protected records is prohibitive.
- In our emerging age of the consumerization of medicine, patients access to records for out-of-group tests or procedures becomes nearly impossible. The imaging center nearby may perform a high-quality MRI for several hundred dollars, as opposed to the several thousand dollars for the same MRI at the hospital affiliated with a patient’s primary care or specialist physician. But, the lack of interoperability makes it difficult for patients, who lack specialized medical knowledge, to ensure the records needed to order and subsequently read the results of these lower cost MRI’s can move between these non-affiliated entities.
Principles for Creating a Patient-Centric EHR System
So, is there a solution to the medical records mess? In designing the records system for First Stop Health’s telemedicine service, we were guided by three principles, which may also serve as a model for addressing the healthcare industry’s current dilemma:
- First, what do physicians need? What if doctors designed the EHR to meet the needs of healthcare providers, and billing teams were then directed to examine these records and determine the procedures involved? Let the provision of the services drive the system, with billing and other factors playing a subordinate role. The system should put the patient at its center, rather than financial exigencies.
- Second, we mandated that all medical record systems MUST easily interface with any standard format, so that the records are truly portable, accessible and able to interface with each other. EHRs are simply too important to be a tool that healthcare providers can use to keep patient’s captive.
- Finally, we asked ourselves: What if HIPAA were repealed and replaced by electronic privacy requirements that reflect the past two decades of development, in digital communications and information storage? Then, we designed this type of next-generation secure records system and found that it was, in fact, HIPAA compliant. My theory that much of the complexity of EHR systems was unnecessary and wrongfully rationalized as required-for-HIPAA-compliance proved accurate.
The First Stop Health Telemedicine EHR
With these principles in mind, at First Stop Health, we designed our medical record system to be both physician-friendly and patient accessible. In this system:
- Physicians have the option of typing, using computer voice dictation, dictation/transcription, cut and paste of preprinted information input systems, or customizing their own input rules.
- All consults, whether voice or video, are recorded and can be played back by both the patients and the physicians. Patients can access both the recordings and typed records on a protected (HIPAA compliant) web portal, to remember what was said and gain maximum benefit from each consultation.
- A comprehensive quality review of all consultations enables First Stop Health to continuously improve both our process and the skills of our physician staff.
At First Stop Health (www.fshealth.com) our goal is to become “part of the solution” to the problems of healthcare. We do it by providing convenient, affordable, high quality care to our members 24 X 7 X 365. When we created the company we never imagined our systems themselves might have relevance to addressing problems associated with the practice of medicine. Now, I believe otherwise.
If EHRs were created in line with our guiding principles at First Stop Health—and new legislation replaced HIPAA with updated privacy requirements reflecting our digital era—our nation’s healthcare delivery system would be dramatically enhanced. Doctors would gain the ability to fulfill their primary responsibility to treat patients, and the balance of how they spend their time would shift. Patients would receive better care as interoperable systems enabled the easy transfer of their records, as appropriate. Finally, the cost of our overall healthcare delivery system would drop: The need for less complex EHR systems would encourage needed competition from new entrants to the market; and the consumerization of healthcare would receive a giant boost.