Has tech's time arrived? (Towards the Electronic Patient Record conference)

For more than two decades, technology companies hawked their wares while physicians mostly yawned.

The problem: selling doctors expensive, deskbound equipment that required reworking everything they did in their practices, while it likely would not save enough money nor improve efficiency. Even though officials from the president on down talked up the need for health information technology, that wasn't enough to overcome the unfavorable cost-benefit analysis that many physicians saw.

But as both sides are forced to make changes to ensure financial survival, the tech industry and physicians may have reached a point at which technology is finally starting to meet the needs of doctors.

In particular, less expensive mobile technology is allowing some benefits of large-scale electronic medical records without the huge upfront costs, while greater collaboration between companies is moving the emphasis away from the kind of proprietary technologies that don't speak with other systems or struggle to adapt to physicians' needs.

And as physicians see practice income fall, particularly as fewer patients have insurance, they are growing more open to using that cheaper technology to shave costs.

"It was strictly financial viability issues that forced doctors to get computers in the office," said Alan T. Falkoff, MD. It was the need for viability that inspired many practices to invest in practice-management systems to keep patient data organized and make billing easier. Now viability issues are forcing physicians to invest in clinical IT, said Dr. Falkoff, a family physician in a five-doctor practice in Stamford, Conn.

Evidence of this change in attitudes and strategies was apparent at the 25th annual Towards the Electronic Patient Record Conference, held in Palm Springs, Calif., in February.

When C. Peter Waegemann, founder of Boston-based Medical Records Institute, a research and consultancy organization that organizes the annual conference, held the first TEPR 25 years ago, he had a vision of every doctor having the capability to store and transfer patient records electronically. There have been milestones reached along the way, he said, although most have been good intentions and false starts.

More gains have been made in the past year than in the past several years combined, he said. A big reason for that success is the rise in everyday technologies, such as the Internet and mobile phones, that are being integrated into health care.

The organizers of TEPR "are achieving," said Louis Cornacchia, MD, president and CEO of the online physician community Doctations. "Maybe not what they thought they were achieving, but they are achieving."

In a keynote address, American Medical Association Board of Trustees Chair Joseph M. Heyman, MD, noted that the challenge for doctors is not a "lack of health IT, but rather information management. Health IT is simply a means to an end, not an end unto itself." Dr. Heyman uses an EMR system in his solo ob-gyn practice in Amesbury, Mass.

Change in strategy

When presentations by James Mault, MD, director of products and business development at Microsoft, Roni Zieger, MD, product manager of Google Health, and Adrian Gropper, MD, chief science officer of MedCommons, concluded on the second day of TEPR, the three, at the prompting of the moderator, shared a group hug.

Besides the laughs it drew from the crowd, the hug was noteworthy. The TEPR presentation was on building a personal health information ecosystem and all three spoke of the importance of working with others to make health data more portable.

But while software vendor MedCommons has collaborated with both Microsoft and Google on their respective personal health record platforms, so far Google has declined Microsoft's offer to collaborate. Dr. Zieger later said that although no plans have been announced, Google is in talks with Microsoft about making their PHRs compatible.

Experts are crediting cooperation for moving IT adoption forward as technology companies move away from proprietary systems and focus on ways to make mainstream technologies useful in health care. Mainstream technologies are tools physicians can use with systems they already have, rather than buying new hardware and software that can be used with only one product.

For example, as use of the Internet and cell phones have become ubiquitous, the way people communicate with physicians and other caregivers has changed. Now some technology companies are focusing on how those technologies and interactions work, rather than producing large-scale systems that might interfere.

"It's not just about the EMR anymore," Waegemann said.

The most compelling evidence of this change was in the conference's topics. There was less focus on stand-alone EMR systems, and there was a three-day track revolving solely around mobile health IT.

"Last year, I and another presenter were the only ones talking about mobile technology. Now that's all we're talking about," said Frank Avignone, PhD, director of business and sales development for AllOne Health, which developed a cell phone PHR platform that was unveiled at the 2008 TEPR conference.

Waegemann said the mobile technologies being introduced to health care have too much of an impact to be ignored. "A few years ago if someone said, 'Put your health information on Microsoft,' I would have said, 'You're crazy.' "

In response to the growing interest in mobile health technology, the Medical Records Institute formed a new organization, mHealth Initiative, and is holding mhealth workshops throughout the year. Whether TEPR even will be held next year remains unclear, but the inaugural mHealth Initiative meeting has been set for December, and the organization plans to make it an annual event.

"It's the Googles and Microsofts who will change health care in the next few years. It will not be the HITSPs and HL7s," Waegemann said, referring to the regulatory groups that are developing standards for the health IT industry.

In the past, physicians were keepers of all the patient records. Now patients can monitor and keep track of their own health using the same devices they use for other aspects of their lives. This evolving patient-physician relationship has sparked a renewed interest in the patient-centered medical home concept, of which many of these technologies are a crucial piece.

The medical home concept, as defined by the American Academy of Family Physicians, encourages things such as e-mailing with patients, remote monitoring and patient portals.

Shifting responsibilities

Physicians such as Dr. Falkoff have found that the more responsibilities practices can place on patients using technology, the less time physicians and their staffs are forced to spend on nonreimbursed activities.

There are many technologies small practices can afford as a way of reducing staff time and resources, said Dr. Falkoff, who shares his practice with two other family physicians and two pediatricians.

The practice has adopted such technologies as a kiosk that patients use to check in, freeing up staff. Patient portals can be accessed via the Web so patients can view and print their records, or send e-mails to physicians or staff. Patients even can send a note before an appointment alerting the doctor to the reason for a visit, freeing up time at the front end of the exam.

Beyond economic pressures, there also have been government pressure on practices to adopt health IT. For the first time, physicians are starting to see cooperation -- and money -- from government agencies.

Alan Greene, MD, a pediatrician and clinical professor of pediatrics at Stanford University School of Medicine in California, compared the health care industry with a revolutionary war. There is a realization that the old system is no longer working but it is still in charge.

"We are at about the stage of the declaration of independence in the road to EMRs," said Dr. Greene, who in 1995 pioneered the concept of physician Web sites (link).