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What Interoperable EHRs Might Have Done to Improve the Patient Care Experience

OPINION – January 30, 2013 -- You will recall in my article last December, about my healthcare experience outside of Oregon, that both the ear doctor and the neurosurgeon professed to have electronic health records (EHRs). The ear doctor advised that he was using the aircraft control type headset to dictate into my medical record, by pushing the button in his ear.
January 30, 2013

OPINION – January 30, 2013 -- You will recall in my article last December, about my healthcare experience outside of Oregon, that both the ear doctor and the neurosurgeon professed to have electronic health records (EHRs).

The ear doctor advised that he was using the aircraft control type headset to dictate into my medical record, by pushing the button in his ear.

When I corrected him, he would re-dictate the correction. The neurosurgeon was complaining about a most popular vendor's EHR, why it did not work for him and the inflexible nature of the product and the company. I mentioned that I had heard that the company thought it was preferable to make no or very little changes for clinicians because it could reduce errors. Neither I nor the clinician seemed to understand this concept, particularly if the physician had to design his or her own workaround or the EHR was not really useful to him.

The ear doctor was in private practice, and affiliated with one health system. The neurosurgeon worked for a medical group contracting with a medical foundation owned by a non-profit hospital system. When I went to the neurosurgeon, I wondered why he did not have access to the EHR that the ear doctor had dictated into. Maybe they did not have the same EHR product, maybe they were the same product, but they were not interoperable, maybe no one designed the interface for them to be interoperable.

Since I learned at an Oregon HIMSS conference last year that EHR vendors typically put provisions in their contracts that one system cannot share their EHRs without the permission of the vendor, maybe I should not have been surprised that my information was not available to the neurosurgeon. Why would one system have to ask a vendor if it could have an interoperable EHR with a system with the same EHR? Most systems have competent in-house counsel that can navigate the maize of HIPAA privacy, consent and other laws and applicable regulations. Why could the providers not make my EHR available in a cloud to enable each of them and others to draw down on them?

At a recent American Medical Informatics Association (AMIA) meeting, there was a lively discussion about how vendors often put clauses in their contracts for the EHR products that the vendors are not liable if there are problems arising from the use of the product. Interestingly, the luminaries at the conference thought that the vendors believed that since the clinicians used the EHR products, that they should be liable. However, these are the very clinicians that often think the product does not work for them in the context of their workflow and are often reticent to use the product. The suggestion was that many vendors seem to think that the clinicians have superior knowledge to the vendor. Interesting, often it is the vendors that charge healthcare institutions to train their clinicians on how to use the vendor's product.

Further discussions at the AMIA meeting revealed what I had heard before--that certain vendors thought that the US would have interoperable EHRs, if everyone used theirs. I thought that this was most interesting. Are these the same EHR vendors who have the clauses in their contracts that do not permit health systems to share their information without the vendor's permission?

Are these the same vendors who believe they should not be liable for their products not functioning appropriately? For those of us old enough to remember Betamax and VHS tapes, and the fierce competition as to what technology would be victorious, think neither. For now, DVDs won out, a product we did not know was to exist. Could this happen in the EHR space, with all the current EHRs investment being for naught?

Getting back to my EHR: My primary care doctor, you may recall, had paper records. He still does. The MRI provider apparently did not have an EHR, that is why I was given the huge x-ray type films. I am neither a clinician, nor an EHR vendor, but it would seem to me that I would have had a better patient-care experience at a much less cost if my information would have been available to all the clinicians and healthcare providers that I visited. In fact, with all the wasted time, if one were to multiply this by the number of people who have had similar experiences, there might be enough capacity to treat the 40 to 50 million people who will now have health insurance, but may not have access to healthcare.

I keep asking myself: WHAT GOOD IS AN EHR IF IT IS NOT INTEROPERABLE? We do not have a universal standard for EHRs or for interoperability. When I reflect upon this, I recall history where there were many different gauges for railroad tracks in the US years ago. Obviously, one train could not go from one track to another if the gauge were different. I think of the Roman chariots, and it is believed that their tracks in the mud or ruts became a standard gauge. What if every railroad had a different gauge? What if every ATM only worked with one bank and you could not use it to withdraw money from your account?

At some point, are we not going to need one gauge for EHRs and interoperability? In the interim, how much will we spend on this technology before we get there? When will the clinicians believe that the EHRs are designed for them to use because the Human Computer Interfaces/Graphical User Interfaces work with their workflow? Who is accountable for this happening?

If Oregon is successful in its launch of the Coordinated Care Organizations that it hopes will help solve our statewide-healthcare dilemma, will it not be easier to do it with an interoperable EHR shared by all the stakeholders and providers? How can patient-centered patient care be realized without it? How will health care information be connected? I am watching with baited breath. We Oregonians are under a microscope. The rest of the country is watching what we are doing? Do we know what we are doing? I sure hope we do.

I wish my experience was similar to that of my wife’s this January. She lives in Salt Lake City, Utah. She visited a sports orthopedist at the University of Utah (the “UTE”) for hip pain. An x-ray was taken during her visit with the clinician. The clinician consulted with the radiologist and had the film available when she came back from the x-ray. The clinician asked her if she had time for a physical therapy appointment that day. This was all in one morning at the UTE. Is this the case of a fully interoperable EHR at one health system? If so, it might be worth a trip to Salt Lake City for me when I next need to consult a physician for a new malady.

Paul R. DeMuro JD, CPA, MBA, MBI, Schwabe, Williamson & Wyatt, PC, National Library of Medicine, Post-Doctoral Fellow in the Ph.D. Program with Oregon Health & Science University.


Submitted by Jay M on Thu, 01/31/2013 - 09:38 Permalink

I dont claim to know every vendors culture but I do have a couple of responses working for one vendors helpdesk supporting EMR on a daily basis. 1. Clauses in contracts aren't there to prevent the sharing of patient information. If a vendor develops a custom report, a custom data entry form, or deploys some other handy custom code that the vendor wrote. That is what I would suspect those clauses are trying to prevent the sharing of. 2. Liability - at some level Vendors supply a tool and if the tool doesn't work or is faulty that is one thing. And most certainly every software product is going to have bugs. However if the tool is simply used improperly (which is often the case) you can't hold the vendor responsible. Interoperability is going to be great, and the standards ARE out there (see HL7) for these systems to talk, but it does require a great deal of investment of both time and money. and it takes some skill too that can sometimes be hard to find.