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Letters to the Editor  |   May 2012
EHR Boat Not Ready to Sail in United States
Author Affiliations
  • John H. Juhl, DO
    Touro College of Osteopathic Medicine in New York City; Physicians Health & Wellness, New York, New York
Article Information
Professional Issues
Letters to the Editor   |   May 2012
EHR Boat Not Ready to Sail in United States
The Journal of the American Osteopathic Association, May 2012, Vol. 112, 261-262. doi:10.7556/jaoa.2012.112.5.261
The Journal of the American Osteopathic Association, May 2012, Vol. 112, 261-262. doi:10.7556/jaoa.2012.112.5.261
To the Editor: 
According to a survey of 3700 physicians in 8 countries reported in InformationWeek,1 only 47% of US physicians agreed that health care information technology (IT) has helped to improve the quality of their treatment decisions, compared with 61% of the other physicians surveyed. The other countries, not surprisingly, were Australia, Canada, England, France, Germany, Singapore, and Spain—all or most of which have coherent, efficacious national medical systems. The United States does not have such a system. 
The main obstacle to US physician acceptance of electronic health records (EHRs) is high cost, due in no small part to the multitude of insurance forms, unique electronic access needs, and various other requirements of the US system. Who in their right mind would want to gamble $20,000 to $40,000 of their own money for a computer program that might not interface with the many different programs used by their vendors—today or next week? 
Patients' acceptance of EHRs is also hindered by certain obstacles. For example, some patients with high health risks will not accept EHRs if they feel that their use will lead to greater medical costs, increased life insurance rates, and reduced job security. (Some companies may “let go” employees who have a larger apparent medical risk.) 
Another patient concern with EHRs is identity theft. In the event of a data breach in your EHR system, are you prepared to pay the average $200 cost per patient medical record for patient notification, restitution, and credit monitoring?2 Are you comforted by the fact that the US Department of Health and Human Services does not require the reporting of breaches affecting fewer than 500 people?2 The “external chart reviews” and “clinical support systems” required for EHRs by the laws of federal and state governments and the guidelines of professional organizations add layers of cost for physicians. 
The contribution of EHRs to improvement of patient safety is primarily dependent on their ability to improve the extraction of outcome data on populations using various drugs, procedures, medical devices, and other treatments. Thus, EHRs will be resisted by various economic interests threatened by this improved ability. 
For myself, an acceptable EHR system would include the following features:
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    ability to import my office visit templates onto an electronic tablet
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    ability to carry forward patients' previous medical and surgical histories, medications, and hypersensitivities to new office visits
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    a laser pencil attachment to the head-piece microphone that, when shined on a particular blank space on the office visit template, will insert spoken words in written form (This capability presumes a more highly functional voice-to-writing feature than the previous 2 versions of Dragon NaturallySpeaking [Nuance Communications Inc, Burlington, Massachusetts] that we have tried.3)
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    a program that keeps score of inputted data for the day's office visits to tally whether enough “bullets” have been documented to satisfy evaluation and management, or E/M, level-of-care codes (eg, 99213, 99214, 99215)
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    a feedback mechanism at the end of the office visit template that automatically tells you how many more “bullets” you need for a particular level of service
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    an updateable library of International Statistical Classification of Diseases and Related Health Problems codes
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    ability to automatically extract billing information to be sent to the appropriate insurance vendor after appropriate review
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    ability to interface with EHR systems of all insurance carriers. This is a major stumbling block for EHRs in the fractured, disjointed US health insurance system
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    ability to easily interface with systems of all laboratories
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    data encryption that does not require “a full-time nanny” (ie, IT specialist)
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    ability to transfer a patient's medical summary, laboratory test results, and procedure reports to a personal database the size of a credit card
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    meeting of all Health Insurance Portability and Accountability Act requirements
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    patients' medical data in a searchable matrix form, so that office, community, and national outcome studies can be performed
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    not being cost-prohibitive in terms of either time or money
The reason that US physicians are hesitant to accept EHRs has nothing to do with whether they know how to use their personal computers, tablets, and smartphones. Rather, US physicians sense that this EHR boat is not yet ready to sail, except for large organizations that have their own on-site IT staffs. 
References
Lewis N. American docs question health IT's benefits. InformationWeek. January 18 , 2012. http://www.informationweek.com/news/healthcare/EMR/232500067. Accessed March 30, 2012.
Dolan PL. Small medical practices are greatly at risk for data breaches. American Medical News. January 16 , 2012. http://www.ama-assn.org/amednews/2012/01/16/bil20116.htm. Accessed March 30, 2012.
Singer N. The human voice as game changer. New York Times. March 31 , 2012. http://www.nytimes.com/2012/04/01/technology/nuance-communications-wants-a-world-of-voice-recognition.html. Accessed March 31, 2012.