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Reframing the eHR Debate in Keynesian Terms

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eHRs – Good for Whom?

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™

We have been reading with interest the posts of dentist blogger Darrell K. Pruitt, DDS.

His comments are cogent when he opines that clinical eHRs are not yet practical in the private dental office arena; that they produce a negative ROI; are time consuming and labor intensive; are not secure; and most importantly that patient care is not really enhanced by them:

Review of the Debate

Moreover, Dr. Pruitt suggests that the old peg-board system of invoicing, with simple paper dental records, is adequate for use today. His argument that dentistry is not the same as whole-body medicine, requires fewer but highly dexterous tasks, and is largely not dramatically different than the profession he practiced several decades ago [sans the cosmetic type initiatives, etc] makes some sense. Of course, the latter issue is actually good news for patients.

Organizational Objections

Dr. Pruitt’s biggest objection seems to be with what he perceives as the heavy-fisted American Dental Association [ADA], and its leaders and related healthcare technologists. According to him, they seem to suggest eHRs as an absolute imperative; that NPI mandates are firm; HIPAA true, and that the association blindly argues contrary to his opposing thesis points above. We trend to agree with him; not the ADA. Why? Well, security among other reasons – for extreme specificity – as we just received word from Dr. Pruitt about a tremendous data breach at a dental school in Florida that occurred a month ago:

“University of Florida officials have notified about 330,000 current and former dental patients that an unauthorized intruder recently accessed a College of Dentistry computer server storing their personal information.”

Though the bad news was delayed for over 30 days, this is a major setback for dental [and all electronic] medical records. 

Read more: http://www.am850.com/news/archives/2008/11/dental_school_security_breach.asp

Archaic Trade Unions

We also suggest that most long-standing and entrenched – formal or informal – “trade-union” organizations like the ADA and the American Medical Association [AMA] are no longer responsive to member needs. And, how can you argue with him when the AMA has seen its membership roles drop from more than 90% – to less than 20% – during the last decade? Membership did rise several percentage points, recently, after a highly public and expensive membership drive; but it was not a spectacular gain. Of course, we all remember the patient privacy breach at a Washington DC VA hospital – 26 million strong – a few years ago.

Read more: http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3206

Related Medical Organizations

Related organizations, like the American Podiatric Medical Association [APMA], American Optometric Association [AOA] and others, seem to strive for increased acceptance in the medical community, muck like the ADA. Such allied healthcare providers “want to be like real doctors” and may blindly follow the AMA and promote flawed – or misaligned – initiatives like SAR-BOX, the Patriot Act or eHRs. Perhaps this is the source of the Dr. Pruitt’s disagreements with the ADA. Unlike some dentists, he seems to be very satisfied in his role as dentist – defender of oral health in Forth Worth, Texas – and one who is wholly comfortable in his professional skin. This is more than can be said for many of the podiatrists and optometrists that we encounter in our consulting activities. Now, unfortunately, the dentists seem to have become another AMA surrogate; or “me-too” group, in this case.

An Opinion

And so, let’s be clear; Dr. Pruitt is correct in his ranting-and-ravings, and they are not the ruminations of some mad-man, or aging dinosaur. But, he is simultaneously both entirely correct, and wholly incorrect. How can this be? Simple; Dr. Pruitt’s perspective is mico-economic in nature, while the ADA’s perspective appears macro-economic in scope. Dr. Pruitt is championing his personal cause, and the cause of his patients in the here and now; time-present. The ADA, and related organizations, champion the road ahead when they promote eHRs; future-present.

About John Maynard Keynes

In our consulting practice, we see far too few clients like Dr. Pruitt, and far too many like the ADA and AMA. And, if it were possible for us to have a “dental-twin”, it would more likely be him; not them. Here is why? We are producers, not consumers. We work hard, live far below our means and generally try to be accountable and personally responsible. This “depression-mentality” has served us well. On the other hand, more profligate doctors, and consumers, are struggling in the current economic malaise. Hence the paradox, pointed out by economist John Maynard Keynes [1883-1946], many years ago.

The “Paradox of Thrift”

Every year thousands of economics students are asked to accept one of Keynes’s lasting inversions of classical economics, namely the proposition that saving may be a private virtue, but a public vice. According to Keynes, a community that seeks to increase its rate of saving would end up impoverishing itself and actually saving less [witness the high-savings rate of Japan]. But, the community that increases its consumption at the expense of saving would end-up being richer and saving more. This proposition is frequently stated in macroeconomics textbooks as the “paradox of thrift.”  It applies to more than finances, of course, like eHRs. Others say, KISS [Keep It Simple Silly], or “don’t waste more firepower than the job requires.”




The eHR Conundrum

Consumers are needed if producers are to flourish. Or, what’s good for me – is not necessarily good for the whole. Is this personal philosophy selfish? For sure, it is. But, it is the stuff of capitalism. Success is not for all. Yet, delaying present satisfaction, for a greater future payout, is not guaranteed. But, it may benefit an economic unit-of-one [Dr. Pruitt], not a unit-of-us [ADA, AMA, society, etc]; at least in the short term.  

Reframing the eHR Debate

According to HIT expert Dr. David Kibbe MBA, the broader message of eHR adoption, and ultimate success, will be its adoption by physicians and nurses. It extends communication, information and data exchange beyond the narrow confines of the four walls of a private office practice or small clinic. In other words – more than Darrell’s World! Yet, health IT needs to empower providers beyond the present parochial business model of fiercely independent private practitioners like Dr. Pruitt, and to act as effective members of a team which includes the patient, medical-home, specialists, and ancillary service providers such as pharmacists and lab technicians; as well as the podiatrists, opticians, chiropractors, etc. But, as Dr. Kibbe believes, digital records are still not enough. An enterprise-wide electronic healthcare ecosystem approach is needed.

More on “Certified” eMRs

Sure, most eMR software systems create digital versions of paper documents, which can be accessed by physicians from almost anywhere.  But, the most commercially available eHRs, including those that are “certified,” are focused on what is good for the doctors and the well-being of their medical practices. They do not yet support the capabilities required to assist patients and doctors together to collaborate and make better decisions; to help manage and coordinate care across a community of providers in different settings; or to reduce the costs of unnecessary emergency room visits, repeated lab tests, medical errors or preventable hospitalizations. It is still consumers versus producers, or as Keyes philosophy suggested; “savers versus the spenders. It is not a healthcare 2.0 collaborative ecosystem.

eHRs [Not Ready for Prime Time]

Further, according to Kibbe, currently styled eHRs have a very limited ability or commitment to capturing and transmitting data on a population of patients that would permit improvement in quality, safety, and efficiency to proceed systematically in a community, region, or state.  And perhaps worst of all, many EMR vendors have resisted the call to make their software capable of exporting and importing a standard set of summary personal health data in computable format, such as the Continuity of Care Record, [CCR], or XML electronic standard. This means that for all practical purposes, most eMRs remain “islands of data” that can’t connect even within the archipelago of data in their communities, not to mention the continents of data elsewhere. eHRs are just not ready for “prime-time”, and perhaps this is what is known by the Dr. Pruitt’s of the healthcare space.

And the Winner Is?

In time, one side of the eHR debate will win, and one side will loose. We are born, we prosper, and we die. This is the nature of evolution, and business natural selection; on many levels. There is no winner in the great eHR debate; only transitions. Out with the old – in with the new!


Change is slow; growth is sure. We know which side will ultimately win. Thereafter, eHRs will continually morph, change and not remain static. And so, the better question in the eHR debate between doctors and their affiliated organizations ought to be – not whither eHRs – but, when; how and at what cost? Colleague John D. Halamka, MD, MS, the Chief Information Officer for the CareGroup Health System, CIO and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE (the Regional Health Information Organization), Chair of the US Healthcare Information Technology Standards Panel (HITSP) – and a practicing Emergency Physician – believes that big IT Winners in 2009 will be eHRs; especially web-based applications. Why? Because the Obama administration has promised $50 billion for inter-operable eHRs!


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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com


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2 Responses

  1. Costliness of eHRs

    According to Jeremy Engdahl-Johnson, Managing Editor at Milliman, we can’t know for sure whether electronic records will increase or decrease costs. As a purely cost-based argument, the debate can go on indefinitely. Ultimately, the quality argument may win out for a reason independent of cost—because it is deemed the right thing to do.

    The idea that healthcare has grown too complicated, becoming “too much airplane for one man to fly,” is often invoked as justification for surgeons’ checklists and better use of tools built on evidence-based medicine. It’s not that our doctors aren’t good; it’s that there are too many details and too many scientific improvements to keep track of.

    The quality imperative—now emboldened by an administration that claims to be intent on change—may clear the way for other changes, generating the will to make a pervasive electronic health environment a reality.

    Find out more at http://www.healthcaretownhall.com


  2. Data breaches described as “epidemic”

    “Health data breaches up 97 percent in 2011”


    “Health data breaches in the U.S. increased 97 percent in 2011 over the year before, according to a new report by Redspin, a leading provider of IT security assessments.”

    Daniel W. Berger, Redspin’s president and CEO said, “Information security data breach in healthcare has reached epidemic proportions – the problem is widespread and accelerating.”

    D. Kellus Pruitt DDS


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