Readers Write

Gary Baldwin, Technology Editor , May 15, 2007

My May 1 column (Would Patients Pony Up?) drew quite a bit of e-mail. I've excerpted several below. A number of other readers called for more payer participation in funding clinical IT. I'd direct you to the two lead news articles in my "editor's picks" below. Thanks to all for writing!

PHR is the way to go

Enjoyed your article on "Would Patients Pony Up?"The answer is: Yes--provided they feel that their personal medical information is safe. There is another angle to the discussion about EMRs--Personal Health Records. That is about ownership and control of the information. We maintain that it is imperative that we as individuals have ownership of information about our most personal matters.

We alone can see to it that the information on our personal "charts" is accurate and from a medical management point of view can arrange to have critical medical information available for our doctor when he needs it. (There are too many stories of how doctors waste time looking for medical records, following up with specialists who do not forward visit reports and ordering new lab work because the results from previous lab work are not available.)

S. Erik Skoug
President, Health Record Registry

Gary's Comment: So many patients are in denial about their own health, I wonder how good a steward they would be of their PHR?

Clinical objectives needed

It is humorous but not surprising to me that we accept the notion that automation should cost more. In any other industry, we automate to get some sort of economic benefit (that must be greater than the cost of automation). In healthcare, we openly discuss the notion that if we "just get rid of this paper" we will accrue some sort of magic benefit. Do you think that when Toyota automates design engineering they want to "get rid of the paper"? Or do you suppose they want to improve the cost or quality of the design process? Do you think that when GE automates a shop floor, they want to "get all the machines to talk"? Or do you suppose they want to improve shop floor throughput? Automation needs a business objective (increased quality, decreased cost, faster delivery, improved customer service) or it is useless.

Now the good news: ANYONE could set a clinical objective for an EMR implementation, but most folks don't. They occasionally have good reasons, but most just haven't thought about it.Tim Breaux
Principal, Quality Deployment

Gary's Comment: Can you imagine if we bought cars through third-party payers the way we buy healthcare?

The limits of technology

I appreciate that you may have enough trust and confidence in technology and automation to place your health in its hands, but many of us have learned otherwise. Technology at best is an "enabler" and not a "doer." Patients choosing their physicians based on whether or not the physician has EMR speaks volumes on the chances for the success of the "consumer directed healthcare movement."

Good physicians will be good physicians regardless of their use of EMR, and unfortunately, poor physicians will not be transformed into good physicians when they install EMR. EMR holds promise for improving the standard of care (and reducing cost), but only when the EMR systems in use by all providers are compatible and information can be passed readily between physicians and hospitals, anytime, anyplace.

Today, physicians and hospitals in a single city often have compatibility issues. Given our collective reluctance to pay taxes and the public furor over high healthcare costs, I don't think many people would Pony Up for EMR once they knew the real costs/benefits. I would rather spend my money on a Personal Health Record that I maintained and could carry with me.

Robert Trinka CEO,

Physicians Healthcare Management Group

Gary's Comment: You're absolutely correct about consumer reluctance. Asking people a question in a poll is one thing, having them actually "pony up" is quite another. But I'd still be willing to pay. I believe that an EMR's reference tools alone can make a good physician only better. There's just too much information for any one person to remember.

'Good examples of bad software'

"And those precarious, well-worn paper charts do not inspire confidence."

So, having your medical record in a format where they could walk out of the office on a thumb drive with 5,000 other records would inspire confidence? For a doctor to obtain real insurance against the liability of identity theft or medical identity theft is currently impossible. An occurrence of identity theft in the office of a small practice could not only put the practice out of business but threaten the life savings of a physician."

Nothing as crass as a glass jar for EMR tips, but maybe something as simple as an earmark on our co-pay. Kind of like the check-off box on the income tax form. If you'd like a small portion of your co-pay to help your physician bring your clinical information into the modern era, check here."

Do you know that the co-pay is subtracted from the total allowed payment so that it is a part of the gross revenue paid to the doctor? For primary care this gross revenue is currently so inadequate that the number of people going into primary care continues to shrink dangerously.

How would a check-off box telling the doctor what to do with his gross revenue increase his revenue? By the way, an "earmark" is a rider on a spending bill, usually one that must pass, and the "earmark" increases the spending. If one were using the term correctly, one would be describing a surcharge above the allowable co-pay which is illegal in Medicare or Medicaid and contractually forbidden in all private insurance contracts.

If one is going to offer valuable insight regarding the EMR then one should be familiar with all of the real issues and not just whether a given program supports HL7, or uses a MUMPS operating system, or runs on an SQL database. When there is a full grasp of these issues one would realize that for the majority of primary care physicians who practice in very small groups, "free" is not cheap enough to justify an EMR.

I'm sorry to be so aggressive but, as an internist and the president and CEO of a large IPA this is a subject which I am constantly studying for our members. If any EMR were of value to our members or their patients I would endorse it wholeheartedly. The current iterations of the EMR, even if certified by CCHIT, are such good examples of bad software that I cannot endorse them for physicians who have no outside source of funding and no protection against the liability of stolen data.

One only has to look at the British IT initiative to see that enormous outside funding does not guarantee success, even in a country where personal privacy is a luxury for the wealthy who can avoid the tabloids, not a right for the lumpen masses.

Bruce W. Landes, MD
President and CEO
Southwest Physician Associates

Gary's Comment: Thanks for clarifying how co-pays actually work. I should have used a word like "surcharge." I was trying to describe a possible mechanism for patients like me to support their physician's use of IT.

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at




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