Healthy balance

Newt Gingrich loves them. The Veterans Health Administration uses them. And Britney Spears despises them.

What are they?

Electronic medical records, or EMRs. Erase those illegible doctor scrawls. Toss those tattered, color-coded patient charts. The future of health care is here, promising patients a digital dose of medicine.

EMRs are widely lauded as a great leap forward in health delivery. Your complete health history travels with you. A distant specialist can instantly review lab tests and notes from your primary care physician. An ER doc can access your complete health history, even while you lay unconscious. Symptoms are quickly linked to diagnoses and treatments. Prescription side effects are cross-referenced to prevent adverse reactions.

But this new remedy has some unintended side effects. Besides the brutal cost and technical challenges of implementing an EMR network, controversy swirls in some key areas: privacy, cost and the digital dynamic between healer and patient.

In many ways, EMRs are a smart health-care consumer’s dream. Patients have online access to their own records. Those with specific ailments—say diabetes—are electronically reminded of needed tests to manage their condition. Patients can now e-mail their doctor with questions, avoiding long hold times. In the future, patients will even be able to review quality scores for physicians.

In the long run, EMRs will provide better care at lower cost.

“I feel like I know my patients so intimately because we’re in contact so often,” swoons Dr. Lisa Liu, assistant physician in chief for health promotion at Kaiser Permanente in south Sacramento. Kaiser claims the most extensive civilian network of EMRs in the nation. (The Veterans Health Administration is all digital and larger.)

Conversely, two doctors writing in The New England Journal of Medicine last year warned that “in the new electronic sea of results” some of the most important patient information may be lost. One patient studied began calling her physician “Dr. Computer” because “He never looks at me at all—only the screen.” The authors offered this unintentionally hysterical conclusion: “Much key clinical information is lost when physicians fail to observe the patient in front of them.”

Doctors are still learning to work with this electronic golden calf. In fact, Liu says that Kaiser physicians are trained to strike a healthy balance between data and patient. “There is an art to it,” she admits. “Some physicians are better at it than others.”

Last month, a Fox TV broadcaster shrieked, “The electronic medical record might be the death of medicine as it pertains to dealing on a human level with the patient.”

The subject of her hyperbole was a coolheaded Peter Neupert of Microsoft. Neupert, corporate vice president for the computer giant’s Health Solutions Group and a health IT guru, had just finished testifying before the U.S. Senate Committee on Health, Education, Labor and Pensions. Neupert politely informed her that the focus of EMRs was not technology, but patient outcomes such as better chronic-care management.

“We were the only technology company testifying,” Neupert later blogged. “I think people were surprised to hear us saying that technology isn’t the silver bullet.”

“It’s absolutely not about the box,” agrees Andy Wiesenthal, associate executive director of The Permanente Foundation and a key player in Kaiser’s health IT effort. “If you do nothing to change how care is delivered, there are not necessarily any quality, safety or efficiency improvements realized.”

President Barack Obama is hearing this refrain loud and clear. In December, his administration announced aggressive plans to spend $50 billion to upgrade health-care IT over the next five years. Obama said rising health-care costs were crippling American business. He referenced health IT in his inaugural speech and wants it in the coming stimulus package. This warp-speed timetable has raised some eyebrows in the health-care world.

That’s lightning fast for a wildly complex initiative, says Jonah Frohlich, senior program officer for the California HealthCare Foundation. “Overlay technology on a paper-based system that’s broken and you’ll get an electronic system that’s broken,” he says.

Kaiser is widely acknowledged as the leader in EMRs, and has the battle scars to prove it. While their electronic clinical systems hearken back to the 1970s, Kaiser first focused attempts on a nationwide system in 1997. It developed two versions before settling on its current HealthConnect project using Epic Systems software (which is quickly becoming the national standard for EMRs). The 10-year price tag: $4 billion. Headquartered in Oakland, Calif., the Kaiser Family Foundation is the largest nonprofit health-care system in the country.

But in 2006, a disgruntled Kaiser employee “went public” by e-mailing all Kaiser employees about supposed system problems and cost overruns. Other rumors swirled about delays and technical glitches.

Wiesenthal dismisses the e-mail as “almost completely untrue” and claims the rollout is on time and on budget. So Kaiser is having the last laugh. Within six years of inception—the end of this year—it will have its entire system online: 13,000 doctors, 150,000 staff members and 8.7 million patients.

“Ask anyone in the industry what they think of that, and they will tell you that it is a stunning achievement,” boasts Wiesenthal. The electronic system includes patient registration and scheduling, billing, clinical information, lab and X-ray results, pharmacy records and prescription refills.

In Sacramento, the UC Davis Medical Center effort is supervised by Dr. Hien Nguyen, medical director of health records.

“I don’t think anything of this magnitude is easy,” says Nguyen, also an assistant clinical professor of infectious diseases. The network of 1,800 UC Davis physicians is 80 percent complete. The financial savings alone, he says, are worth the effort.

“So much of our premium dollar goes to administration,” says Anthony Wright, executive director of Health Access California.

At Sutter Health, half of an expected 5,000 physicians are now digital. Although no Sutter hospital is yet online, the first is slated for later this year. It will allow 180,000 Sutter patients to access their health records, schedule appointments, get lab results and request prescriptions.

EMRs are part of a much bigger movement: Health 2.0. Health 2.0 embraces the next generation of health care, termed “personalized medicine” or “user-generated health care.” It means a greater emphasis on wellness and more responsibility by the patient. For providers, it means breakthrough technology like genetic screening, artificial organs and smart cards detailing medical information—even your sequenced DNA. Health 2.0 has its own conference, even its own Facebook page.

A leading proponent of EMRs and Health 2.0 is former Speaker of the House Newt Gingrich, founder of the Center for Health Transformation. He’s said the United States could save about $400 billion in health care by implementing health-care IT and best practices nationwide.

But with tomorrow’s vast network of medical information floating electronically, how are medical records kept safe? Privacy has become EMRs most heated topic, making headline gossip by the ubiquitous Britney Spears.

In a highly publicized case last year, workers at UCLA Medical Center were caught snooping at the electronic records of pop’s roller-coaster diva after her admission to a psychiatric ward. Disciplinary action followed, but not before badly damaging the reputation of the hospital—and EMRs. Another celebrity hospital in Los Angeles, Cedars-Sinai Medical Center, accused a former employee of stealing data from more than 1,000 records. Cedars-Sinai is at the epicenter of the privacy controversy because of its phalanx of celebrity clients.

In response, California quickly passed two laws bolstering protection of patient records, including penalties up to $250,000 for each privacy breach. Earlier in the year the state had already extended its “breach notification law” from financial data to cover medical records to alert patients of possible “medical identity theft.”

EMR access is role-based, with different levels of access ranging from receptionist to surgeon. EMR security utilizes “electronic fingerprinting,” which informs IT techs who has looked at a file and whether changes are made. At times “electronic glass” must be broken. Users must provide a clinical reason for changing a patient record. Periodic audits are done, and unauthorized personnel suffer a similar fate: They are fired.

People already feel comfortable banking online and buying books with Amazon, says Frohlich. “The same kind of trust has to happen in health care.”

At Kaiser, there have been privacy breeches, “but not yet of the kind where someone hacks in and gains unauthorized access,” says Wiesenthal.

Another concern—at least for physicians—is expense.

The average cost per physician to implement EMRs is between $20,000 and $50,000, says Jose Arevalo, medical director for Sutter Independent Physicians. This cost includes the EMR system, licensing and training. He terms annual maintenance costs “fairly minimal.”

Disgruntled physicians complain that they are bearing the brunt of the cost—not the health-care insurance plans. “That’s their biggest concern,” says Wright, “who pays for it.”

Like it or hate it, Britney, the health-care train is coming fast, and it’s digital. Today there are fewer doctors—or patients—opposed to this brave new world of medicine. In fact, says Kaiser’s Liu, patients are now grilling physicians about EMRs. If they don’t have them, they’ll find a doctor who does.

“It allows patients to be much more proactive,” says Frohlich, “It could be the actual rebirth of medicine—if it’s done right.”