Try to imagine a scenario in which a bank that uses paper records still survived.

Banks have more transactions, of course and banks are a fairly competitive business. Doctors are not. Because the burden of payment has been shifted to insurers, few shop doctors so doctors have little incentive to cut costs by going to electronic records or even taking other measures to be competitive. If people were more finacially responsible for their heathcare as they are with High Deductible Health plans, they would shop and doctors would be subject to more of the market forces than they are today and would be looking for ways to improve their bottom line.......just like banks.

Comparing banking to medical records is a lousy comparison. There is probably more data in one CT exam than in all the data that a branch bank does in a day. A hospital needs to connect the labs, x-ray, pharmacy, billing, personnel, ordering system in with its electronic medical records.

Electronic medical records also need data entry unlike a bank because things like physical evaluations and consultations are much longer than entering in a wishdrawl number.

Also, medical facilities need to control access much more than banks. The pharmacist, the nurse, the x-ray tech, the physical therapist all need different levels of access and it has to be managed in facilities with large turnovers.

A good example of problems with medical records are physicians who have privileges at different hospitals. They need logins and training at each hospital.

There are also very few banks with 1-3 people. You're looking at a tremendous overhead for independent practitioners.

One would expect the utility to increase in larger organizations, which also correlates with adoption.

My partner and I both see doctors in one of the largest group practices in the Detroit area, and I have to say electronic records are awesome. Every doctor we see has instant access to other doctors' notes, imaging, lab results, etc. A couple of clicks brings up the history of a particular lab, so the doctor can look at trends rather than just single data points. Every doctor can see all of our prescriptions at a glance. Prescriptions are sent electronically to a pharmacy, eliminating errors in dispensing from crappy handwriting. I'd never go back to a situation where each doctor has to rely on my memory of what other doctors are doing, images have to be couriered around, etc.

As the son and sometimes former employee of a doctor in single, private practice, I have to say that the huge burden of switching to electronic records is a huge hurdle to jump. We've talked about moving over to electronic records for at least a decade, and as the supposedly "tech saavy" member of the family I have been a huge advocate of this switch. We know it would be a huge improvement, we wouldn't have to spend so much money to hire staff just to manage the paper filing that we currently have.

The problem is that electronic records systems are a huge investment. Imagine taking the confidential decades long medical records of over 10,000 people and transferring them from poorly bound paper folders to electronic copies. Buying the system and paying for the conversion of your old records is a huge cost that it just unrealistic for solo practices.
Not to mention that this stuff cannot be done half-assed. Any server that backs up medical records has to be backed up 2 and 3 times on off-site locations. Every transaction must be recorded in all these locations, because when a prescription is written, or a test ordered there has to be a record somewhere. Currently, there is a paper trail, but if a server crashes or memory is lost the doctor is liable to have a backup somewhere. Not to mention how dependent a system is on consistent uptime. Our scheduling system is currently run off a small electronic server. I remember several days when it went down. The office was brought to a virtual standstill. We couldn't confirm appointments, make new ones, it was a mess.

So for all the great perks to moving over to electronic systems, its isn't likely you will see doctors with slim margins making that investment anytime soon. As long as insurance companies keep the burden of record-keeping on primary care physicians, they will have little incentive to make such a large and risky move.

I emailed this posting to my dad, a dermatologist based in St. Louis, MO. He is nearing retirement age. There are the thoughts he emailed me:
The problem with EMRs is that they cost a huge amount for the software and hardware greater than $100,000 and they are not yet standardized so one could be left with outdated software. They also add a huge time constraint adding an extra layer of office clerical work. There is also a large worry about confidentiality with this information out there in cyberspace. The Defense Dept. and Medicare can't protect Social Security numbers even now. EMRs sound great on paper but I'm out of there when they are mandated!

My thoughts:
I agree that doctor offices are too small to invest in this technology. And I didn't think of the out of date problem. Individual confidentiality is an incredibly important issue to weigh against the benefits EMRs would provide towards managing public health.

Large group practices and banks have the scale to support IT departments, small groups and solo practitioners don't. In order to switch to an EHR, small groups need to select and purchase hardware, cable it up, select and purchase software, install it, train users, convert paper records, establish backup, update, and maintenance protocols. That's a non-trivial amount of expertise, work and expense. It's also not clear that there is a huge improvement in quality, either. In a large group, hospital, or clinic setting, there is a lot of potential for decreasing overlap and improving communication between doctors with subsequent quality improvement. In a small practice, not so much...

In the national health systems that we admire like France and Taiwan, the government supports and maintains EHR that allow communications between doctors all over the country. In the US we have HIPPA which actually prohibits automatic communication between physicians to preserve privacy.

I went and tried one of the new Clinics in with the Pharmacy that are popping up in Vegas. Monday morning walked in, they said hello, pointed me to a little sign in computer that asked 2 minutes of questions then walked me to the back, answered some more questions electronically, had the vitals taken, medicine prescribed and sent electronically to the Pharmacy and was out in less than 10 minutes. I didn’t see a piece of paper anywhere so I’ll assume they are all electronic.

Besides having Bronchitis and getting the Rx filled at Walgreens when Target has it for $4 it was the best medical experience I ever had. No waiting room for an hour, quick and to the point, I waited longer to get the Rx filled then the entire office visit. Paid $59 cash and was done, no billing or insurance to wait for.

The question for Progressives is will you allow the Wal-Marting of Healthcare? You say you want all the investment and resources Corporations would bring but in places like Chicago you block it from happening. The quickest and most likely only way we will get to where you claim we need to be is Corporations drive independent practices out of business.

Single Doc offices are just not efficient. We need to consolidate offices into larger group practices who have the resources to make the investments needed.

Arnold Kling on the same”
http://www.american.com/archive/2008/june-06-08/how-to-fix-healthcare-delivery

Electronic medical records represent another false panacea. Paper records are a symptom, not the cause, of fragmentation and mismanagement. A dysfunctional process will not be turned around simply with a new computer system. Information technology can be used successfully only after procedures have been rationalized and reorganized.

The autonomous, self-directed doctors produced by our medical schools are not suited to treating complex patients. Instead, what we need are team players, implementing consistent corporate policies. Independent skilled craftsmen, flying by the seat of their pants, can add a deck to your house. That will not work for building a skyscraper.

Why compare a small doctor's office to a bank? Might as well compare it to Wal-Mart for all the sense that makes.

The relevant comparison is to other small businesses with a few professionals and a secretary or two, like a small law firm or a CPA's office.

changing things is hard

With regulation very hard.

What are affects of HIPAA on the cost of maintaining electronic records.

What about the FDA?

What about CLIA?

There are whole industries that support validating and ensuring a computer system adheres to all the regulations. Many small practices can not afford to implement an electronic record system do to regulatory cost.

Most already pay a firm to handle EDI/electronic billing with medicare/medicaid because it too cumbersome to handle by themselves. They would still need to maintain this even if they paid for an electronic record system (no small practice could afford this in their system).

Then you can get into IRBs and other regulatory requirements if they participate in studies. This would not necessarily need to be part of their electronic record system, but if it was not, they would need to maintain 2 systems (1 paper, 1 electronic) for patients in studies.

So changing is not simply a matter of installing a software program.

That was my comment at 2:16.

For once I agree with Floccina. The problem is structural. Medicine has exploded with new treatments, diagnostic tools, and specialties while maintaining its old infrastructure. Newer docs graduating from training are choosing more frequently to go into larger group practices mostly because of more steady income and improved lifestyle issues, but also because they provide better medical care. It's pretty clear from the data that large multi-specialty groups have better outcomes. However, a lot of what people dislike about "HMOs" is really the large group experience.

Nate's example is also illuminating as another kind of care fragmentation. He's not getting his record all updated in one place because CVS's medical records aren't going to communicate with Walgreen's EHR. Because of that fragmentation, no one is ever going to look at Nate's record and say, "Hey Nate, you get a lot of "bronchitis", maybe we should talk about asthma" (or smoking, etc.) He also is seeing different providers rather than building a trust relationship with a single or small group of providers from whom he would be comfortable hearing, "It looks like a viral infection, so I don't think you need antibiotics for now."

Gr. Would it be so hard for the Times to link to the NEJM article, or at least give a reference?

Also, medical facilities need to control access much more than banks. The pharmacist, the nurse, the x-ray tech, the physical therapist all need different levels of access and it has to be managed in facilities with large turnovers.

That comment is simply absurd - there isn't an industry that cares more about access control than banks and finance. The risk of fraud is so incredibly high it is unfathomable that anyone could take that comment seriously.

Bob Montgomery - I think that was Ezra's point. Why are doctor's practices not consolidating to take advantage of the economies of scale? Or perhaps banding together to offer joint electronic services?

This is an age-old phenomenon of established independent proprietors who lack the resources or inclination to update their traditional systems being displaced by larger, more highly-capitalized groups who exploit their capital and economies of scale.

Pretty soon, insurance companies will offer better deals to doctors with electronic records, and meanwhile lower-margin practices will find themselves unable to compete with more efficient, larger ones.

The question is whether we feel that the independent proprietor/small group practice is worth saving. If we do, then we'll come up with a way of easing the ability of doctors to convert to electronic records while maintaining their independence. If we don't, then many of those practices will get absorbed into larger organizations with unified electronic records systems in which the physicians are more like employees. It's the same in any number of other industries.

... the core problem is indeed 'lack-of-competition' in medical doctor services -- especially among small practices.

Why should doctors change their old ways ?? They make very comfortable livings with the status quo... and their local patients have little real choice in finding more efficient doctors.

Federal & state governments enforce a nationwide medical cartel for physicians. The doctor's labor union (American Medical Association) has complete legal control of medical colleges & numbers of graduates -- deliberately restricting the 'supply' of doctors... thus ensuring minimum business competition to licensed doctors.

Electronic records management isn't rocket science, nor is it expensive. It's overwhelmingly used in small retail businesses across the nation, including humble Mom & Pop operations.

Competition is the driving force for innovation & progress -- and that's precisely what's missing in the business of physicians.

So, what's needed to fix this is ... Big Business? I thought Progressives were supposed to be against Big Business.

Just kidding: Gabriel Kolko put that myth to rest about 40 years ago.

Electronic records management isn't rocket science, nor is it expensive.

The one my group purchased last year was $1.5M with annual maintenance at $100K. It hasn't got the greatest user interface, if you ask me, but the cost was substantially lower than some of the other products since we already had billing software from the same company. I don't know that anyone has broken out the costs of converting the current data base into the new format. We will be dropping our patient schedules down by 50% per day for the first 6 weeks that the new system is in place although other users say that is overly optimistic.

I might be inclined to say that those costs are considerable, but of course that's a relative term. To you $1.5M may not be much money.

Exactly. The doctors want to know who is going to pay their adoption costs, which consist of systems acquisition and data conversion. The system costs are vastly (100x -- 1000x) higher than they should be, primarily because no one knows how to procure contract IT services from an opaque and corrupt marketplace. But data conversion is the killer, because it is unimaginably labor-intensive and quality is critical: if the data loses integrity in the conversion process, then you have lost ground, not gained it. This is also why it can't be farmed out; paper charts can only be converted (with useful accuracy) by people who know the context.

The only entity that has the clout to make this happen is the insurance industry. Look for insurance companies to begin buying IT consultancies: that is when you will know that things are going to move.

[ "The one my group purchased last year was $1.5M with annual maintenance at $100K." ]

________

...sure, and you can likely cite Electronic Medical Records (EMR) systems that cost $500M+ for large clinics & hospitals -- but we are talking about 'small' physicians offices with less than 4 Doctors.

Initial EMR cost for a small practice, professional system is about $15K - $30K per physician, plus about 15% of that for annual maintenance.

That's less than most doctors spend on their cars or country club memberships.

A bare-bones EMR software system costs less than $2,000.

Electronic records management isn't rocket science, nor is it expensive.

[ "The one my group purchased last year was $1.5M with annual maintenance at $100K." ]

________

...sure, and you can likely cite Electronic Medical Records (EMR) systems that cost $500M+ for large clinics & hospitals -- but we are talking about 'small' physicians offices with less than 4 Doctors.

Initial EMR cost for a small practice, professional system is about $15K - $30K per physician, plus about 15% of that for annual maintenance.

That's less than most doctors spend on their cars or country club memberships.

A bare-bones EMR software system costs less than $2,000.

Electronic records management isn't rocket science, nor is it expensive.

In my conversations with medical office staff the confidentiality issue is a huge one. Medical information clearinghouses already keep and sell way too much information about patients, and if they had access to chart details (and don't think they wouldn't in any widespread system) the results would be really ugly.

(Of course, I'm speaking as half of a couple expecting a baby; months before due date we're already getting solicitations from the cord-blood storage people and other folks pimping medical services for newborns.)

And good luck to the guy with a lot of "bronchitis" at the next job switch, when the HR department says, "Nah, this hire will add way too much to our insurance costs."

Oh, and while we're at it: when a bank needs real security, like for safe-deposit boxes, what do they use?

It's not some fancy computerized system, it's a nice little ledger where you can see the record of previous visits written in ink, all supervised by an honest-to-goodness human being.

Maybe the iron rule by (mostly conservative) economists over our legislative, regulatory, and taxing policies - principally associated with Friedmanomics - is being to be challenged. Certainly the walls of the fortress are under attack, and the hot oil to pour on the attackers is running low.

Like war, which is too important to leave to the Generals, national and international policy is too important to leave to the economists. Viva la revolucion!

As the game is set to be released on September 18th many players will be pushing hard to level their characters as fast as possible as well as farming as much gold as they can on the process. Warhammer gold is valued the highest during the start of the game when every player is striving to get as much of it as possible into their own hands.

good!