Electronic Medical Records

JEFFERSON CITY - As the health care debate rages across the U.S., President Barack Obama's plan for expanding the use of electronic medical records is being met with skepticism in Missouri.

Supporters see electronic medical records as a major money-saving device that could transform America's health care system, but many health professionals, including several physicians in the Missouri legislature, doubt the technology could deliver the promised savings.

The federal stimulus package provides $19 billion in assistance for doctors and hospitals to ditch their paper systems in favor of electronic record keeping.

Obama has said much of his $900 billion plan can be paid for through changes to the health care system, including $80 billion from switching to electronic medical records.

To get funding, a hospital or doctor's office must use a certified computer record-keeping program that includes a patient's medical history, allows physicians to order tests and write prescriptions, and interfaces with other systems.

Although there is significant support for the switch from a variety of groups, the president's estimation on the amount electronic medical records would save has drawn skepticism.

"Just putting something on a computer doesn't save a great deal of money," said Doug Ervin, a Republican state legislator from Holt and former employee of Kansas City-based technology company Cerner. "It's what's in there and how it's being used that saves money."

According to a survey by the federal Centers for Disease Control and Prevention, one-quarter of America's doctors already use electronic medical records. But with the other 75 percent of doctors and hospitals still on a paper system, there is little interface between systems.

"Right now we've got fragmented data. There's no communication between hospitals, doctors, clinics or physical therapists," Ervin said.

Interfacing would open up records to be seen not just by internal departments of hospitals but would allow doctors to share that information with specialists or other doctors more quickly and legibly.

"The interface is what's really important," said Julie Eckstein, a director with the Center for Health Transformation and a proponent of electronic medical records. "I can walk into a Jiffy Lube anywhere in the country, and they can tell me when my last oil change was, but if I go into a hospital they can't tell me anything without running a test. We know more about our cars than our health in this country."

But electronic medical records, and getting them to interface, can get expensive. The federal government has made no proposal to start a nationwide database for records either.

"It was going to cost me in excess of $30,000 to implement electronic medical records in my office," said Dr. Wayne Cooper, a family physician and state legislator. "It just was not practical for my office."

Many small practices use transcription services to make records more legible, but some doctors are hesitant to replace exchagne that cost with the price of electronic medical records.

"Even with the financial incentive in the form of the stimulus, the reality is small and solo doctor practices may not be inclined because they don't see a positive return on investment," said Neil Jordan, director of the Health Economic Center in the Feinberg School of Medicine at Northwestern University in Illinois. "These are still small businesses, and they can't invest in things that would run them out of business."

Ervin said even with stimulus money, the long-term costs may not be covered.

"Stimulus money goes away. Who's going to be paying for it after the money goes away? You have to maintain the network, the servers; you need disk space and a data center. You've got to keep a footprint in hardware," Ervin said. "You need an administration to monitor new users. Is the system compliant? Is it quality? Then there's tracking security breaches. It's huge. Are the people operating the system trusted sources? Are they going to be there over time? The idea relies not just on an infrastructure but how to fund it."

Although installing and maintaining the systems could come at great cost, there is a potential for savings beyond the cost of paper.

Medicaid fraud and medical errors could both be helped by electronic medical records, proponents have said.

Eckstein, a director with the Center for Health Transformation, said electronic medical records could allow the government to apply the same methods credit card companies use for tracking theft to Medicaid fraud. "It's hard to catch fraud in a paper system, but with electronic records you're moving at the same speed as criminals," she said.

Proponents also have said electronic medical records could also help cut down on a variety of medical errors and streamline several processes like prescribing medicine. Electronic records could also be used to alert doctors if they are prescribing a medicine that should not be taken with another drug. The clarity of the writing could keep health professionals from misinterpreting poor handwriting. Better communication between hospital rooms and labs via records could be used to ensure that tests are run quickly and properly and cut down on running duplicate tests if a patient is sent to another doctor.

The conversation about savings and technology goes beyond electronic medical records.

Proponents of the technology are pushing personal health records, a record that patients would own and control who would be able to see it.

"You know that form you have to fill out every time you go to the doctor? Well if that was part of your personal health record, you wouldn't have to do that," Ervin said.

Proponents argue that personal health records, in addition to giving consumers a copy of their records they can take with them, would make it easier for consumers to make money by, for example, granting researchers access to their records and what drugs they are taking.

"Drug companies could have a great deal of interest in what medicines you're taking, as say, a diabetic. Today's data is sold in various ways. Why can't you get in on that game? You would get some economic benefit from that besides just the research," Ervin said.

However, the ability to release personal information quickly is unappealing to others who question the security of such systems.

"I'm concerned about personal health information floating around in cyber space. That's never safe," said Rob Schaaf, a primary care physician and Republican state representative from St. Joseph.

But even if electronic medical records provide an avenue for change in medicine, some question whether that will translate into savings.

In a study published in the Health Affairs journal, researchers found that one hospital increased their profits once they switched to electronic medical records, mostly because of increased efficiency in billing practices.

Obama's $80 billion dollar figure was taken from a study by RAND Corp., a nonprofit, nonpartisan research group, a study that has been given a skeptical look by the Congressional Budget Office.

In a witness statement to the U.S. House Ways and Means Committee in 2008, then Congressional Budget Office Director Peter Orszag argued that the RAND study pointed to the potential impact of the widespread adoption of electronic medical records and health information technology could have, rather than the likely impact. Their estimate is overstated, he said, because RAND researchers ignored studies that "failed to find favorable results" from the use of health information technology.

"The RAND study was based on a lot of assumptions," Jordan of Northwestern University said. "They assume that EMRs are associated with higher quality care, but a lot of the literature and research out there has not reached this conclusion."

The study also assumed widespread participation, which is in itself a process because the system would rely on transitions by doctors and openness of technology companies.

"We have the technology, but the problem is a competitive one. Do programmers want them to be inter-operable?" Jordan said. "Tech companies may want to dominate the market or don't want to share their source code in the public domain."

Some doctors aren't just opposed to the start-up costs of EMRs but said the systems don't function well to their needs and take too much time.

"The criticism of current EMRs offered is that they don't make it any easier for docs to do what they do," Jordan said.

Electronic medical records require a certain learning curve, Ervin said, because their features go beyond those on paper charts and include more windows, options and functions designed to incorporate more than standard charts.

"Now it takes 20 minutes to get logged on, look through the garbage and find what's really important with my patient," Schaaf said.

It will take commitment from doctors and industry alike to ensure savings.

"We need institutions that are actively engaged in EMRs and learning how to use them to improve their use of medicine," Ervin said. "You can't just flip the switch and start saving money."