By Chris Rangel*, MD
The Internet beta 0.5 version was nothing like it is today. Back in
the ’80s and the early ’90s the most common way to access the outside world was
to use a phone modem to dial the number of a remote computer. These primitive
servers usually ran DOS based software called a Bulletin Board System (BBS)
which allowed users to post messages to each other.
For the most part, these
servers were isolated and did not communicate directly with each other. If you
wanted to connect to a different BBS you literally had to hang up on one and
call another one. There were usually no centralized servers that could link and
share information among multiple BBSs. This sharing of information among
multiple interconnected computers, servers, and networks is essentially what
the modern internet is and once the world wide web started to proliferate in
the mid to late ’90s the old BBSs became extinct.
Facebook is a perfect example
of modern Internet use. It’s essentially a vast central database with millions
of users who can easily access information using multiple devices, upload and
download data in multiple formats (text, links, pictures, video) from multiple
sources and all from a single internet connection.
It sounds like Facebook would make a great starting template for a vast
interconnected medical records system. But the reality is that the electronic
medical record (EMR) industry is still
stuck in the era of the BBS. The similarities between modern EMRs and the BBS system are striking. Like
many old Bulletin Board Systems the vast majority of EMR systems do not
communicate with each other (nor even the outside world). Not only are they
often incapable of communicating with another EMR or computer but even in 2012
most new EMRs don’t even have an option for sharing information with other
systems! This is one of the biggest paradoxes and failures of almost all EMRs.
Designed for an industry where the sharing of medical information among
different facilities and health care providers is critical to the timely,
effective, and safe delivery of medical care, the majority of these systems are
designed to share information only within the limited confines of the specific
facility or health care system that they serve. EMRs are essentially
information islands cut off almost completely from direct contact with the rest
of the interconnected world.
The system at the hospital where I work is a perfect example of this
isolationist mentality. In its current form, the hospital EMR cannot send
or receive information from doctor’s offices, labs, or imaging centers outside
of the actual facility. Acquiring old documentation still requires one or more
phone calls, several human intermediates, a fax machine (40 year old
technology) and open business hours (no luck if after office hours, on
weekends, or holidays). Even worse is that the system can’t even communicate
with older electronic systems within the same facility and has no capability to
input and store faxes or scans in a format such as PDF for internal viewing.
This means that we are still stuck with a hybrid EMR-paper chart system that is
often more cumbersome and inefficient than using either system alone.
And how did it get to this pathetic point where a guy in rural Brazil can
upload a picture of his strange rash to someone in China in real time but I
can’t get critical medical information on a patient found unconscious until
their doctor’s office opens the next business day? Given all of the concern
about online privacy and hacked Facebook accounts you might think that the
health care industry is cautiously avoiding systems where private information
could be compromised (never mind that there has not been a massive collapse of
the credit markets from widespread identity theft and fraud from 100s of
million of Facebook users). The motivation of the health care industry in
avoiding interconnected medical record systems is not to protect patients but
rather, to protect itself.
Specifically, they want to protect themselves from competition. The
majority of health care facilities and health care providers still think about
medical records the same way they did 100 years ago – as property or
proprietary information. A physical medical chart is considered to be the
property of the facility or provider who generated the chart even though the
patient is considered to be the “owner” of the information contained within the
chart. A Paper chart is usually stored at the same facility where it was
created and patients often prefer to return to the same facility or provider if
for no other reason then because “that’s where my records are.” Changing
facilities or providers can often be a problem for patients who must go through
the bureaucratic hassles of making a formal request for their records and then
having to pick them up and hand-deliver them to a new office or provider. This
system is effectively a disincentive for patients who wish to change providers
or health care facilities and is, ironically, a barrier to the sharing of
information.
Not surprisingly, the electronic version of the medical record system
continues this same isolationist mentality. Even though digital information
replaces paper folders and charts, electronic records are usually restricted to
the system that generated them. Most EMRs are designed to be run on a server or
computer that physically exists within the same office or facility and without
any direct connection to the outside world. The only way to share information
is the old fashioned way – i.e. the electronic record must be printed out and
either faxed or hand-delivered to another office or facility. In this way, most
EMRs are little more than a hard drive replacing a filing cabinet. But wait,
that’s not all. Most EMRs are themselves proprietary software. Most of the
expensive systems in particular are not compatible with transferring information
to other EMRs without extensive and expensive modifications. If all EMRs could
communicate with each other equally then providers would just purchase the
cheapest ones thus damaging the finances of the industry. Right?
Wrong. Business is ripe with examples where standardization and
compatibility among different products has lead to expanded market size and
share even among competitors. The electronics industry is just one example.
Another example is the Internet and web browsers. If Internet Explorer were only
able to access web sites running Windows server software, then the massive
growth and success of the Internet would have been severely blunted. Instead,
the industry got together and decided on a common language (HTML) that is
usable by any browser. Obviously industry standards can be voluntary or by
government mandate. So the question is; why not make all EMRs capable of
communicating and sharing information with each other? The Federal government
recently had the chance to do so and severely blew it.
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided financial incentives for early adopters of
electronic health records and even provided definitions of “meaningful use” and
what information an EMR should be able to record and store. But the single
biggest failure of HITECH was that it did not define standards of compatibility
nor even require compatibility among any of the thousands of different
electronic medical record systems. Hundreds of millions if not billions of tax
dollars will now go towards further entrenchment of the current isolationist
proprietary EMR industry. And this is not good for patients or consumers
either. In theory, if all electronic medical records were freely and easily
transferable among different providers and facilities, the artificial barriers
for patients to changing providers and facilities wound be gone and providers
and facilities would have to compete based solely on the quality and efficiency
of their services rather then relying on holding medical records hostage in
order to generate return business.
However, improved competition among health care providers is not the
primary aim of open and efficient transfer of health related information.
Accurate and up to date health care records that are easily and universally
accessible have the potential to improve the safety, quality, and efficiency of
health care delivery. Costs can be decreased by reducing the need for repeat
labs and tests. Older patients in particular would benefit from accurate
medication lists and lists of prior drug reactions and allergies to reduce the
possibility that providers will prescribe medications that could interact with
a patient’s other medications or be contraindicated for any one of their
medical conditions. Ensuring that open and free communication of medical
information exists between EMRs appears to be beyond the scope of the current
records industry. This is something that only the Federal government will be
able to do when and if it decides to get serious about modernizing health
informatics.
*Chris Rangel is an internal medicine physician
who blogs at RangelMD.com.