The going rate for a compromised medical record seems to be $1000 (well, at least  that’s the asking price) as seen in papers filed in the eleven class action lawsuits against Sutter Health following the theft of a desktop computer last fall. The computer contained unencrypted protected health information on about 4.24 million members. The eleven class action suits are likely to be consolidated for ease of handling by the courts.

For an outfit whose most recently reported year-end financials show just under $900
million in income on just over $9 billion in revenue, a $4.24 billion claim certainly qualifies as a big deal. The data breach claims against Sutter Health were filed last year following its self-reporting of the computer theft, and are in the news again due to the potential consolidation.

The company had reportedly begun to encrypt its data last year, starting with more
vulnerable mobile devices, and moving on to desktop computers, but had not gotten to the desktop in question by the time of the breach. It remains to be seen how these facts end up affecting the final damages awarded in this case.

The takeaway for other covered entities and business associates out there: If the OCR HIPAA audits aren’t enough of a motivation to get cracking with beefed-up data privacy and security protections, the potential exposure of Sutter Health in this class action suit should be reason enough to get started on this work as soon as possible, and to make it a high priority. Suits like these may be grounded both in state law and in indirect theories flowing from HIPAA/HITECH breaches (since there is no private right of action under HIPAA). The exposure is there, and a number’s been put out there to quantify it. However expensive and inconvenient data encryption and other privacy and security measures may be, they are surely worth avoiding $1,000-a-head lawsuits and months of negative publicity.

_ Recently, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should feel frustrated that he was never confirmed.

In his parting interview with the press, he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:

*Patients are over-treated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Patients are over treated

When I was an emergency department resident 20 years ago, the faculty and staff of Harbor-UCLA medical center taught me best practices for safe, quality, efficiency care.   When I make decisions today, I reflect back on that intense training.  However, thousands of journal articles have been written since then, there’s new evidence suggesting more effective treatment plans, and new therapies are available.   How do I ensure the just the right amount of care is delivered – neither too much, nor too little? Decision support embedded in electronic health records.

EHRs can provide alerts and reminders – just in time advice as to what my patients need.  Educational materials and literature can be embedded in the workflow for easy reference.  Population/panel health tools can identify those patients who need follow-up or are deviating from care plans.

There is not enough coordination

The United States does not have a healthcare system – it has a disconnected array of clinics, pharmacies, labs, hospitals, and imaging centers.   Meaningful Use Stage 2 is likely to require significant healthcare information exchange as well as the transport, vocabulary, and content standards needed to support it.  Although the journey to a completely connected healthcare system will take a few years, the next 24 months will include a quantum leap in care coordination as state health information exchanges connect patients, providers, and payers.

US healthcare is burdened with excessively complex administrative system

Like the tax code, healthcare regulations are dizzying in their complexity and volume.   Some are so arcane that experts cannot agree on the interpretation.    If rules can be built into EHRs such as the precise definitions for quality reporting, automated electronic coding of visits based on structured documentation/natural language processing, and payments made on objectively measured processes/outcomes instead of the quantity of care delivered, regulatory complexity can be reduced and money saved.

The enormous burden of the rules

Approximately 25% of my IS staff work on compliance related software requests – building new functional or purchasing new products to meet every increasing numbers of rules.    We all want to do the right thing, but if no one can understand the rules and the amount of overhead needed to comply is financially unsustainable, the rules are too burdensome.

Electronic health records can enforce automated care plans, provide feedback at the point of care and support administrative simplification with bidirectional electronic transactions between payers and providers.

Fraud

Although no system is foolproof, electronic health records can reduce fraud by automating the kind of data transfers that will help detect fraud and abuse.    Emerging new analytics companies are already working on techniques to discover patterns of care that do not make sense – Medicare billing for deceased patients, redundant procedures or services, and variation in billing practices among physicians that can identify outliers.

In addition to these 5 areas of waste reduction, electronic health records are an essential part of a learning healthcare system which gathers data for clinical trials, clinical research, and unique population health measurement such as pharmacovigelence, syndromic surveillance, and immunization compliance.   Don Berwick is a great supporter of the EHR’s potential to increase quality, safety, and efficiency while reducing waste.

Although healthcare reform is controversial, healthcare IT reform – the federal 5 year plan to increase the use of electronic health records and healthcare information exchange – has broad bipartisan support.

As Don Berwick returns to the private section, I’m hopeful that he’ll turn his energy back to fixing the US healthcare system and that he’ll be a tireless champion for electronic health records.

_ On Wednesday the Centers for Disease Control and Prevention (CDC) released the results of its yearly survey on Electronic Health Records (EHR) adoption for office-based physicians. No surprises. Generally speaking, the majority of physicians in ambulatory practice are now using an EHR, and over half of surveyed doctors say that they intend to seek Meaningful Use incentives. The report is also presenting results broken down by state, so you can learn what folks are doing in your immediate vicinity. The more instructive exercise is to compare last year’s survey results [Figure 1] to this year’s estimated EHR adoption numbers [Figure 2].

The most immediate observation is that 6.2% of physicians have adopted an EHR in 2011, thus returning to EHR growth rates preceding the 2009 -2010 slowdown, which was largely due to the confusion created by Meaningful Use regulations. The next observation is that the percentage of docs that have at least a basic EHR has gone up by 8.9% in 2011. A basic EHR is one that has “patient history and demographics, patient problem list, physician clinical notes, comprehensive list of patient’s medications and allergies, computerized orders for prescriptions, and ability to view laboratory and imaging results electronically”. Although the survey instrument in 2011 did ask about more advanced functionality, and is practically identical to the 2010 instrument, the CDC did not publish a separate number for those with fully functional systems in 2011. Although I cannot be certain, I would assume that most of the growth in 2011 was fueled by certified EHRs, which by definition should be fully functional. So if I had to guess, and I hope CDC will release the numbers so I don’t have to, I would estimate that in 2011 we have at least 20% of physicians using fully functional systems, which is roughly double what we had in 2010.

Another interesting trend that has been holding since around 2007 is that about a quarter of office-based doctors have some type of bare bones software in their office and they are not upgrading to even a basic EHR. Considering that over half of those surveyed intend to apply for Meaningful Use incentives, this trend is bound to change in 2012.  Some of these folks may have purchased a fully featured EHR, but chose to either not turn features on or chose not to keep up with upgrades to newer versions. For ambulatory EHR vendors these numbers translate into a market opportunity ranging from 50% of the market to a full 80% of ambulatory physicians.

It would be very beneficial if CDC released the complete data set from this survey (anonymous, of course), so we could gain a better understanding of EHR adoption patterns by practice type, size and location. Although it is widely acknowledged that larger practices and employed physicians are further along the curve, the rich details provided by the survey instrument should help both vendors and various organizations engaged in efforts to spur technology adoption, better target their work, and it could also illuminate any disparities which may affect quality of care for vulnerable populations and physicians who serve them.

In summary, the new CDC survey is showing a stable growth in technology use by office-based physicians, modestly improved by government initiatives over the last two years, and well positioned to further improve in 2012 and beyond.

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Productivity Optimization – Numerous carefully estimated anecdotal studies consistently show that introduction of an EHR in ambulatory practice can reduce provider productivity by 50% or more. This directly translates into 50% (or more) savings in health care expenditures for office visits. Unfortunately, the same studies also show that in most cases this reduction in office visits is transient, with most providers regaining ability to charge for as much as 80% of their pre-EHR visit volume within six months to a year. Still, 20% long term savings is significant and could probably be optimized further by introducing more speed tempering features into certified EHRs. Equally rigorous studies show preliminary evidence that the savings realized from introducing fully functioning EHRs in Emergency Departments far exceed those in the ambulatory sector. Unlike other Socialist countries that were compelled to nationalize the entire health care system just so they can reduce productivity and discourage utilization by creating long waiting lines, Yankee ingenuity is producing better results at lower costs.

Banishment of THE Pen – The Physician Pen has been long known for being the most financially devastating instrument ever invented. In spite of pharmaceutical reps efforts to the contrary, EHRs are successfully removing all pens from medical practice, including but not limited to, the Physician Pen. Where physicians used to carry several handsome pens in that little pocket right under their embroidered name and title, they now carry an EHR contained in a device that may or may not fit in a less accessible pocket and either way requires both hands, ample light and an adequate supply of battery power to order the simplest thing. The better EHRs also provide various speed bumps on the road to ordering by popping up multiple warnings and good financial advice equidistantly placed at 10 to 15 milliseconds intervals. Data from the very similar retail industry shows that impulse buying is greatly increased by simplifying the process, such as the one-click checkout at Amazon. The reverse logic must also be true, so increasing complexity should reduce impulse ordering in medicine. Judging by Amazon’s successful strategy, the savings in health care are expected to be spectacular.

Customer Intimidation – As EHRs become better at measuring the abysmal state of our health care non-system, and expose the horrors and frequency of medical errors by either careless omission or profit-driven commission, it is estimated that health conscious consumers will increasingly avoid dangerous encounters with the medical complex, thus further reducing utilization and cutting costs. Strategic publicity campaigns advertising security and privacy breaches in other computerized industries, and in health care if any are found, should eliminate another segment of customers. However, the largest cost savings are projected to come from customers refraining from seeking care for, or even mentioning, potentially embarrassing health problems for fear of public exposure through interconnected EHRs.

Accelerated Attrition – EHRs are very powerful tools. So powerful that the prospect of having to purchase and use an EHR is more than enough to prompt older physicians, particularly those in private practice, to consider retirement or transition to other occupations. The evidence shows that there is direct anecdotal correlation between negative reaction to introduction of EHRs and acceptance of cost-saving team approaches to provision of medical care. The semi-natural attrition of experienced and highly compensated physicians who insist on treating, and charging for, every sore throat and every knee scrape, in spite of mounting evidence that lower paid resources can refer those to appropriate specialists with equal outcomes, should in the course of time increase the amount of savings directly attributable to the prevalence of EHRs.

Free Labor Procurement – EHRs are particularly adept at encouraging and showcasing the historical selflessness and ethical conduct of medical doctors, by providing multiple means for doctors to contribute to the well-being of their patients practically free of charge, at all hours of day and night. From the ubiquitous email to the occasional webcam session to the continuous evaluation of uploaded self-quantification vital data from patients empowered to have their health expertly monitored, physicians using EHRs can provide this simple courtesy service to their customers from the office, the home, the yacht or the golf course. These proactive preventative measures should result in extensive reductions in disease burden. Constantly connected physicians, armed with the latest monitoring tools, could detect strokes, heart attacks and maybe even cancer years before actual manifestation of symptoms. And at no cost to society.

The implications for policy makers are pretty straightforward. EHR adoption should continue to be encouraged at all costs. EHRs must evolve to seamlessly and continuously connect to all consumer monitoring devices, which implies a preference for cloud based technologies, and a security breach here and there is not necessarily an impediment to success. EHRs should continue to increase the levels of automated decision support, improve analytics and increase frequency and scope of various alerts. Basically, keep up the good work. We’re right on target.

The term patient-centered has become a serious contender for the most flippantly used term in health care publications and conversations. Of course meaningful use is still #1 on the popularity charts, with ACO quickly moving up, but even meaningful use and ACO are almost always accompanied by patient-centered as a way to add legitimacy and desirability to the constructs.

Even Rep. Paul Ryan’s new recipe for fiscal Nirvana is touting patient-centered health care as one of a litany of fictional achievements made possible based on an array of wishful thinking assumptions. But perhaps the most common usage of patient-centered terminology is the Patient Centered Medical Home (PCMH), which is touted as the ultimate patient friendly solution to our health care difficulties. Since PCMH is heavily reliant on Health Information Technology (HIT) to achieve patient-centeredness, and since Meaningful Use of Electronic Health Records (EHR) is being increasingly aligned with this goal, it may behoove us to explore the features and functionality that would qualify an EHR to support a patient-centered approach to health care delivery.

But first, what exactly is patient-centered health care? From reading the NCQA medical home specifications, the Meaningful Use definitions, the HIT suggestions from PCAST and the brand new ACO regulations, all of which assert a patient-centered approach, one would conclude that patient-centered care is made possible by providing all patients with timely electronic access to the entirety of their medical records including lots of patient education, electronically coordinating a multitude of transfers of care, empowering non-physicians to provide most medical care, measuring a bewildering array of health care processes and constantly evaluating and reporting on population metrics, while somehow allowing patients and families to express their wishes regarding the nature of care within the boundaries specified by each proposal. I am excluding the Ryan budget proposal here, since other than having “patient-centered” typed in various spots, there is no reference to actual health care delivery, or what is left of it after most seniors, sick and disabled folks are reduced to begging for medical care. Computers and EHRs can, and to some extent already do, support many of the above activities, but is this truly patient-centered (singular) care, or should we add an “s” and refer to a plurality of patients-centered, or population-centered, care?

In 2009 in a landmark Health Affairs article, Dr. Berwick summarized patient-centeredness as follows: “The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care” and he very much liked the Harvard maxim “Every patient is the only patient”, since it implies an “attitude of “guest” in the patient’s life, and it also expresses confidence in the feasibility and desirability of customization of care to the level of the individual”.

When articulated this way, patient-centeredness becomes more of a mindset directive for those who provide medical care and those who design health care delivery systems. There is precious little that an EHR can do to ensure patient-centered care, and most all it can do is act in a supporting role, as it always should, for patient-centered health care providers. This is not to say that the computer-enabled capabilities to evaluate, manage and measure population health indicators, such as registries and clinical process measures are not beneficial, but these computerized aggregation and management tools have almost nothing to do with the concept of patient-centeredness as expressed by Dr. Berwick.

EHRs are more than an electronic chart. Even for small practices, EHRs are also enterprise/business management software. In both capacities, EHRs can contribute their fair share to a patient-centered approach to health care. The following list is not intended as a complete EHR design document; instead it is a collection of technical features and functionalities that could be rather easily added to existing software in an attempt to help place the individual patient at the controlling center of health care provision, according to Dr. Berwick’s vision of patient-centeredness.

• Transparency – A well-documented medical record shared in its entirety with patients through a Patient Portal would go a long way to provide transparency into medical treatment decisions, but in its current form an EHR may be too lengthy and too complex for most patients (and most physicians too) to follow and comprehend. Many of today’s EHRs include patient education materials regarding a particular disease following diagnosis, a medication that was just prescribed, or a particular diagnostic test ordered. It would be infinitely more conducive to transparency if Patient Portals would include full subscriptions to such sites as UpToDate and test results documentation, including reference ranges and abnormals for each test resulted in the chart, in plain and simple language. Another patient-centered feature available in many EHRs is the longitudinal record (or flowsheet), but this is rarely, if at all, available to patients. Providing ability for patients, particularly those with chronic conditions, to obtain and customize longitudinal views of their health records would allow patients to understand how various therapies and various behavior modifications are affecting their wellbeing and their disease progression. If and when, the business side of the house allows it, EHRs can be extremely helpful with price transparency, since computers are best at calculating various options and optimizing figures. I can see price calculators sprouting up in Patient Portals allowing patients to locate and compute the most affordable treatment option for their individual circumstances.
• Individualization – I am pretty sure that Dr. Berwick was referring to much more consequential events here, but in a small way, EHRs can contribute to tailoring experiences to individual needs. For example, an EHR should know the age and education attainment level of an individual patient. As a result, it could display very little text and lots of pictures for the very young, and perhaps larger fonts and more advanced content for the retired professor, or more numeric data and statistical information for an engineer. Something as simple as making sure every graphic has an alternative textual description and every mouse action has an equivalent keyboard action, would be very helpful for patients with impaired vision. An EHR would also know if the patient started a new medication recently, so it could preemptively solicit patient input on how things are working out and provide that information back to the nurse. Generally speaking, there is a wealth of personal information in an EHR that with some creative thinking could be used to provide individualized experiences to each patient.
• Recognition, Respect, Dignity – These are a tall order for a piece of software to facilitate. Nevertheless, there are little things that could help. Even the most thoughtful clinician cannot remember everything about each patient at all times. How about allowing the patient to insert one short reminder in the EHR, to be displayed each time someone opens their chart? A simple thing like “scared of room with clown picture” will save mom, baby and doctor a lot of trouble during a routine visit. Or relating to Dr. Berwick’s fear of being called Donald by an anonymous nurse in a hospital, a chart could have a little reminder to address the patient as Dr. Berwick or Don. Trivial to implement. And here is something to alleviate the “anonymous nurse” problem. Remember those patient photos that every self-respecting EHR has in the chart? How about having photos of all treating clinicians also display in the patient chart? Most folks have no trouble remembering what their doctor looks like, but if the patient is very young, or very old, or in the care of many specialists, it may be very helpful at times to have a visual record handy, and this is trivial to implement as well.
• Choice in all matters without exception – EHRs cannot make policy, but as described above they can aid patients with obtaining information to make the choices allowed by the system they find themselves in. It is important that the information provided to patients through EHRs should have no administrative bias, and I would prefer an unedited, reputable third party source. For example if a brand new ACO decides to cut expenses by increasing utilization of palliative services, patients should not be covertly influenced to forgo other, more expensive, options with a carefully selected collection of education materials. Basically, EHRs should maintain integrity of clinical information and not allow management manipulation of vulnerable patients for financial gain. I believe regulatory intervention should be required.
• Related to one’s person – The first thing that comes to mind here is advanced directives, and Meaningful Use is moving in the direction of requiring all EHRs to have the capability of creating and storing advanced directives. Coupled with advances in information exchange, this feature should ensure that folks are treated the way they want to be treated when the end is near. Much care needs to be exercised when those directives are available to the patient and his/her family online to create and modify.
• Related to circumstances – Most privacy and security minded EHRs have a mechanism for allowing physicians emergency access to records for patients who are not under their care. This type of access, termed “breaking the glass”, is logged and audited to prevent improper access. Patients have emergencies too and many times they don’t know who to call or what to do. This is not about the 911 type of emergency, or the midnight earache when one can call the exchange. This is about truly unusual circumstances, when you know something is very wrong, perhaps during a hospital stay, and speaking with your physician or surgeon is imperative. EHRs could provide this safety valve, with appropriate telephony forwarding rules and controls to prevent abuse.
• Related to relationships – By definition relationships are between people, but once relationships are selected, EHRs can help solidify and formalize their existence. For example, the original PCMH definition listed a personal physician at the top of the list of core features of a PCMH. Although the current NCQA requirements for PCMH certification do not explicitly pose this requirement, an EHR can help an individual patient who is fortunate enough to have a personal physician make good use of this feature. An EHR should display the personal physician name on every screen where patient specific data is displayed. All patient data should be tagged with the personal physician identifiers for purpose of clinical data exchange so that anyone viewing a patient’s records will immediately know who is the patient’s trusted advisor, advocate and representative, and where all medical information needs to be sent. The originating EHR should automatically copy all orders, results, procedure notes, admissions and discharges to the personal physician.

Finally, remembering that “every patient is the only patient”, we need to consider what EHRs should not be allowed to become. EHRs should resist the temptation of surrounding physicians with layers and layers of electronic data and communications, until each patient becomes nothing more than another blip of bits and bytes in an endless stream of the same. EHRs should not be constructed with a primary mission of collecting research and evaluation data points, either about patients or their doctors. Those who build EHR software, and those who regulate what is being built, should remember that if a treating physician is a guest in a patient’s life, researchers, population managers and governments are very much uninvited guests, and as such should humbly wait by the door, hat in hand, and respectfully accept whatever patient-centered care can spare for their secondary uses of data.

Though EMR costs can vary greatly (BAC Medical Marketing/Mitochon Systems is offering a free EMR system), most practitioners believe that reputable EMR systems will pay for themselves over time and lead to increased revenues. Still, many physicians worry about the time it will take to recoup their initial investments. Here are some things to look for when considering an EMR system for your practice:

EMRs can improve your office’s efficiency

EMRs make charting faster and easier. A comprehensive EMR system’s functionality should include appointment setting, billing links, coding tools, chart evaluation, email and messaging, patient tracking, reporting, template management and more, all in one fully integrated system. Even though an EMR investment can be costly, over time this investment will result in greater savings for both clinicians and health insurance companies. Remember that EMRs also saves physical space. Instead of big, thick paper files cluttering the walls and shelves of your office, all patient data is easily accessible by computer.

EMRs can increase your profits

EMRs should eliminate the high costs of medical transcription fees, saving you thousands of dollars. Good EMR software should improve your office productivity through easier access to patient information and improved workflow. EMRs should enable you to support your billing and claims processing with complete, accurate documentation. A more efficient office enables you to see more patients, thanks to easy access to patients’ medical history and easier charting.

EMRs should deliver a real return on your investment

With the right combination of powerful and easy-to-use features, a good EMR system will make your practice more efficient at an affordable price. Under these conditions, most practices can see a positive return on their investment within months after their initial implementation.

EMRs should be supportive, easy to use and flexible

The right EMR system should support today’s latest technologies. These include wireless networking, voice and handwriting recognition, remote access and running on commonly available computer platforms such as Windows®, Mac®, Linux® and other networks. The right EMR system should also mesh well with other EMR systems to facilitate the fast, accurate exchange of information between practices, hospitals, imaging centers and labs.

With the right computer system and EMR software, you can make your practice more efficient and see a continuous return on your investment.