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Electronic health record adoption an issue for health care CIOs

Adoption of the electronic health record and related technology tools for physicians could revolutionize health care. But first, health care CIOs need to overcome cultural obstacles.

CAMBRIDGE, Mass. -- When patients, physicians and -- here's the big if -- payers embrace the electronic health record (EHR), life will be different in pretty amazing ways, according to Dr. Karen Bell. For the first time, patients will be treated by a personal team of clinicians. When a new drug for hypertension comes on the market, all patients (not just Nobel laureates like James Watson) will be able to map their genotypes and phenotypes to that medication to determine if it's right for them. Hospitals will be held to the "perfect care" standard -- the elimination of all medical errors in instances of preventable harm.

But the path to perfection will not be easy or, for that matter, linear, said Bell, director of the Office of Health IT Adoption at the U.S. Department of Health & Human Services. Privacy issues, interoperability issues, liability and physician reimbursement for all that extra virtual attention are potential deal breakers as the medical practice goes electronic. But most important, people have to understand why e-health is good for them.

Bell was among a panel of experts on the forefront of EHR who spoke at the recent EmTech08 conference on emerging technologies at MIT. Other panelists were Dr. John D. Halamka, Harvard Medical School CIO and dean of technology; Craig Feied, chief strategy officer, Microsoft Health Solutions Group, and professor of emergency medicine at the Georgetown University School of Medicine; and Girish Kumar Navani, president of eClinicalWorks, a medical software company based in Westborough, Mass.

Amid utopic visions of errorproof medical delivery enabled by technology was a caveat familiar to CIOs of all stripes.

"Culture eats technology for lunch," Bell said. "Until you engage providers, patients and the public on the value of e-health, you can build it, but they won't come."

Incentives not aligned for EHR

American doctors have been slow to adopt electronic health records, despite the potential EHR benefits, said Halamka, who also serves as CIO of CareGroup Inc. and chairman of the New England Healthcare Electronic Data Interchange Network.

Between 15% to 18% of U.S. physicians use electronic health records. In Massachusetts, where e-health ranks high on the state's agenda, the percentage climbs to 50%. The low national adoption rates are not surprising, he said. Doctors spend between $40,000 and $60,000 to get electronic records and can expect to see a 25% decrease in productivity during the first six months of use.

"The incentives are not aligned," said Halamka, who writes a blog called Life as a Healthcare CIO.

At CareGroup, Halamka oversaw the adoption of EHR at the Harvard-affiliated Beth Israel Deaconess Medical Center in Boston and at its community hospitals.

At Beth Israel Deaconess, CareGroup built a Web-based EHR system for doctors who were required to adopt the platform by July 30. To help its community hospitals get on board by Dec. 31, 2010, CareGroup established a hosting center with medical software provider eClinicalWorks that operates as a "turnkey" ASP and subsidizes 85% of the cost, excluding maintenance and ongoing expenses, he said.

The CareGroup platform is linked to Google Health, Google Inc.'s new, free repository for personal health information, as well as Microsoft HealthVault, also free, for patients who want to manage their own medical records.

Enabling patients to "own" their medical records certainly will remake the health care system. But the aspect of e-health that Halamka said he believes will really improve medical care is the "decision support" that an automated and optimized medical technology infrastructure can provide physicians in their daily practices. The medical literature published every month is more than a doctor could read in a year.

"Fifty percent of what I learned in medical school is wrong," he said. "The problem is knowing which 50% is wrong."

Automated systems that connect a patient complaint with large databases of medical information will result in better-informed decisions, he said. Add to that the possibility of physicians consulting on the same case in real time, and now the patient has a team of doctors at his side, instead of just one.

Doctor knows best

EClinicalWorks' Navani, whose company is developing decision support tools for medical practices, said the use of electronic medical data is widespread. It is not uncommon today to see the results of an electrocardiogram recorded electronically, for example, fed into a person's electronic health record for his doctor's review. Still uncommon, however, is seeing two doctors collaborating on patient care electronically.

"But change is coming," said Navani, who estimates it will likely be a decade before the system has enough doctors -- 100,000 is a good number -- and enough patient data to really leverage electronic health records and offer automated clinical decision support to provide better health.

"Until you engage providers, patients and the public on the value of e-health, you can build it but they won't come."

Microsoft's Feied, a pioneer in medical training computer programs and medical intelligence software, said physician collaboration is the critical element for improving health care. He offered an impassioned testimonial. An emergency room physician who estimates he treated 80,000 patients "with my own hands," Feied said the thing that stuck out as he looked back on his career was how many times he was put in a position of "guessing over and over," "flying solo," in an information vacuum

In situations where people "die right in front of you," he said he often felt he was "one data element away" from stopping a patient from dying.

Feied helped develop a comprehensive clinical information system called Azyxxi, for the rapid integration, organization, display and mining of data in real time from across regions. The system, bought by Microsoft, now goes by the name Amalga.

If the goal is to deliver perfect care, an automated, optimized e-health architecture can provide clinical decisions support, based on the patient record, pertinent medical information and real-time assistance from a "co-pilot," Feied said.

Erika Jonietz, senior editor of MIT's Technology Review and moderator of the session, kicked off the questions with a concern she's heard raised many times in her coverage of e-health: the element of clinical decision support baked into the software.

"The benefit to doctors [of clinical decision support] seems nebulous," Jonietz said.

Medical culture is made up of human beings who have dedicated up to a dozen years to becoming experts in their fields, she pointed out. In all the fervent testimonials to the benefits of automated and optimized medical practice, the panel seemed to be glossing over a roadblock familiar to CIOs of any industry: users who might not cotton to an automated system.

More likely than a hip hip hurray would be "'I know what I am doing; why do you want to tell me what to do,'" she said.

As for proof of patient indifference to e-health, the panel had to look no further than the poll taken before the session, when something like 70% of the audience said they would not leave their current physician in order to have a physician with electronic health records.

But Halamka countered that the lives of primary care physicians -- snowed under by paperwork that does not require an M.D. but is required nonetheless, frustrated by prescribing a medication only to find out it's denied by the insurance company and terrified of making a mistake -- is sheer misery. He predicted they will welcome the help, and patients will be better off for it. As the system stands now, "all the medical students are becoming dermatologists," he said.

Let us know what you think about the story email Linda Tucci, Senior News Writer.

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