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September 22, 2012


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I share and agree with both of your sentiments entirely. Having practiced in a low-overhead micropractice for 9 years in Portland, OR, I had to throw in the towel recently because of the increasing uncompensated demands of insurance companies and declining reimbursement for primary care across the board despite having an efficient practice. When the HITECH act came into effect several years ago and mandating that unless I acquired a certified EHR or otherwise, I would be financially penalized, I started to see that my practice model would not be able to sustain itself much longer even though I did everything that was defined by "meaningful use" even back then. Looking around for a certified EHR was a nightmare and the one I was using already jumped in price significantly after certification was expected in EHR products. For the high price tags, it's unreasonable for a practice aiming to lower overhead to deliver quality care to spend more than 50% of your yearly income on an EHR. Especially for an EHR that I felt was substandard for its ease of use and an empty promise that it would help me deliver quality care for my patients.

So, I took a gamble several years ago, opted out of Medicare, developed my own EHR that would exemplify what it would mean to have a user-friendly system that does not dictate what a doctor should do.

I don't pretend that an EHR is a panecea for all the ails in this system. What Sherry said was so true, the underlying problem is the flawed payment system that prioritizes high cost care rather than low cost prevention. But how do we get there from here? I don't know, but I fear that the leaders of primary care are following the same script and we're going nowhere.

This EHR mandate program is a boondoggle for the EHR companies and the certifiers who certify these programs, but in the end, do not help primary care physicians, especially those who practice ideal medicine. When I was researching what it would take for me to certify my product, I was taken aback by the high cost of what should be common sense standards that no one should "own".

I often describe EHR as simply a tool, like a pen and paper to document and share information. EHRs are not expected to perform miracles. The ones that work transparently so that doctors can practice medicine rather then getting bogged down on what "meaningful use" is, and checking boxes is the ideal system. Furthermore, EHRs, like pens and paper, should be equally available and accessible to all medical providers, not to those that can afford it.

So after sadly closing my practice a month ago in frustration and contemplating my next career, I decided to see if I can promote the EHR system that I developed on my own and used for several years with success (my patients didn't even realize I was staring at a computer screen constantly while I was documenting my encounter, that's my measure of success).

To make it accessible for all doctors, my project is a community-driven, open-source project that would be accessible to all doctors, especially those who practice the IMP way. I chose not to have it certified (for the same reasons - prohibitive cost) with the belief that if any system is truly and uniquely doctor-friendly and serves the purpose of improving quality care (but not in a direct way, but allowing doctors to connect with their patients and not the computer screen and check boxes), then doctors will utilize and migrate to using EHRs in a way that people have moved to using smartphones in a very short period of time.

As doctors, we just didn't have many good choices and being forced to make a bad choice or a choice we regret is not a way to make people move in that direction.

Perhaps primary care is the place to start and it starts with having a community of like-minded doctors that stand behind what they want in an EHR, not someone dictating how to change the practice of medicine all because of how an EHR works. If you want to read more of my opinions and my new project, I have two blogs: one of my practice http://aboutfamilyhealth.blogspot.com and one of my EHR project http://noshemr.wordpress.com.

@shihjay2 - Michael Chen, MD

L Gordon Moore

Your points are good. Exemplar systems are indeed making very good use of digital records that can lead to better care, communication and more.

My concern is the apparently widely held belief that HIT and EMRs are sufficient means to improving the problems in the US health care system. They can play a role, but these technologies hold a position and receive attention disproportionate to their contribution to important outcomes.

All too often in the US we attend to parts of the system while failing to address issues with much greater impact on outcomes.

A researcher on a PCMH review team (actually visiting practices to assess performance) found technically proficient practices that met every check-box and also saw some practices that had none of the technology but delivered on access, caring and compassion in a way that some of the technically brilliant practices lacked. He said he'd take his elderly mom to the latter practice every time.

I know this isn't the point you're trying to make, but some appear to be satisfied with "recognizing" practices that meet technical standards but lack evidence of delivering on fundamental attributes of good primary care - and that's a travesty of quality improvement.

Regarding Epic: one thing the federal gov't should do is to mandate real inter-operability. If they're not willing to do that then maybe they can mandate that everyone buy into Epic, though a monolithic and monopolistic system worries me.


Gordon - it isn't an either or question. The resources being spent on EHR's (a tool) by the govt aren't taking away from pimary care nor access.

We have very solid evidence that EHR's do in fact serve as a critical piece of the communication infrastructure necessary to drive improvements in quality, access, effectiveness and patient centered care but by themselves they can just drive you into the wall faster.

The millions of patients at places like Group Health in your region, Kaiser, Mayo and the VA are all leaders in both quality, cost, patient satisfaction and ALL of them have robust EHR's (the same one is used at most of the large systems now). In fact 1 in 4 US doctors is on the same EHR - Epic. The VA has used a somewhat arcane system for over 20 years (and the majority of residents have trained on it) and they have the highest quality for the lowest costs.

Don't blame the tool for flaws in our payment systems (the highest quality at the lowest cost happens in integrated systems of care) or for doctors who still practice in small solo offices when they need to be part of larger systems of care. There is no question however that primary care is where the innovation is going to happen going forward.

Take a look at this article by the head of Group Health physicans for some suggested solutions.
http://www.ghinnovates.org/?p=2710 The very first one? Digital Infrastructure

@cascadia - sherry reynolds

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