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Tuesday, December 22, 2009

Rethinking the EMR

The few hardy souls who have read this blog from the beginning, 15 months ago, know that my primary purpose was to enhance the financial productivity of family physicians. My secondary purpose was to help increase the number of American medical students matching to family practice residencies, which I am convinced will only follow the money. Call me cynical.

Along the way, I started carping at the Academy. This was not my original intent. It only happened when I began to suspect that Academy policy might be inimical to increased FP earnings. While I admired the courage and initiative it took to launch the patient-centered medical home (PCMH) demonstration projects, I was shocked that there was no method of financial scorekeeping incorporated in the project design. (See my previous post.)

Since I am a pragmatist, not a utopian, that raised my hackles.

The more I learned, the worse it looked. The medical home guidelines seemed to be written with large practices in mind, although the great majority of FPs work solo or in small groups. The EMRs promoted by the Academy were expensive, lumbering dinosaurs, a fact that was explicitly noted by the review team. The uncritical support given by the Academy to ObamaCare, whatever that turned out to mean, seemed foolish given the lack of cost controls in all plans under consideration. The AAFP president, at a White House “summit,” sounded sycophantic. And when the Wall Street Journal published a silly editorial bemoaning the potential siphon of funds from specialists to generalists, the Academy didn't respond.

By now all my bells were ringing.  

Then I couldn’t convince my state academy to allow a debate about the PCMH, which badly needs an honest debate. Then I went to the national meeting, and the Town Hall had been moved up to a “delegates only” time slot.

I feel like a Grinch who is trying to steal Christmas. Gone is my optimistic, forward-looking personality. I have been mugged by reality, and let me tell you, it’s no fun.

So I’m going to wrench myself back in a positive direction. Let’s start with the EMR.

Dr. David Kibbe, the closest thing the Academy has to an IT guru, wrote an excellent article for FPM about what is wrong with the current EMR approach. What we need in EMRs is modularity, not comprehensiveness. We need “plug-and-play” capabilities that can be tailored to specific practice needs, and swapped out when better ideas come along. We don’t need high-overhead vendors who control vertically-organized software that makes aircraft carrier redirections in a swift-boat economy.

Dr. Kibbe writes, “It also signals that it's time for the AAFP to reconsider its recommendation that members adopt comprehensive EHRs.” What we want are iPhone apps, not mainframe computers.

In a lengthy Wall Street Journal interview, the owner of a company designing web-based EMR components (“cloud computing”) makes the same point. “If a regulation changes or an insurer adjusts a payment policy, it is reflected on Athenanet almost in real time; on the clinical side, the program can adapt at the same rapid pace as medicine itself. … the main benefit is the ‘collective intelligence’ that he [CEO Jonathan Bush] is starting to weave together from the 87 percent of American physicians who practice solo or in groups of five doctors or fewer.”

Locally, the president of the Kansas Medical Society (KMS), Dr. Joe Davison, is a family physician. With his leadership, KMS is promoting a Health Information Exchange – which would use cloud technology to create a platform solving the problem of interconnectivity among the thousands of different computers and medical software programs in our offices and hospitals.

Now I’m not dumb about corporate politics and finances. Web-based solutions threaten the fat cats in a lot of software companies who may directly or indirectly support the AAFP.

But surely this is more deserving of a dialogue than a monologue, which is what we have been given up to now.
I have been waiting for years for the AAFP to show some political leadership. This is one place to start.

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About the Author

Doug Iliff, MD, is a family physician in solo practice in Topeka, Kan., and a former member of the FPM Board of Editors.

Note: This blog is no longer updated; this is archived content.

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Making It is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.