"4. They don't inter-operate. (When I request old records from other physicians with electronic charts, I enter the pertinent data into my electronic chart by typing it in.)
If any skilled group of software engineers were to write a decent, usable EMR that was extensible, and didn't cost an arm and a leg, with an eye to being excellent first and profitable as a consequence, they could be up for a Nobel prize. "
Whenever this topic comes up, the same answer always eventually comes out to address "4", which is of course VA's VISTA/CPRS. Not only is it customizable and extensible, but the program and code are free to anyone who wants it. And I don't see the programmers from the VA winning any Nobels any time soon ;-). Read "The Best Care Anywhere." Even if you disagree with the premise, Longman presents an interesting section on how VISTA, and later CPRS came into being. It's his position that an important (if not primary) reason there is not adoption of electronic medical records in the private sector is because it can actually create a competitive disadvantage.
Massing huge amounts of electronic, easily accessibly medical information on an individual is really only advantageous to the patient, provider and system if the patient remains with the same providers and same health care system, which of course is true for the Veterans treated by VA. Long term, detailed information on a patient is advantageous on the patient level because you can monitor more easily preventive health measures and track health status over time; for the provider it means decision making can be more informed which should improve outcomes; for the system it means better outcomes and presumably more competitive advantage. But here's the rub: patients don't stay with the same providers or same systems. Health care has become so complicated that person's change their care plan, and hence their providers and health care system often. If I'm Blue Cross, I can guarantee you I know exactly what the rollover of the person's in my panel are from year to year. If I'm a hospital administrator, I know exactly how many person's come and go through the plans I have contracts with and how many are seeking care at my facility. As you point out, unless a facility takes a stab at VISTA/CPRS, EMR's can be insanely expensive to develop. And deployment, penetration and compliance within a facility/system is a herculean task requiring a major change in culture to ensure adoption. So, as some sort of health care system administrator, for every patient that moves to another plan and hence gets care from other providers in other hospitals, I have just given my competitors an enormous advantage in their care of this patient. The patient is able to bring them their complete, beautifully printed out and organized medical record to aid their providers in the care of this person.
Now, of course, it also says I would have the same benefit when patients come to my system. The problem is who is going to budge first? And if someone else budges, and I can attract those patients to my system, then maybe I don't have a good incentive to develop an EMR for my facility in the first place. Maybe I should spend more money on a finely landscaped, aesthetically beautiful, modern bed tower? Because, really, the patient is going to leave and go elsewhere eventually. When they change jobs, their health care plans change. When life circumstances change (e.g. they now need a family plan), their health care plan changes. There's a ton reasons person's change health care plans, and very few of them have to do with actually wanting to see a certain person or get care at a specific facility. Without these lifelong relationships between patient, provider and system, it's hard to convince a facility of any size, be it a small practice of primary care providers to large health care systems buying up hospitals, to invest the time and energy in an EMR. And it will remain this way until there are clear financial incentives to do so; or the health care system is totally revamped such that lifelong relationships between patients and providers is again feasible.