By WALKER MEADE, Herald Tribune Correspondent
What would it mean to you never to have to worry that you forgot to tell your doctor about some past condition? Or never to have to fill out another medical form? Or never to have to call 11 times just to get your medical records when you need them?
For many people, these are little annoyances; for some, they are major headaches. But they should all disappear when the medical profession switches over to digital record keeping.
The time clearly is at hand for the dramatic transition in the medical world from scribbled notes to generating computer printouts. This year Congress will spend $17.2 billion to bring the medical profession kicking and screaming into the digital world.
It's a wonder it took so long. The government's own survey published recently in The New England Journal of Medicine reports that doctors who control patient management electronically say that such record keeping helps improve the quality and timeliness of care.
So why isn't a viable system up and running already? Fewer than 20 percent of American doctors have begun to use digital patient record keeping.
"Bringing patient records into the computer age, experts say, is crucial to improving care, reducing errors and containing costs in the American health care system," according to a story in The New York Times. "The slow adoption of the technology is mainly economic. Most doctors in private practice, especially those in small practices, lack the financial incentive to invest in computerized records."
And hospitals have the same problem. An extensive study of more than 3,000 U.S. hospitals, reported in March on the online edition of the New England Journal of Medicine, found that only 1.5 percent had comprehensive systems -- that is, systems that have hospital-wide capacity for clinical documentation of cases, test results, prescription and test ordering, and support for decision-making that included treatment guidelines.
The problem, as it is for private practices, is cost. It takes heavy investment -- tens of millions of dollars -- to upgrade a hospital-wide system. According to The New England Journal of Medicine, "The Obama administration's incentive payments for adopting electronic health records includes more than $40,000 per physician and up to several million dollars for hospitals." That is, as they say, a drop in the bucket.
So to help fill the bucket, the federal government also announced a Medicare project that will offer doctors incentives to get with the program. The federal effort is designed to help 1,200 small practices in 12 cities and states make the conversion. Individual doctors will be offered up to $58,000 over five years to see if incentives can improve the spread of electronic health records.
Meantime, both Microsoft and Google have started services that offer patient-controlled records. The companies store the records in their own data centers and are intended to link and exchange information with the electronic patient records in doctors' offices.
Difficulties aside, the switch to electronic record keeping is beginning to take hold in Sarasota.
Dr. Bruce H. Berg, the regional campus dean of the FSU College of Medicine in Sarasota, is in the vanguard. After he served in the Air Force, Berg developed an interest in information systems and administrative medicine, which led to his selection as the lead physician to help install an electronic medical record system at Sarasota Memorial Hospital. He subsequently became the chief medical information officer and then the patient safety officer for the hospital. He also serves as a consultant around the country for electronic medical records, patient safety, physician behavior issues and bioethics.
"EMR is a way of keeping a variety of patient, laboratory, consultations, testing and other information, including office and hospital data on a patient, in a manner that allows ready access and analysis," Berg says.
"As far as patient access is concerned, most EMRs allow a patient to access the record to whatever degree is desired. Memorial, for instance, has an extensive back-end system that can only be accessed by people privileged to do so. It has a 'right package,' which means we can determine who can see what and under what circumstances.
"For instance, my students who work with doctors at Memorial can see the EMR records there. But as soon as they leave that practice, access is denied them.
"It's possible for patients to see records, but direct access to the system is not available at Memorial now."
Berg explains that although patients are entitled to their records -- physicians and hospitals are only caretakers -- traditionally, physicians are sometimes reluctant to give patients full access.
"There are several reasons for that," he says. "A lot of the language doctors use is a little direct -- it might be said differently in the record than a physician would say to a patient -- and that can be alarming without explanation. Sometimes the language is highly technical and really needs explanation.
"At Memorial we have a group of people who do nothing but oversee who can have access to patient records. In terms of having a fully functional, operational, order entry, results review, policy-attached electronic medical records, Memorial Hospital is one of the best in the country."
While it's one thing for a big hospital to have both resources and will to achieve proficiency in electronic medical record development, it's quite another for an individual physician to manage that.
Locally, Dr. John J. Collins, in partnership with Dr. Steven Grogg, has one of the few small practices that has a system up and running. Their EMR facility has been in service since the office opened in Sarasota nine years ago.
"Our system's primary function is record keeping for our patient encounters, which is pretty much the same as it would be in a paper-based world, except that we keep the information in a more useful way," says Collins, who, with Grogg, practice pediatrics and internal medicine. "On an ongoing basis, it allows us to mine data and take care of our patients both as populations and individuals. For instance, we can track disease states and monitor how well we are taking care of our patients against national averages."
When Collins and Grogg see patients, they do not dictate the results of the examination for transcription later.
"The program we developed has templates that allow us to enter data directly into the computer and we can modify those templates on the fly to account for whatever a patient may have a problem with," says Collins. "There is always a laptop in the examining room."
The two physicians believe they can record more of what they talk about and what they see in an examination than a doctor would who has to dictate later.
"We are also probably more accurate in our record keeping," Collins says. "For the patients' sake, it allows us to collect the information and to synthesize a better working hypothesis about their condition."
Everything dealing with a patient's care is easier with an EMR system. When Collins needs to supply records to a patient or to a physician, he prints them to a PDF file, which resides on a CD that the patient can keep. So there are not reams of paper to deal with.
And the system does the billing for the practice with a click of a button.
"Although you still have to have a staff to deal with insurance companies," Collins says, "because charges acceptable to those companies vary right down to the plan level. No computer is sophisticated enough to deal with the constant changes in the rules of insurance compensation yet."
Though the system is remarkably efficient, "the initial cost is very high," says Collins. "We started our practice from scratch with electronic medical records. In our start-up costs we had to buy all our computers and servers in addition to implementing our electronic records. So what it cost us was about $70,000 per doctor," Collins says. "And I did a lot of implementation myself, so we probably saved about another third of the usual cost."
One of the most powerful tools the system offers is the ability to mine the data it collects.
"I can monitor things like blood pressure, cholesterol and diabetes. So when I'm talking with a patient, I can look at all their recorded blood pressures as a trend over time. I can see what medications they were on in any given time frame. Which means I can show them what improvements or what detriments those medications have caused.
"Or I can look at all of my patients and see how I manage blood pressure as compared to all other physicians," says Collins. "I can see if I'm close to meeting the 120/70 goal on average. I can get a percentage of patients who achieve that goal and then look at the MQUIC (Medical Quality Improvement Consortium) database and see that about 70 percent of doctors meet that goal.
"So then I can select all of my patients with their last systolic blood pressure of over 140, call them up and say, 'Come in and let's talk.' I can do the same thing with hemoglobin A1c in my diabetics because blood pressure and cholesterol control are even more important in those patients since it is a leading indicator for heart attack and stroke. In our practice we are in the 95th percentile (of all physicians) in achieving that goal of blood pressure control for our patients.
"So you can look at every diabetic you've seen in the last eight years and see that, out of your 8,000-patient base, you have 600 diabetics. Then you find out you only see 200 of them regularly and you immediately want to know where did the other 400 go. So if my number looks bad, you say, 'Hey, I'm not seeing these people,' so you start sending letters and making phone calls."
That leads to a much more proactive and preventive program. And that, perhaps, may be the hidden benefit of electronic medical record keeping. Because the majority of physicians in the United States are in groups of under five doctors, they need to be able to share information about a patient's medical history quickly and over time.
"In my practice, we don't have any privacy concerns because we host our own data, we have our own server and that's in a locked closet in this office," says Collins. "There is no other access here except by the staff, and I run access logs to see who has looked at what. So it's easy to see who's just poking around and who's doing their job. In the next four months, we will have a patient portal so patients can see their own records. It includes secure messaging so they can send messages to me and get messages from me in e-mail format. The security here is that they will get a message that tells them to log into their account to see a message. The message will always reside in my server so it's not hopping around the Internet."
Although there are many issues to be resolved before EMR can become an effective tool for improving medical care and reducing costs, ways will be found to allow diverse computers to talk to each other, to secure the privacy of patients, and to pay for the expensive hardware and software required. And when it is all said and done, our waiting time to see our doctors should be shorter, our medical bills less horrific, our prescriptions more accurately filled and our lives significantly better.