As an independent consultant offering assistance to small medical practices in the selection and implementation of electronic medical record systems, I have had many conversations with physicians devoted to their reservations about “going digital”.  When ranking the issues, cost is not near the top.  The real issue is usability.  While the push by IBM, Dell and others to address the cost of the technology is admirable, the technology itself is, first of all, disruptive, and second, ergonomically inadequate.

You cannot simply drop an electronic health record system into a medical practice and expect everything to run smoothly.  Many tasks and responsibilities in the practice workflow will become redundant, while new opportunities will not be realized because the practice model has not adapted to take advantage of them.  Dealing with these issues requires suitable planning and due diligence, as outlined in publications from the American Medical Association and others.  Doing it right will take considerable time away from the practice of medicine to deal with business and technical issues, as described by Robert Miller and Ida Sim in a paper published in Health Affairs in April, 2004.

The man-machine interface offers another challenge, as working with a computer in the consulting room requires a very different set of skills from using pencil and paper to take notes.  Physicians fifty years old and more are highly resistant to this, and because they are likely to retire by 2015 are unwilling to make the transition or the investment.  But even younger practitioners find the computer in the consulting room highly distracting, and an impediment to all-important patient communication.  Making the switch requires extensive training and a redesign of work methods.

Consultants like me offer assistance in planning for change and in identifying and implementing the electronic medical record system that is the best fit for the practice.  We believe doctors will be best served by following a disciplined process of goal-setting, analysis and re-design of work flows, and solicitation of competitive bids from all the technology providers, including IBM and Dell.

Now, some might understandably take me to task on the issue of cost, not least because I often point out the sizeable costs incurred over and above that for the system hardware and software.  If a practitioner does a comprehensive ROI analysis that includes the opportunity cost incurred for training and system management issues, then yes, cost will be the most significant hurdle to investing in EMR.  On the other hand, it is not this total cost of implementation and ownership on which the big vendors are competing or seeking to leverage for market penetration.

The fact is, these opportunity costs will be incurred no matter whose software a practice adopts.  They can be somewhat mitigated by following a rigorous process of product and vendor selection:

• articulate a vision for the practice after five, ten, and fifteen years;
• set goals and objectives to be realized by adopting EMR;
• document and understand the practice workflow as it is today and as it will be after implementing EMR, and how the change will be managed;
• evaluate EMR product offerings based on the vision of the practice and the demands of the specialty;
• select a vendor in competitive bidding in which they are asked and must explain how they will address the key concerns of the practice.

In the process of articulating the vision for the practice, the practitioner should consider how he wants the practice to be perceived by both new and long-time patients, and how this perception should be encouraged by the experiences of making appointments, seeing the doctor, learning test results, asking questions in person, on the phone or by email.  And consider how administering the practice could be made less onerous.  What can an EMR do to help reduce the effort and issues involved in getting paid by patients and insurers?  Then approach vendors and ask them how they will help meet these goals and address these concerns.

I am all for the big vendors making a real effort to make their products affordable.  But I caution practitioners to file this away for future reference.  You have a lot of work to do before you can even decide which vendors to consider.

The legislation says, first of all, that Medicare will pay for end-of-life counseling for patients who request it.  Full Stop.  Elsewhere, it lists certain pieces of information that Medicare wants to collect from practitioners in order to monitor health care quality.  Full Stop.  Somehow, from these two points that do not even appear together in the legislation, McCaughey derived the assertion that they mandate patient monitoring by “death panels” with the power to grant or deny medical services.  Stewart rightly pronounced this “hyperbolic” and “dangerous”.  McCaughey, of course, is sticking to her guns, which forces us to ask whether she is as foolish as she appears, or whether she is determinedly cynical in using such hyperbole to stir resistance to the reform of the health care system that most of us know is absolutely essential.  The disruptions of town hall meetings orchestrated by lobbyists for the health insurance industry would seem to indicate the latter, but one could make a strong case for silliness, just from watching her in action in that interview.

Yet this affair touches on another issue that requires some serious thought.  The Department of Health and Human Services wants to monitor the quality of health care in a way that has not previously been possible, and to provide incentives for improving that quality based on benchmarking how health care practitioners do their jobs.  Potentially, this suggests an intrusion into the privileged communication between doctor and patient that makes many people very nervous, and rightly so.  If all the information about you can be gathered by a government agency, and if that information is in any way accessible to other parties, it is subject to abuse.  It can turn up in pre-employment background checks and result in loss of job opportunities.  Insurance companies could deny or cancel life or disability insurance coverage even if they could not deny health insurance.  Banks could deny credit by asserting too great a risk that you would become ill or die before you can pay off a loan.

HIPAA requires that patient data be kept secure, so a hospital or a medical practice has the responsibility that patient clinical records are protected from prying eyes within their systems.  But once an Electronic Health Record is transmitted from the practice or institution to any other body, the security and privacy of the data is out of their control.   As long as data is communicated among entities that are all subject to HIPAA, it is most probably secure.  But what happens when some of that data becomes available to entities not covered under HIPAA?

Data Mining refers to what used to be called “statistical analysis”.  By accessing, combining, slicing and dicing data from disparate public and private sources, it is possible to tease out confidential information on individuals.  As a simple example, suppose one has the following data sets available: aggregate pharmaceutical prescription sales dimensioned by patient demographics, but containing no individual identifying information; quality-of-care data from physicians with demographic dimensions; grocery store customer retention data that includes customer demographics and customer names; marketing information databases from warranty cards; and credit card transactions.  By combining the data from all of these sources it is possible to attach personal identification to health care records and identify patients and their medical conditions.  There are a handful of organizations that possess or have access to these kinds of information stores and make a business of doing precisely that.  Interested readers should seek out Robert O’Harrow’s “No Place to Hide”, published by the Free Press division of Simon and Schuster in 2005 for an eye-opening and scary view of industrial-scale data warehousing and data mining.

There are many good reasons that this industry exists, and we all benefit from it far more than we realize.  But it is a largely unregulated industry whose major clients are very rich, very powerful, unregulated or loosely regulated entities, including the banking and insurance industries.  The same health care quality data that will be collected by DHHS will almost certainly be demanded by the health insurance industry, and even if DHHS does not share data with Acxiom, for example, Cigna and United Health almost certainly will, thus bypassing the safeguards of HIPAA.

We all like to think that our personal privacy is guaranteed by the Constitution, though there is a body of legal opinion that says otherwise.  On the other hand, we all willingly give up much of that personal privacy when we opt into customer retention programs, or enter into a contract for insurance or other services, or apply for a loan or credit.  We now interact over the internet with so many entities via credit card that we have no idea just who knows what about us.  We can no longer control just how much information about our personal lives is actually available.  We need much stronger protections against abuse of this information than we are currently provided.

Electronic Health Records are absolutely essential to improving the quality, availability and affordability of health care services.  Less than a third of all health care practitioners currently use them, and DHHS seeks to increase that ratio significantly by 2011.  While practitioners and hospitals begin the process of adopting EHR, Congress should be considering how to prevent intrusions into patient privacy by commercial data miners, as well as abusive practices in the financial and insurance industries.

Let’s divert the public’s attention from the silliness of the Betsy McCaugheys of the world and focus on a real threat.