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VISION — EMR: Keeping it Simple
From The Journal of Medical Practice Management
Volume 25, Number 3, November/December 2009

To put it bluntly, the government's emphasis on big, traditional, template-driven EMRs as a one-size-fits-all solution is naive. And there are additional stumbling blocks to establishing a universal system for converting to EMRs and allowing records to be seamlessly moved around. Some of these are:

  1. Privacy concerns

  2. Financial considerations

  3. Disruption to office operations

  4. Finding easy and secure methods of transporting of records

  5. Government interference in the process

I would like to address these issues one by one, suggesting solutions to these dilemmas, and in conclusion provide a blueprint for moving forward while minimizing the burden of doing so.


Privacy concerns are of paramount importance. As health records are transmitted around the world, every precaution must be taken to keep them from falling into the wrong hands. It does puzzle me, though, as to why this has become such an up-front-and-center issue with the advent of electronic records, while it has been considerably less so with the "paper" system. Electronically, the additional privacy risk is pretty much limited to the need to protect against hackers. But the paper system can be "hacked" much more easily than the electronic system, since it would be just a matter of surreptitiously making one's way into an office and photocopying from the chart. An employee of the doctor's office, a maintenance person, or anyone with access to the office can make copies of records, or scan the records and e-mail them anywhere.

My point is, if someone wants the records badly enough, that individual can get them. No worldwide EMR network can be created with 100% security (hackers have even violated the Pentagon). The current method of rendering records unreadable to unintended recipients is to encrypt the files on the sending end and decrypt them on the receiving end. With the aid of virtual private networks (VPNs) and file transfer protocols (FTPs), both of which are commonly used technologies, keeping records safe from forbidden hands is made all the easier.


Financial considerations are obviously going to play a significant role in any medical practice's decision to move forward with implementing an EMR system. If you believe that all you will need to do is tell the federal government that you want to purchase an expensive EMR system, and that shortly thereafter a Stimulus check


will be forthcoming in the mail, then I have some swampland here in Florida to sell you. I am already reading that to qualifY for Stimulus money, you may be required to buy a system that is sanctioned by the CCHIT, which may not even include some EMRs currently in use, no matter how suitable they might be. If I read the CCHIT price list correctly, certification will cost the EMR company close to $150,000, guaranteeing that the "big boys" will have a monopoly on access to the certification process and virtually eliminating entrepreneurs with products that are simpler, more practical, and less expensive.

Certainly the federal government needs to be confident that basic standards are met when it allocates money for HIT, but its onerous bureaucracy may defeat the purpose. Solo and small group practices, and perhaps even larger clinics that don't enjoy wasting time and money wading through bureaucratic red tape, may thus opt out of the Stimulus/CCHIT program altogether and absorb the out-of-pocket costs of an inexpensive system that meets their needs.


Disruption to office operations really comes back to financial considerations. I am familiar with a 50-doctor multispecialty clinic that adopted an EMR system and forced providers to completely change their daily routines. The doctors were told to interact with their computers, use templates, etc. That formerly 50-doctor clinic is now a 39-doctor clinic, and according to its currently unemployed prior administrator, it is now having serious financial difficulties. I believe that the desired goal can be accomplished without forcing such changes to the daily routine of providers and the office's day-to¬day operations.


A method of easy and secure transporting of records from one place to another currently exists. As previously mentioned, encryption, FTP, and VPN processes are already common practice. And there is already an industry-standard protocol for two-way communication between facilities, called Health Level 7 (HL7). HL7 is the good news. The bad news is that HL7 interfaces between two facilities must be uniquely fine tuned, often involving the need for extended back-and-forth test transmissions, and often negotiations between the two parties as to the cost of creating the "inputs" and "outputs."

I have witnessed this process many times over the last few years, and the cost from an EMR company to its clients for establishing those connections has been as much as $25,000 per interface, and in many cases two interfaces are required, one to send information into the EMR and another to retrieve information from the EMR.



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