Electronic medical records systems work, but not together

Digital medical records figure to reduce medical error and speed your access to the best and cheapest treatments, even as they pile up mountains of data invaluable to public health.

Why, then, does a windowless office in Truman Medical Center need to scan 2.9 million pages of paper medical records that started out as electronic ones?

Why do scanners at a regional center run by medical giant HCA Midwest Health churn through hundreds of thousands of pages a day?

The page-reading repeats itself constantly at doctors offices, clinics and hospitals across the country — nearly every sheet a testament to how bureaucracy can defeat technology.

All that scanning springs from institutional rivalries over control of your medical data. Records emerging from all that scanning give your doctor the digital age version of something pieced together with duct tape — and rendered less valuable in the process.

“It’s a triumph of marketing over health care,” said Ross Koppel, a professor of sociology at the University of Pennsylvania who studies health information technology.

Typically, the pages start out as electronic medical records. But hospitals, clinics and doctors offices don’t all share them in digital form.

That’s why quasi-public outfits emerged to channel the information from competing systems to the clinicians who need them. Those health information exchanges share medical records to caregivers with promises that they won’t be sold to researchers, marketers or drug companies.

But those different groups often can’t agree to share the documents with one another in the most functional, electronic form. The organizations may work on different security rules for control of the data or disagree on whether records should move between clinics by default or only when a patient opts in.

So instead of a few keyboard taps, offices might need to exchange phone calls and emails. Then the records must be printed out. Maybe the patient carries them from one clinic to the next. Or they’re put in the mail, or faxed. Next, they must be fed into scanners, which occasionally skip a page.

“It takes work to get over the technological problems … but you can do it,” said Joshua Vest, an assistant professor of health care policy and economics at Weill Cornell Medical College. “A lot of the challenges are organizational and political.”

Sometimes the exchanges do play nice with one another. In Kansas, state law insists on it. Any outfit certified by Topeka to operate as a health information exchange must share records with any other organization with that same go-ahead in Kansas.

Missouri makes no such requirement, so competition has set in.

For now, that’s produced digital dead-ends that force the conversion of dynamic electronic documents to less valuable paper ones.

Imagine you’re the patient of a doctor in the massive HCA system. Get referred to an HCA specialist or hospital, and a potentially life-saving medical record follows you seamlessly — always available in its richest form to your latest caregiver.

But go from there to a St. Luke’s hospital — that system participates in the Midwest Health Connection exchange — and the scanners start humming. Move on to Truman, a member of the Lewis and Clark Information Exchange, and the print-fax-scan process cranks up yet again.

“Competing (health information exchanges) is pathological,” Koppel said. “They were created precisely to fix a problem that shouldn’t exist in the first place.”

A better record

When a doctor looks at the snazzy, functional electronic medical record kept on you by his or her institution, everything is just clicks away. But to see what came from a competing health exchange, the physician often must refer to the clunky results of all that scanning. It’s like toggling between a Google search and a stack of old notebooks.

The scanned records are cumbersome to read. None of the data fills into the forms created to make use of digital record keeping. Those sections can’t be easily updated.

Few in the medical industry dispute the transformational promise of electronic medical records. They could spare you from a lethal dose of an allergy-triggering drug. They might avoid orders for duplicate tests and procedures that cost the country hundreds of billions a year. And they offer great data collections that make researchers salivate.

Already, Kansas City area hospitals say the data they’ve collected speeds the time it takes to fill medication orders. It’s taught them how to better avoid bedsores. And it’s led them to ways to reduce patient falls.

“It’s the future,” said Jeffrey Hackman, a physician and the chief medical information officer at Truman. “It’s more efficient, and it’s better for the patient.”

That promise of better medicine helped drive the federal government — motivated partly to kick-start an imploding economy — in 2009 to begin giving the medical industry nearly $31 billion to dump paper records and go electronic. At least one estimate suggests doctors, clinics and hospitals will soon push that investment toward $3 trillion over a decade for hardware, maintenance and software updates — costs baked into your medical bills and insurance premiums.

All that spending proved a boon to Cerner Corp. — the fast-growing North Kansas City-based digital medical record keeper that recently landed a multibillion-dollar Pentagon contract — by flooding the industry with money.

The medical industry was widely seen as slow to enter the digital age — partly because of the expense, and partly because of the complexity and high stakes of medical care.

That prompted Congress to give doctors and hospitals subsidies for going electronic on the condition that the records be put to “meaningful use” within five years. Meaningful-use standards that kicked in last year began to require electronic sharing between medical professionals.

But the Government Accountability Office and others have found the execution lacking. They say Congress and the Obama administration pushed hard to get electronic medical records working without insisting that they immediately work together.

In a report last year, the GAO criticized the Department of Health and Human Services for promoting universally available medical records without setting clear goals that could make that happen.

“We didn’t start out the system with interoperability,” said Linda T. Kohn, the director of health care at the GAO, the investigative arm of Congress. “It was not a priority.”

Robert Wachter, a physician and author of the “The Digital Doctor,” said the federal government acted wisely to push for digital records quickly and emphasize data-sharing later.

“My hospital is better and safer now that it is wired, even if it didn’t communicate to other institutions,” he said.

Data control

Consider where Truman Medical Center was in 2013. It wanted to join a health information exchange so that electronic records could move about in their most powerful, electronic form. It settled on the Lewis and Clark Information Exchange.

Mitzi Cardenas, Truman’s vice president for strategy, business development and technology, said it chose LACIE partly because its system dovetailed well with the Cerner software Truman was already using.

That same health exchange had also signed other big names in the market, such as the University of Kansas Hospital and North Kansas City Hospital. And, she said, LACIE was further along than others in the record-sharing game.

“LACIE was more mature at the time,” she said.

Meantime, the Missouri Health Connection, yet another exchange, had been growing with a strong foothold in the St. Louis area. It now includes 77 hospitals and some 7,000 clinicians. In Kansas City, it includes the St. Luke’s Health System.

LACIE and MHC have had talks but can’t come to terms on a data-sharing deal. LACIE wants to team with MHC as an equal player.

“We have offered to connect with them many times,” said Mike Dittemore, LACIE’s executive director.

MHC argues the state would be better off if health information organizations in the state such as LACIE became participants within one all-encompassing MHC network.

“Our participants all agree to work by the same rules of the road,” said Mark Pasquale, the chief operating officer of MHC.

The Kansas Health Information Network shares records with LACIE and expects to share soon with MHC. But the organization’s executive director, Laura McCrary, said such deals require overcoming technological issues, such as making dueling software systems work together.

But “the biggest challenge is trusting another organization to use the data in a way that’s approved by your doctors and hospitals,” she said. “This data is worth a lot of money … to pharmaceuticals, to Wall Street, in ways that are not about patient care and treatment.”

While the exchanges have a mixed record of cooperating, one large medical network belongs to none. HCA is building an internal network, as its regional chief information officer said, to “focus first and foremost on our own institution.”

Besides, HCA’s chief information officer Jared Mabry said, external health information exchanges “don’t necessarily talk with each other.”

This story was originally published August 19, 2015 at 6:44 PM with the headline "Electronic medical records systems work, but not together."