Last week Microsoft announced a new personal health record product called Health Vault, which is designed to provide a patient-centered medical document that will contain personally relevant medical information, and perhaps copies of tests such as EKG’s and records of blood pressure and glucose measurements.
Simultaneously with that announcement, Bill Gates wrote an op-ed piece in the Wall Street Journal where he praised the promise of health information technology (HIT), while bemoaning the slow progress we have made in this arena.
Well, Mr. Gates, not to be impolite, but welcome to the table. Maybe your influence will help us address the obstacles.
HIT is one area in medical practice that has been consistently difficult and stubborn to address broadly and successfully. No matter how much progress we have made in medicine over the past three decades, the barriers to success in HIT remain daunting and the goals elusive.
HIT is not a new concept.
Years ago, I used to regularly interview billing system vendors for my own practice. Finally, after many, many years, companies were able to develop products that were useful in handling the business side of a medical office. When good products became available, as well as systems which used that information to process insurance claims, doctors embraced them.
When it comes to medical records and the promise that HIT has to improve the quality of medical care, however, we are still way behind the eight ball and have a long way to go.
What are some of the problems?
Here is a short list (which could be much longer):
- There is resistance among many physicians to adapt.
- Systems don’t talk to each other.
- You can’t aggregate information.
- You can’t effectively mine the data to measure quality accurately or consistently, or perhaps more importantly to help medical practitioners and other providers improve the quality of care across institutions and within communities.
- The available systems cost too much to install, too much to maintain, and after spending what may well be hundreds of thousands of dollars for a modestly sized practice, you have no guarantee that a particular system will meet your needs, and you don’t know if the company will stay in business.
The result is that when it comes to the practice of medicine we are far, far behind where we need to be.
For example, back in the mid-1990s I had the opportunity to give a talk in New York to a business club. I emptied the plastic cards out of my wallet on the table in front of me, and showed the audience the only one that didn’t have a magnetic strip to enable the transfer of information: my health insurance card.
Today, I emptied my wallet and looked at my cards. Nothing has changed. Still no magnetic strip and no easy way to transmit information. So, when I get my screening colonoscopy in December, the doctor’s office is still going to have to call 1-800-whoever and find out whether or not I am covered and how much I have to pay.
Nobody has a system that reminded me that I needed a colonoscopy or prodded me to get it done (that was my wife’s responsibility). No one offered me any resources—online or otherwise—to help me understand why I needed a screening colonoscopy or what I could expect, or how to interpret the results.
I know the answers to all of these questions, but I am a doctor who works in this field.
What about the rest of the country? How do they get reminders or information or help understanding more about the procedures they undergo or understand in plain English the results of the tests they have just received? (By the way, you can go to www.cancer.org or call 1-800-ACS-2345 and the American Cancer Society will be glad to help you answer these questions.)
Mr. Gates commented that we should have personal health records where we can store copies of our EKG’s. So, if I show up in an emergency room with chest pain (not that I want that to happen, but that is a different topic) the doctor can quickly compare the EKG in the emergency department with the one that I had previously.
That is not a new idea. A friend of mine, about 10 years ago, developed the technology and was even written up in a major business newspaper. But he was way ahead of his time. He couldn’t make the business model work, and his idea and his efforts—like so many that have been around for a decade or more—did not succeed.
The result is that we are no where near accomplishing Mr. Gates’ dream.
If I sound a bit frustrated, it is because I am. There are many voices of influence out there who make it sound like all we have to do to fix medical care delivery and quality in this country—aside from assuring access to care—is to put an electronic medical record in every doctor’s office and then we would be fine.
Oh, but it should be so simple.
The proponents of electronic medical records—including some prominent politicians--have not dealt with the hard reality that the very physicians they want to install electronic medical records have the least resources—financial, human and otherwise—to accomplish the task.
They can’t afford the systems, they can’t afford the maintenance, they can’t afford the consultants to help make it work, and they don’t have the time to load in all of the quality parameters they need to do the job.
Large medical practices clearly have an advantage, and can accomplish these tasks. But many small medical practices simply don’t have the resources, and frequently find it hard to justify the commitment.
We are making progress in HIT to some degree, but on my personal scale of progress we have moved from Neanderthal to infantile (next steps on the scale would be juvenile, young adult, adult and mature adult) when it comes to realizing the potential impact of HIT on how we deliver health care in this country.
In short, there are pockets of glowing success among a morass of inconsistent and ineffective programs and offerings.
Look at the concept of health information exchanges, or HIE, as an example of the promise and the problems.
The idea behind HIE is that a community or region can bring their data together on a single, accessible platform with the goals of improving health outcomes and exchange of information to reduce duplicative and unnecessary medical tests. This is but one example of what could be accomplished if we had effective, electronic records and the societal will to weave them into the process of medical care delivery and quality measurement.
Unfortunately, having a health information exchange that works requires everyone from the local doc to the pharmacist to the hospital to the insurers to the state government to get on board.
You don’t have to be a rocket scientist to imagine how hard that has to be.
First, consumers and health care providers need to trust HIE and want it. Then, someone has to set the rules for it. Then, someone has to pay for it. Then, someone has to make it work.
But, time and again, these efforts have difficulty getting off the ground let alone succeed because no one can build the sound business model or develop the considerable community commitment that will make it really happen.
Personal health records as envisioned by Microsoft are also not a new idea.
Many organizations and companies have made an effort to make these happen (In the interest of full disclosure, I sit on the advisory board of an organization called i Health Alliance, which deals with privacy issues related to personal health records. I receive no compensation for this service. The board is affiliated with a company called Medem, which has a personal health record called i Health Record.)
I personally believe—as do others, including some well known medical professional associations—that personal health records are important, and represent a step forward in where we need to go, namely establishing a patient-centered medical record that can be used not only to record the fundamental data such as name, illnesses, allergies, and so on, but a vital, living record which helps notify people about possible medication problems, alerts them to the need for getting screening tests, and helps them learn more about their medical conditions.
But who is going to enter the data into these personal health records?
The patient? That’s possible, but as noted by one commentator patients have not exactly been lining up for the product. Having them accurately complete the document is going to be the exception rather than the rule.
The insurance companies are moving into this field, as are some large corporations (through a company called Dossia) who fund their employee’s health care. Will we use insurance data to fill out the personal health record? Maybe, but you had better check the data.
If you think the credit reporting companies have problems with data accuracy, you can only imagine the problems that may arise from using insurance claims data to provide you with your personal health records.
What about your doctor’s office? First, they have to have an electronic medical record system. And, even if they do, their system has to talk to, let’s say for example, Microsoft’s system. My friends, that isn’t going to happen until all the systems have a completely seamless way of talking to each other.
That’s right, we still don’t have complete standards on communicating information from one doctor’s HIT system to another, and that goal—although currently being worked on—still has a long way to go.
Mr. Gates is absolutely correct: we could do a much better job of making our health care system (or, some would say “non-system”) more effective and efficient through the use of HIT and HIE.
I happen to agree that patient medical records should be more transparent to the patient, including the opportunity to receive educational information on what they see in their record at the moment they see it.
I happen to agree that we could harness the power of data from electronic health records to make better medical decisions, spot problems earlier, and improve the health of our country.
I happen to agree that patients should be able to determine who should see their medical information, and how it should be used (except in medical care situations where that information is needed to treat a medical condition).
But eventually all of the talk and well-intended ideas must give way for someone to figure out how we can make this happen for the thousands of medical practices around the country that need help in getting a quality electronic medical record system into their offices and pay for it.
Someone has to figure out how we are going to get these systems communicating to each other in real time with meaningful (and privacy protected) information, test results and other relevant data.
Someone has to figure out how we can aggregate information at a community and national level to improve the quality of health care.
Someone has to figure out how we can align our various state and national laws and regulations to make this happen within the boundaries of good medicine, good policy, and with attention to adequate privacy safeguards.
If Microsoft and Google can get these problems solved when so many others are still struggling, hey that’s terrific. These are well-established, innovative companies who understand technology and what it can do. They have the financial resources to make it happen.
But a word of advice from the trenches: don’t be surprised if the barriers to success are substantial.
Unfortunately, despite a lot of effort by a lot of people, we are still crawling along. I can’t wait until we stand up and walk.