EMR Success Depends on How it is Used

This is a cross-post at THCB

E-Health - It All Depends on How It's Used
By MERRILL GOOZNER


IMHO, the key points in the excellent blog post:

"Technology isn’t a quick fix. Just ask General Motors. In the 1980s, the auto giant spent $50 billion to automate and computerize its plants in an effort to compete with Toyota. Today, GM is emerging from bankruptcy while Toyota still leads in producing high quality, fuel-efficient vehicles. What happened? “The Japanese have a great way of describing the error that General Motors made,” said Thomas Kochan, co-director of the Institute for Work and Employment Research at the Massachusetts Institute of Technology Sloan School of Management. “It’s workers who give wisdom to these machines.”

Will the Obama administration’s $20 billion push to flood the nation’s physician offices and hospitals with electronic medical records (EMRs) suffer a similar fate? The July/August cover story in the Washington Monthly by Phillip Longman pointed to one possible stumbling block on the road to widespread diffusion of EMRs – self-interested software firms pushing proprietary systems that can’t talk to each other.

But there may be an even greater danger. The people who actually deliver care will fail to achieve the potential health benefits of having every patient’s EMR at their fingertips."


“Technology doesn’t change lives,” Riley said. “It’s the process around the technology that brings results.”

“The evidence is very clear that improving patient care requires the coordination of nurses, service employees, doctors and technicians working together in a coordinated fashion,” said MIT’s Kochan, who studies union-management partnerships around the country. “You cannot get sustained teamwork in an adversarial relationship.”


"It’s a lesson reform advocates in Washington ought to keep in mind as they craft legislation. Getting health improvements and lower costs from EMRs is not a given. It will require creating workplace environments that know how to make the best use of those records."

“To demonstrate higher quality and become more affordable, we had to take a systemic approach that required a hundred percent engagement strategy,”

"The Japanese called their strategy kaizen or continuous improvement. EMRs, like statistical process controls in a manufacturing setting, are only a tool for generating information. It takes people changing the way they work to actually improve quality and lower costs."


Blog Comments: (Emphasis added is mine)

"In a full-blown kaizen-based management system, managers empower front-line workers to work "on" the system, rather than merely functioning "in" the system. This includes, as Merrill points out, reorganizing workflows and daily activities to assure improved results."

"Technology alone will never solve the problem. My dad always said (and I'm sure he wasn't the first) "You can buy a fancy hammer, it sure as hell won't build a house for you..." Work flow redesign and technology integration, when married together in a thoughtful way, can have huge positive impacts on patient care. "


My Humble Opinions:

The story referenced in in the Washington Monthly includes 2 institutions that implemented information technologies. I question the causality attributed to the successes vs. failure. The author attributed success to the use of open source software when it is likely that success was more likely related to the approaches toward implementation. Implementation has to start with the people/process and then bring in the technology. It appears the institution that was less successful probably brought in a big vendor and then attempted to change the people/process. There are many references in the literature that confirm that starting with the technology, rather than the healthcare delivery process itself leads to the use of health information technology in ways that have inferior outcomes, and actually harm patients. The degree of success in any implementation of proven software is more likely to be related to how well the local decision-makers understand the process rather than the choice of software and vendors.

If "first do no harm" means anything, it is time for clinicians to just say no when the implementation process is upside down!

Meaningful Use

In following from the previous post, a tentative definition of meaningful use is now available. Many administrative rules remain to be announced. Additionally, a tentative grid defining how “Quality” is to be defined/measured is also available. In the coming weeks, we intend to offer some evolving explanations of “meaningful use” and quality measure definitions over time, and explain how they specifically relate to SOAPware. We at SOAPware, Inc. also intend to start filling in the details and time lines as to the hows/whens of the “meaningful use” process as it relates to the SOAPware EMR. This will be largely presented via SOAPedia. I will initially digress to report the “meaningful use” measures are largely an affirmation and validation of what we have anticipated and predicted would take place, and we are on track to meet the rules within the announced timeframes and schedules.

At this time, “meaningful use” is still a work in progress and a bit of a Shangri-La, but it is generally being built in a predictable and mostly reasonable fashion. “Reasonable” does not necessarily mean the easiest or most cost-effective, but much remains to be defined within details to come. At SOAPware, Inc., we have started the process of creating maps, creating-collecting the proper tools, and offering guidance as to the most effective approaches.

With SOAPware v4, we had a bicycle to elegantly manage the narrative, free-text that served a large base of users very well for more than a decade. Now, we are anticipating the next decade, and are at the base of the "mountain trail" with a new generation of product that is more equivalent to an airplane in that it is able to encapsulate real data within what appears much as free-text. This is one of the key reasons why we are uniquely capable of meeting requirements for meaningful use with a minimum of additional or wasted effort. Long ago, we recognized that narrative, free-text bicycles (i.e. what is delivered within the greater than 80% of EMR’s in current use) would have to be physically, manually carried over the snowy goat trails of the data peaks (i.e. would require duplicate information entry and dual workflows in order to create the necessary data in a form that is reportable).

Of note, some others promising “meaningful use” solutions are arriving at the base of the mountains in large, expensive vehicles that are very flashy, and they are making a lot of noise claiming that they are the preferred means to guarantee passage to Shangri-La. They will probably get there, but we suggest the physician passengers realize the fare could be pricey, and the physicians will be largely creating the roads a shovel-full at a time as they endlessly point-and-click in order to create the real data. But, indeed, just about anything is possible with enough money and enough point-and-clicks. In contrast, we intend to fly over as much of that as is possible, and will soon be providing more real examples rather than just hype.

In recent years, our focus has had to be on building the airplane as quickly as is possible. Its basic elements are in place so that it can fly, and now we can install the advanced avionics (completing e-prescribing tools, billing, registry, portal) and auto-pilots (smarter data items and documentation templates along with wizards to manage) as we complete the basic flight instructions (i.e. our new implementation guides). So, we have no intent of just sending out our airplanes (or throw out a bunch of computers and software and turn physicians into data entry clerks) into practices and expect them to be able to fly.

It is our expectation that our easily achievable, step-by-step guides to flight/implementation within a practical and affordable airplane-like set of tools is what is likely to allow SOAPware physicians to sail over the current industry travel modes that have largely failed to actually arrive at any location close to a Shangri-La in significant numbers. For SOAPware users interested in reviewing the early drafts of these implementation guides, please send requests to lmccraw@docs.com.

Where to start?

At this point in time, having clear goals and plans as to how to manage the change are the places to start. We strongly advocate that physicians assess their medical practice as to its change readiness, and plan the change process (with the help of step-by-step implementation guides). This is far more likely to lead to success rather than prematurely purchasing systems that may or may not be able to deliver much beyond a sales pitch. Clinician leadership needs to precede and lead purchasing decisions.

Successful change is a skill that is carefully-diligently planned and practiced. It is not something stumbled into, acquired from the "right vendor," or mandated from the government.

Few plan to fail, but many fail to plan!

The Obamainable Snowplan

I never cease to be amazed at how many physicians think they are about to slide into a free EMR or a free lunch by the government or some other entity. Especially, “bright” assumptions regarding the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American recovery and Reinvestment Act (ARRA) have already snow blinded many. The 2009 economic stimulus package (the Act) passed by Congress and signed into law on 2/17 intends to promote EHR adoption. The Act promises incentive payments to those who adopt and use certified EHRs. In order to receive the stimulus money, the Act requires doctors to also show "meaningful use" of an EHR system.
I invite you on a journey to a simple place of deeper understanding that is a bit hidden. It is in the Journal of Family Practice Management in an article written by Steven Waldren, MD, David C. Kibbe, MD, MBA, and Jason Mitchell, MD, - "Will the Feds Really Buy Me an EHR?"


How much money is available to physician practices?
Short answer - $44,000 per physician over five years. See the table of scheduled payments available. The wise start climbing in the Spring, not the Fall.

If I already have an EHR, can I qualify for the incentives?
Short answer – Yes, but snow shoes must adapt to changing altitudes and snow types.

What do I have to do to qualify for the incentives?
Short answer – Use a qualified system and demonstrate meaningful use. Travel with proper visas, and pack-in that which can reveal you arrived.

Will there be any money to help with implementation?
Short answer – No direct money, but assistance with implementations may come through Regional Health Information Technology Extension Centers. Sherpas may show up, but not to carry you.

Are there any penalties if we don't adopt an EHR?
Short answer – Yes. But, no canings. Too cold for that.

Will the government incentives cover the full cost of an EHR?
Short answer – Not likely if the sherpas arrive with a tour bus.

What should a practice do if it is currently in the process of buying an EHR?
Short answer – Depends, but make certain vendors chosen are committed to supporting incentives. Preferred sherpas are skilled, know the route, and are committed to arrival.

How will the HIPAA amendments affect medical practices?
Short answer – Greatly. but no more than would a Communist, Chinese government.

Is it true that practices will have to track every time they disclose a patient’s medical information even if the disclosure is for payment purposes?
Short answer – Yes. All tracks have to be traceable, even in blizzards.

When do the new HIPAA regulations go into effect?
Short answer – Clue... the year has a 4 in it, and it is not 1984.

What else do the HIPAA amendments require?
Short answer on privacy breaches deserves a koan... In blizzard, all private britches revealed.

Are there fines for breach of patient privacy?
Short answer – Yes, but at least there is not yet mention of any removal of gonads.


Commentary from "Will the Feds Really Buy Me an EHR?"

"While this unprecedented investment in health information technology is seen as a positive development overall, there are some cautions. First, widespread adoption of EHRs over the next five years could stress physician practices and cause short-term declines in productivity. Second, the emphasis on EHRs could hinder the adoption of equally beneficial health information technologies that have fewer implementation hassles, such as e-prescribing or e-visits. Third, the "free money" for health information technology could essentially reward EHR vendors without the market requiring them to first improve their products. Finally, physicians may be hesitant to participate in yet another government incentive program, given the recent difficulties many of them have faced with the Physician Quality Reporting Initiative.

Despite these serious obstacles, an investment in our nation's health information technology infrastructure is much needed and long overdue. The complexities of modern medical practice will increasingly require the use of electronic records, which will enable physicians to track their patients' health in new and exciting ways."

---

Sorry doc, but no sherpas are going to meet you at the base and carry you to Sangria-La. However, if you have wise guides, proper gear, and angle toward the peaks, you are likely to avoid monstrous abominations that are waiting.

:-?

High Performing Patient Centered Practices

From Terry McGenney at TransforMED - Link (Emphasis, added, is mine)

"Practices need to perform as efficient and effective teams and function as the complex, high volume, low margin businesses that they are. This is the only way practices will thrive in today's environment while positioning themselves to capitalize on health care reform."


A High Performing Patient Centered Practice

The Patient Centered Medical Home (PCMH) continues to be a very hot topic at multiple levels across the country. The federal government is aware of the need for every patient to have a medical home as part of the health care reform efforts. Most states have incorporated the attributes of Patient Centered Medical Home into Medicaid legislation. Multiple insurance companies nationally are doing pilots that evaluate and reward patient centered medical homes. Many large multi-specialty groups view PCMH as providing a framework for meaningful system redesign. Most recently hospital systems are focusing on the PCMH concepts within the concept of Accountable Care Organizations.

What remains absent is the engagement of individual primary care practices, the ones taking care of patients and best positioned to make a meaningful impact on the US health care system. The reason for this is that while government, payers, large groups and hospitals understand the potential "up-side" of the attributes of PCMH at the system level, individual practices have difficulty appreciating why they should start the difficult journey of transforming their practices without payment and possibly tort reform. Practices continue to question the "win" at the practice level. The issue becomes more complicated with the blurring and confusion around the concepts of a Patient Centered Medical Home. Even practices that want to become medical homes get confusing, mixed message on what a medical home actually is. Practices are often not clear on what they are to transform to. Meaningful, substantial practice transformation to a PCMH is more than doing a better job of disease management or implementing an electronic health record. Primary care practices need to focus not so much on the PCMH, but the attributes of the TransforMED patient centered model which will not only enable practices to become real medical homes, but most importantly—high performing, patient centered practices.

The TransforMED model provides a framework and common language for meaningful change. This change is true system change and not just minor adjustments to a inefficient and sometimes ineffective system. Everyone understands that a practice needs to be "patient centered". Everyone does not understand that the practice needs to be "high performing".

Primary care practices will not survive even with health care reform without the transformation to high performing practices. Practices need to be "high performing" not only in their ability to leverage technology, provide and capture meaningful outcomes and expand access. Practices need to perform as efficient and effective teams and function as the complex, high volume, low margin businesses that they are. This is the only way practices will thrive in today's environment while positioning themselves to capitalize on health care reform.

The transformation to high performing patient centered practices needs to start now. The concept of a patient centered medical home has been slow to get traction at the practice level. There are many reasons for this that are not likely to change. The concept of a high performing, patient centered practice is one that practices can embrace and can deliver immediate value. Primary care practices need to drive change and not simply position themselves to react to change.

A Remedy For Health-Care Costs

From Business Week, June 25, 2009 - The Family Doctor: A Remedy for Health-Care Costs?

... CCNC pays primary-care physicians in the experiment a premium of only $2.50 per patient per month to emphasize preventive, coordinated care. Yet a study by Mercer Human Resources Consulting Group (MMC) estimates the state saved $161 million on health-care costs in 2006 as a result...

A SMARTER OPERATION

...An ordinary day for Anderson, but extraordinary in the context of U.S. medicine. Unlike most primary-care doctors, Anderson and his team take ample time to counsel patients, guide them through lifestyle changes, and monitor chronic conditions with frequent checkups. He has helped patients avoid heart attacks, diabetes, and unnecessary surgeries by focusing on prevention and disease monitoring. He does all this while seeing 30 to 35 patients a day, compared with 20 to 25 for most practices. And he accepts Medicare. "This is what I always wanted to do," says the 56-year-old Anderson, who converted to a medical home five years ago. "I'm seeing far more patients and delivering the best care I've ever done."

Anderson has three full-time nurses on staff and one part-timer, where most doctors have one or two. The nurses spend much of their time updating patient records, a job that once ate up hours a week on Anderson's schedule. "The history-taking just kills the doctor's time. I don't have to do any of that," Anderson says. It helps that he has an electronic medical-records system, found in only 17% of doctors' offices. Anderson also belongs to a group of 300 specialists and primary-care doctors, all on the same computer network, making it easier to consult with any doctor a patient may need.

Anderson's nurses spend about 30 minutes with each patient on each visit, working through a long list of questions, assessing new health problems, and reviewing old ones. The nurses also discuss preventive measures and treatment options. Once Anderson takes over, he can spend the visit addressing a specific complaint and warding off future crises. To make sure he hasn't missed anything, he has a nurse sit in with him and the patient during the exam, pointing out details in the medical record that a busy doctor could easily overlook.

As sensible as this routine may sound, it goes against the grain of most primary-care practices. Medicare and other insurers pay doctors on a fee-for-service basis that rewards quantity of care over quality. There are no reimbursements for discussing diabetes management with a patient, say, or talking over a case with a specialist. "The main hurdle to getting the medical home accepted more widely is the lack of compensation for cognitive work," says Harvard Business professor Clayton M. Christensen, co-author of The Innovator's Prescription: A Disruptive Solution for Health Care.

IBM's Grundy is campaigning to change all that. There is some self-interest here, as IBM sells the electronic health-record systems that are a must for well-run medical homes. But Grundy, the son of missionaries who fought AIDS in Africa, also argues for social responsibility. He worries about the on-site clinics that many companies are establishing in an effort to control their health costs. "That's just opting out," he says. "We need to transform the system if we don't want two-tiered health care."

...

Anderson insists it is possible to set up a profitable medical home with current reimbursements, but only by increasing patient volume. In fact, he made the switch strictly for economic reasons. "Even though I was working 50 to 60 hours a week, I wasn't able to pay my bills, and one of my nurses was going to quit," he says. "I had to increase my patient load."

A few years earlier he had heard a lecture about a Kentucky doctor who was able to see 50 patients a day after converting to a medical home. The efficiencies came from relying on a team approach, where nurses take on a lot of the record-keeping once left to the doctor. Trying the same model, Anderson hired an additional nurse, added some 15 patients a day, and was able to increase his annual billings by $200,000, to $620,000. He personally earns $240,000 and works 45 hours a week.

Medical-home enthusiasts are lobbying for a change in primary-care reimbursements in any health-care bill that emerges from Congress, with a payment structure that rewards collaboration and prevention. They have a friend in Senator Max Baucus (D-Mont.), a key player in the health-care reform effort. As he points out: "Watching over a patient's full medical history... is a quality measure and a cost-control measure."

Also see Comments at Transformation to the Patient-Centered Medical Home in Annals of Family Medeicine

Ghosts of Medical Records Future

American physicians will soon join the company of physicians in all other advanced countries, and largely discard the use of paper records. They will increasingly focus on selecting medical record systems that offer true data collection and exchange rather than ones that just focus on managing narratives.

The vendor/government/academic/payer policy-makers will initially haunt the nation with onerous and often abusive privacy/security rules and attempt to convince patients and their doctors that the system is reasonable and secure. Only a minority of physicians and patients (i.e. about 30%) will trust and participate in the official health information exchanges. So it will fail in the same fashion and for the same reasons the U.K. system is failing. However, at the same time this national health information highway is faltering, and in spite of massive attempts to bail it out, an alternative system will evolve and grow. This system will be patient-centered and controlled and be more similar to the one in Denmark. It will most likely evolve out of the PHR movement where patients can designate and control where their records are stored and how they are accessed. At any time, patients will be able to check the access log to see who has viewed their records.
Sadly, there will be much patient and physician confusion and chaos during this phase. Those with wisdom will consistently make choices to be flexible and adapt in order to avoid the shifting waves of false promises and siren calls from ghosts of the past.

Patients will increasingly monitor their online health performance measures in the same fashion they monitor their bank accounts and financial performance. This societal shift will not really gain traction until the payment system evolves to directly incentivize them in some fashion. They will increasingly choose physicians that can share information with them directly and electronically. Electronic and social media communication will become the norm, but most patients will wisely choose a trusted physician to be the primary administer of their personal health records.

Physicians’ medical records and data collection tools will become a blessing rather than a nuisance. Physicians will increasingly see how introduction of information technologies offer welcome relief. They will learn how to allow patients and medical assistants to create and maintain most of the medical histories. Systemic collection of data by patients and assistants will finally start to return the gold to the patient and the doctors deserving of their trust. Physicians will learn how to quickly review the information (that is true data and not just narrative) available, clarify-edit what is less than accurate and have more time to deliver the high-touch care that the technology will never address. Because they no longer have to be busied creating massive narratives, they can finally focus more on the person to person interaction and communication. No longer will they have to focus on collection and documenting masses of information that is better collected systematically by others in advance. Doctors will finally recognize that even though they really enjoyed the old back and forth multiple question-answer routine with patients, they (and their patients) greatly prefer the better outcomes of the alternative approach. Physicians will express amazement that they were data clerks for such a long period of time. Doctors collecting and creating most of the patient encounter documentation will be recognized to be about as sensible as blood-letting. Their focus will be more on monitoring the dashboard views reporting the well-being of their patient population and on addressing alerts when measures are out of range.

Medical record information exchange will rarely take place via paper or fax. However, the initial attempts to force, direct electronic transfer of health information will likely be a series of nightmares as the top-down approaches create a succession of terrors for patients and their doctors. Only later will more sensible methods grow and spread that originate from within the affinity and trust existing between patients and their caregivers.

An unpleasant haunt for the near future will be a phase where it will be necessary for physicians to report “performance” data. While this pseudo-performance reporting will be necessary for physician financial survival for a few years, it will be a temporary approach that will eventually be relegated to the trash bin of false promises.

The future will offer important choices for patients and the physicians deserving of their trust. Some choices promise grave consequences. Other choices could deliver what was always important, but lost.
Will medical records continue to be viewed as a costly nuisance, or will patients and physicians eventually claim their gold?
Will patients step up to recognize, own and be accountable for the gold available, or will they continue to allow others to blindly rob them? Will they become involved and properly manage their gold?
How long will it take physicians to recognize their world is quickly shifting to one that is not going to be rewarding them for how many tasks they can individually complete, but how well their team manages the well-being of the population of patients trusting them?
How many and how soon will physicians wake up to a richer perspective?
How much nightmarish anguish will physicians experience before they finally change their perspectives?
How many doctors will tremble into early retirement or early graves?

We can dream that, someday, patients and physicians will finally use information technology to claim what is rightfully theirs. It would be a true revolution, and could finally liberate them from the vendor/government/academic experts and payer entities that have so prominently littered the path of healthcare history with the bones of “good ideas.”


Return to a Medical Record Carol?

Ghosts of Medical Records Present

Medical records are still primarily paper, but electronic forms are relentlessly growing. Medical records are rarely, if ever, just private between patients and their physicians.

Patient’s uneasiness grows as the awareness of the importance of medical records increases. Increasingly, patients are becoming aware as to how information in their record is being shared with entities not having their well-being in mind. (However, few have even a clue as to how many others are accessing their medical information. Paper makes this fact easy to hide. Once the record is copied and mailed, there is no trail for the patient to follow.) There is a growing uneasiness as to the potential harm caused by their health information. Patients increasingly feel they are little valued beyond their potential to deliver profits to entities over which they have no control. Patients still have little input into the content in their records and even less access. Important health information is not even available 20% of the time when they see their physicians.

Physicians increasingly see medical records as more of a growing nuisance. The focus has switched to one of having enough volume or “bullets” in the record in order to simply be paid for services. Doctors increasingly dream of ways to get off the “hamster wheel” that herds patients through the system as the leeches suck away their life blood.
A minority have found that they can use an electronic record in order to create the volume of narrative that is necessary to simply be profitable and remain in business. In 2008, 96% of electronic medical record systems that were in use are of this type. Doctors still mostly seek out systems that can do little more than manage their simple narratives and preserve their obsolete information gathering process. Therefore, these record systems do little more than automate the inefficient, low-value information that is familiar. Because 96% of this health information is only narrative, it makes for pleasant reading, but delivers little gold. So, the gold is usually left for those other than patients and their physicians. For more than 80% of physicians, when asked about using comprehensive electronic medical records, the response is “Bah, Humbug” along with a growing sense of isolation and bitterness.

In a world that is increasingly driven by data, physicians and patients have little. What little data exists in the system is mostly the infected diagnosis and procedure codes that drive the flow of gold in the system. This and associated putrifaction in the disease-care system has caused what could be valuable information in the record to often become an actual threat to both patients and their doctors. Not only are medical records no longer mainly private between patients and their doctors, but the fax machine has increasingly replaced snail-mail as the interoperability exchange of preference.

Increasingly, patients and physicians feel they are pawns in a system bringing great wealth to others, and the doctor-patient relationship has been gravely degraded in many ways.

Even in the present, most physicians say “Bah, Humbug” to electronic records and a re-design of information flow that would allow them to manage patients with less total work, greater patient/physician satisfaction, greater income, and better data. Currently, there is a dearth of good souls to take their hand and show them the path to enlightenment. Rather, the typical approach is little more than to throw in a bunch of computers and software and attempt to turn doctors into data entry clerks. Is it no wonder they would rather work harder doing what is familiar, and cling to ghosts of the past? However, a few have awakened to see that it is possible today to plan/implement medical record systems and information gathering in a fashion offering greater rewards, and have chosen to no longer live with the lingering ghosts of the past. Only a chosen few have discovered that technology can actually allow them to give unto the leeches what belongs to the leeches, and thus free them to be able to focus more on the gold of the doctor-patient relationships.


Return to a Medical Record Carol?

Ghosts of Medical Records Past

Medical records were paper. During the 70’s and 80’s, physician’s records were often on cards, rather than in folders. Medical records were largely private between patients and their physicians.

Patients weren’t too concerned about medical records. Quality of care was primarily based on the quality of the relationship with their physicians.

Physicians viewed medical records more as convenient notes to self. Few, beside the physician, had interest or need for the information. The records were little more than narratives placed on paper. Healthcare services were more episode-based and problem-focused. The doctor could focus on the patient and not on medical records.

System medical record demands for sharing and interoperability were low. Snail-mail of paper copies was the primary interoperability method.

The health information world was much simpler and the key focus was on the doctor-patient relationship. There was little to no real data to measure quality or performance across the population. There were few interferences. Most were happy, but there was growing need to increase documentation as various leeches began to crawl out of the drains.

Almost all turned a cold shoulder toward embracing the potential value within the record itself. It was just too inconvenient, even when possible. Besides, the real gold was still primarily in the relationship between patients and their care-givers. Patients usually financially rewarded, directly, their care-givers as a result.

This is a world that is blowing away in the wind. Yet, dreams of what was, but can never be again, still haunts and provides many “Bah, Humbugs” opportunities across the land.


Return to a Medical Record Carol?

A Medical Record Carol?

Why are so many patients and physicians feeling and acting so scroogy when it comes to dealing with the healthcare system?

Are they perhaps living-experiencing the effects of some great societal shift of some type?

Perhaps they have not fully awakened to the awareness that information is the new gold as society has transitioned from the industrial age into the information age?

Why is there a lack of awareness that “The Medical Record” contains many bags of gold?
• PHR - The personal health record, the patient’s bag of gold.
• EMR - The electronic medical record, physician’s bag of gold.
• EHR – The electronic health record, the medical system’s bag of gold.

Could there be frustration caused by attempts to use Industrial age informational tools while the world is advancing into the information age?

• What choices are patients and their physicians making today, and what are the likely, future consequences of those choices?

If information is the new wealth and power, why are so many thinking the only choices are either to be miserly or impoverished? How has life experience led to this either/or view of the world?

• What are our collective ghosts of medical records past?
• What are our collective ghosts of medical records present?
• What are our collective ghosts of medical records future?

Is the gold not just financial wealth, but power and control over what really matters?