Rush for EHRs could ‘stick docs with bad systems’

By Joseph Conn / HITS staff writer

Lyle Berkowitz is not an electronic health-record systems basher; far from it.

Nor is he opposed to the federal government subsidizing hospitals and physician offices, although he says the proposed maximum payments of $44,000 for most office-based physicians like himself in the American Recovery and Reinvestment Act of 2009 won’t cover the true cost of installing an EHR.

No, what gets Berkowitz going is the poor quality of the user interface of the current crop of EHR systems on the market.

“I think the stimulus bill money is not worth it for the current EMR systems that we have,” said Berkowitz, a practicing internist, an EHR system user and medical director of clinical information systems with the Northwestern Memorial Physicians Group, Chicago, Berkowitz was also a presenter at the recent Healthcare Information and Management Systems Society convention in Chicago on “How to Improve EMRs and Incorporate Innovation In All We Do.”

“The actual cost of buying and implementing these systems as well as factoring in the lost time and problems—it’s significantly more than $50,000,” Berkowitz said. “It’s probably more than $100,000. The systems alone are not the real cost, when you factor in the change management that has to take place.”

One potential problem is the stimulus law, with its deadlines for purchasing an EHR system, and, eventually, penalizing them financially if they don’t, that could make physicians “buy something and rush into an inadequate system,” he said. “And they all are inadequate; they’re not all evil, but certainly none of them are perfect.”

If that is all the federal IT subsidy program achieves, then, “all we’re going to do is stick doctors with bad systems,” Berkowitz said. “If the end goal is to just get doctors to use EMRs, that’s a bad end goal, a horrible end goal. If the goal is to increase quality and efficiency, we have to rethink our entire reimbursement system and reward quality and not quantity.”

The key, Berkowitz said, will be federal interpretation of the “meaningful use” requirement in the stimulus law. The National Committee for Vital and Health Statistics, an HHS advisory panel, held two days of public hearings this week on the meaning of the phrase in advance of HHS rule-making on the stimulus bill to be completed this year. Everyone is still wondering what the phrase means, Berkowitz said, but “by putting in that language, I think they got some good advice from some people and they realize their end goal is not simply getting everybody to use an EMR.”

Berkowitz is a board member of the Association of Medical Directors of Information Systems, a professional association for physician informatics. He also heads an IT consulting firm and serves as the program director of the Szollosi Healthcare Innovation Program, a not-for-profit organization working to improve information sharing among collaborating physicians as well as between physicians and patients. Better communication, according to an explanation on the organization’s Web site, includes a concept called “information visualization,” an exploration of ways to improve the interface between information source and the healthcare information user—both clinician and patient.

So, Berkowitz has done a good deal of thinking in the past few years on the ideal physician/computer interface.

“Any screen I see should essentially have two parts,” Berkowitz said. “It should have historical information or data I need to make a decision. And that data is going to be pulled in from all parts of the record, vitals, labs, meds history, evidence-based medicine guidelines. The other half should be today’s history, physical exam and plan. This is where I’m going to document what I see today and what I’m going to do today. There is no reason a computer can’t pull most of this information in and pre-populate everything I’m going to do. It significantly cuts down my work and leads me in the right direction.”

“To get this information now, I have to jump to every different screen to find all this, or if it’s on one screen, it’s not an articulate screen, it’s just mashed all together,” he said. “I don’t know if the EHR vendors should be doing this, or whether they should be giving us the tools to do it, because they haven’t done it too well thus far.”


“I think we should create a single, iPhone-like platform on which everyone can create applications,” Berkowitz said. “Making it an open platform on which everyone can create applications and then you get the best of both worlds, a government platform for standardization and then you get everyone making the customized things that make your practice run.

“That’s how you spend $20 billion,” Berkowitz said, referring to early estimates of the amount of the stimulus law’s subsidies for healthcare IT, a figure now estimated at about $36 billion. “That’s a much better way than rewarding vendors to make poor product.”

Berkowitz said the further opening of IT systems under modification—a trend already under way—is likely to continue with or without the stimulus funds.

“I am optimistic that we’re starting to see EMR vendors acknowledge they don’t have a one-size-fits-all “user interface” and they’re opening up APIs (application programming interface) so some people can create their own user interactions,” Berkowitz said. “If we see more of that, I think it’s a good sign that we have a chance to bring innovation back into the EMRs and let doctors figure out creating the user interface that works for them and leave the underlying data schema to the vendor.

“Right now, we have documentation as an end result as the focus of the EMR, and what we need is a workflow tool where documentation is an end result of those tools,” Berkowitz said.


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