This is Dr. Peter Madras' presentation that was given at the Health Innovators meeting on July 21st. For more information on Health Innovators, please visit us at http://www.healthinno.org

1. REMAKING THE
ELECTRONIC HEALTH
RECORD
Response to the Broken Promises of
the EHR
PETER N. MADRAS, MD

2. DISCLOSURE
WHERE DID MY OPINIONS COME FROM?

3. DISCLOSURE
WHERE DID MY OPINIONS COME FROM?
Asentral Inc Medical Record Bank

4. The Great Computerization
Failure
THE UNFULFILLED PROMISES OF THE EMR
MAY BE THE GREATEST FAILURE IN
COMPUTERIZATION HISTORY:
◦ Adoption
◦ Interoperability
Care Integration
Cost Reduction
Cost Recovery
◦ Patient Safety
◦ Practice Efficiency
◦ Patient Engagement
◦ Computerized Reports

5. Gingrich and Kennedy
New York Times May 3, 2004
$7.3 Trillion over next decade
Prevent half of 98,000 deaths from
errors
Kellerman and Jones:
Rand Corporation 2005
Saving $81 Billion Annually
The Great EMR Promises:
Cost Reduction

6. The Great EMR Failures:
Savings
1. No change in the slope of the
overall health cost curve
2. Office of National Coordinator
Beaurocracy of HITECH,
Meaningful Use
4. Enormous Burden on Hospitals
and caregivers

7. The Great EMR Promises: Improved
Quality and Safety
IOM 2001: Identified Communication
between providers as a critical area in
patient safety, and called for EMRs as
means of achieving this goal.
◦ General assumption that the EMR would
enhance communication and thereby
agreement between providers.

8. The Great EMR Failure: Improved
Quality and Safety
Reality: Decreased “Face to Face Time”
Pre-post study of EPIC showed decreased face-to-face
communication, worsened overall agreement. “.. (Online BMJ
Quality and Safety from Tampa General Hospital April 2014)

9. The Great EMR Failure: Improved
Quality and Safety

10. The Great EMR Promises:
Adoption

11. 1.Provider Adoption:
Only 40% of MDs and 27% of hospitals are
using at least a basic EMR system, and
2. Patient Adoption:
1. 90% Respond that they should have full access
2. 42% Signed up when offered
3. 20% viewed their records more than once.
What It Will Take to Achieve the As-Yet-Unfulfilled
Promises of Health Information Technology Kellerman and
Jones of the RAND Corporation, HEALTH AFFAIRS 32, NO. 1 (2013): 63–
68:
The Great EMR Failures:
Adoption

12. The Great EMR Failures: Adoption

14. Physician Impression of
Electronic Medical Record

15. Failure to Adopt:
Physician Impressions of
Electronic Medical Record
2012 2013
Unfavorable
Very
Favorable
Unfavorable
Very
Favorable
12.4 5.4 16.1 3.3

16. PARTIAL LIST OF REASONS FOR
POOR ADOPTION
Interference with the Practice of Medicine.
Physician as a data-entry person
Protocols and Algorithms.
Software Straightjacket
Computerized Notes, Discharge Summaries, Consults
Patient Resentment
Rigid Algorithms, Standards of Care,
Unfriendly Software
Excessive Training time for additional burdens

17. THE GREAT EMR PROMISES:
INTEROPERABILITY
Many Definitions:
◦ HAVING ALL NEEDED MEDICAL INFORMATION
WHEREVER AND WHENEVER NEEDED
“Prime Directive” of computerizing
medical records. All other functions are
“nice to haves” but pale in importance.

19. ASCENDANCY OF PRIVACY
1890 - 1965
FROM
The right to
privacy
TO
RIGHT OF
PRIVACY
TO
CAUSE OF
PRIVACY
1965 - 2014 2003 -2014

20. From a Right
to a Cause
“The increasing sophistication of
information technology with its
capacity to collect, analyze, and
disseminate information on
individuals has introduced a sense of
urgency to the demand for
legislation”.

21. TECHNOLOGY AND LIBERTY
The ACLU’s Project on Speech, Privacy and Technology
“One of the project’s major
initiatives…is focused on
updating and expanding
privacy laws to include new
developments in
technology….”

22. Are New Technologies the Enemy of
Privacy?
◦ “Privacy always has been and needs to be
weighed against other goods (benefits)
without an apriori assumption that privacy
must trump all other considerations”
◦ Amital Etzioni Know Techn Pol (2007) 20:115-119
RESOLVING THE PRIVACY –
INTEROPERABILITY STANDOFF

23. REMAKING THE EMR:
A CLOUD BASED MEDICAL RECORD UNDER
PATIENT CONTROL
Criteria for Success:
◦ Present all relevant Medical Information wherever
and whenever needed.
◦ Present such information in simple and intuitive
form.
◦ Make no demands on physician practice patterns
Allow physician’s undivided attention to the
patient
◦ Devoid of extraneous features

24. REMAKING THE EMR:
PATIENT CONTROL
Basis
◦ HIPAA states that patients own their
medical information,
◦ A computer based system can guide the
patient, surrogate or counselor in:
Every aspect of Health Data Collection,
Assembly, Storage
Controlling access to maintain privacy
◦ Patient, Surrogate, Caregiver, Family

25. COMPONENTS OF A PATIENT
CONTROLLED MEDICAL RECORD
1. Software Driven, easily
understood and handled by the
patient or surrogate.
2. Provides the Method for
◦ Record Acquisition of Every Encounter
◦ Assembly, classification and storage of every
record.
◦ Accessing record as allowed by the client.
3. Allows Diary entries related to
status between visits.

26. Remaking the Record

27. REMAKING THE EMR:
USELESS EXTRANEOUS FEATURES
Digitized History and Physicals
Scheduling
Billing
Automated Notes
Conflating Hospital Records with
Individual’s Health Record

28. REMAKING THE EMR:
CONCLUSIONS.
The Patient Controlled
Medical Record can be:
Simpler
More Comprehensive
No Demands on the physician
Minimal, if any cost to the health
care system.