Three out of four Americans believe their health record should be easily shared between doctors, and nine out of ten Americans believe it should cost no money to do it. These are the results of a recent survey conducted by ORC international on behalf of the Society of Participatory Medicine.

The co-chair of the society further went on to say, “We have the technology. What we need is for healthcare providers and systems developers to put patient’s interests ahead of business needs. None of them would exist were it not for the patients”.

As a chief technology officer in the medical record space I’m very interested in the statement that we have the technology needed for record interchange within the US at zero cost. This certainly isn’t my experience.

Of course, this conversation will inevitably revolve back to meaningful use, a key goal of which was to install medical record systems that would allow providers to capture and exchange medical data with other providers and patients. By buying a certified EMR and attesting to its use in accordance with a series of arcane rules you could receive a rebate that would help defray the cost of your purchase over a period of several years. For those who choose not to comply, a pseudo tax on your Medicare reimbursement rate was the penalty.

At this point in time approximately 90% of physicians use an EMR. Something less than 20% of them have managed to achieve the meaningful use requirements, and the deadline for meaningful use stage II has been extended.

Occasionally I sit and wonder how the government modelled the meaningful use project in terms of its impact on the consumer. Was it one of these “back of the envelope” kind of things? After all, what should an EMR cost? How did the legislators ensure that EMR and records exchange prices would be consistent with operational savings? Were the legislators really sure that medical costs wouldn’t rise as the technology cost wended its way inexorably to the consumer?

One of the requirements of meaningful use was records interchange. According to the article providers who bought systems from EMR vendors are now finding that they require expensive upgrades ranging from $10-$50,000 to actually exchange records. Is it reasonable to say that the EMR which claims certification to meaningful use stage II should automatically provide this functionality?

It really depends. If the provider purchased a base system and did not buy the optional modules for records interchange they should not really be surprised to have to pay more in the future. This isn’t as bad an idea as it may sound, because technology improves and being the first one on the ground is not always a competitive advantage. For example, as we now move into the era of FHIR (fast healthcare interoperability resource) standards some of the earlier specifications may become less useful.

A good example would be buying the first smartphone on the market. I owned most of them, and they really didn’t become more than toys until about four generations in. In a similar vein, some institutions have actually moved away from their first-generation EMR. This is a very expensive proposition, but the technology has come a very long way and the conversion may be necessary to maintain an effective business.

In the software industry it’s typical to charge anywhere from 20 to 30% of the base price of a product on a yearly basis to cover upgrades and support. Who is paying for this cost, and any other operational and capital costs that are also needed? Who is accumulating the money for the purchase price of the next EMR?

The answer that you will hear is that all of these items would be covered by reduction in operational cost of the hospital. However, this isn’t what we’re seeing. Today providers take two hours per shift to complete patient charts, and I would contend that the operational cost has actually increased. For a great analysis of this trend I recommend you take a close look at “The Digital Doctor” by Robert Wachter.

So, if the operational cost appears to be increasing, and the licensing and capital costs are new, then it is only reasonable to expect that there has been a net increase in the cost of healthcare. After all, nobody is reducing their fees as a consequence of their EMR.

Do I believe that records should be easily to exchange? Well of course. However, I’m also a pragmatist when it comes to understanding the complexity of the technology needed to do so. It may take at least 10 years before we get there.

Should the exchange of records be free?  Sure, and in fact, in some cases it is.  Continuity of Care is an excellent example.

If you are unfortunate enough to get cancer and be transferred into one of our customers we will be able to retrieve your records at no cost to you or our customer. The source institution may end up paying for infrastructure or per message costs, but these are just considered part of the cost of doing business and are never passed on. The maxim is “if you want records you have to be prepared to give them”.

From a patient’s perspective the situation is a little bit more complicated. HIPAA allowed for reasonable costs for photocopying records but since EMRs were not in wide use at the time of it’s writing, there are no guidelines on electronic exchange. Should we assume a similar intent of “reasonableness” should apply?  I think so.

At this time it’s really not clear what a reasonable charge would be, but I have paid personal health record vendors anything up to $100 to retrieve my records on a one-time basis from all my providers. Yes, that’s expensive and beyond the reach of many people.

To conclude, yes your records should be easy to exchange and free to boot!  Unfortunately, this is an idea that’s a little ahead of it’s time and at this point there are few guidelines for providers and technology vendors. As the meaningful use monies wind down it seems likely that patients will, unfortunately, foot the bill until some real operational costs defray the additional expense.

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