Making the Case for a Coordinated Medical Record System

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Editor’s note: This article is the first in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system and how it could reshape healthcare.

In the 1850s, Florence Nightingale wrote that medical record-keeping needed to be revised. She noted that medical records were in a deplorable state, as none were maintained in a uniform manner. There was a complete lack of coordination among caregivers.

Flash forward to 2009, when Jerry Adler, a Newsweek magazine journalist, wrote that the nation will miss a historic opportunity if millions of American doctors adopt a hodgepodge of standalone electronic medical record (EMR) systems that don’t communicate with each other. Adler was one of very few who pointed out that the government’s $35 billion dollar EMR incentive program was not well conceived.

By not heeding the advice of Nightingale or Adler, we ended up with more than 2,000 individual EMR products that don’t communicate with each other. Simply digitizing medical records in multiple fragmented EMR systems has not increased the quality or decreased the cost of healthcare. And now the focus is on how to connect the information in all of these disparate systems.

Because so much has been invested in deploying these 2,000 products, it’s natural to think that the easiest way to solve the connectivity problem is to leave all of the individual products in place and just connect them with a new set of industrywide standards. But building a house on sand is usually not a good strategy. Sometimes it’s best to retreat, regroup and attack a problem from a radically different perspective.

To frontline physicians, it is not at all clear how a new set of information standards is expected to help solve the real-life quality and cost problems that they deal with every day. Unless a clear, convincing and detailed explanation becomes available, no one is likely to reboot, retool or buy any new standards-based information system. Physicians and health systems bought their current EMRs without this type of upfront analysis being available. They are not inclined to make the same mistake again. If a convincing argument can’t be made for a standards-based solution, then alternate types of solutions need to be pursued.

At least 30% of all healthcare dollars — that’s $1 trillion, or 6% of GDP — are spent on the personnel, systems and services that only move information around the industry. Most of the healthcare industry’s quality and cost problems, like misdiagnoses, inappropriate medications, duplicate tests, medical-legal issues and fraud, are primarily information-related. Because of these factors, it is critically important that we all get this part of the industry right.

I am a retired neurosurgeon, and throughout my active career I always served on medical records committees. These dual frontline clinical and back office administrative experiences gave me a somewhat unique perspective in understanding that one of the major foundational problems in the healthcare industry is that everyone has a limited view of a patient’s healthcare record. Nowhere in the industry is there a complete and comprehensive picture of any patient. It is very much like the blind men and the elephant problem.

It is understandable that this problem existed when all medical records were on paper, but it should not continue to be a problem in this digital age. Unfortunately, the ways in which the healthcare industry has chosen to digitize and interconnect itself still leaves the elephant sitting in the middle of the room, unidentified.

A few years ago, in an effort to address this problem, I teamed up with Vern Schatz, a computer network engineer who was instrumental in the early deployment of the credit card system, and a technical team to develop and beta-test a Coordinated Medical Record system. We use that term because the technology is not meant to define a particular product, but rather a patient-focused and data-driven type of information system that is distinguishable from care site-focused and encounter-driven EMR and HIE systems.

Like its credit card industry model, a Coordinated Medical Record system literally produces a single record that contains all of a patient’s clinical and financial healthcare information over space and time. And the data within each record is organized in a way that makes it maximally useful for all of the various clinical, financial and administrative purposes for which any patient’s record is needed. The founding principle of the system was simply, “follow the patient.” We modeled the Coordinated Medical Record after the credit card system because it had already figured out how to capture information from many disparate sites and organize it in a single central record.

Following our beta tests, our company cooled down due to funding struggles, so I am not attempting to sell a product. Our project actually ended prior to the government’s EMR incentive program. However, we learned a lot from our development and testing programs, and what we learned is still pertinent today. Based on our experience, we shared Adler’s frustration as we watched the ill-conceived EMR program being rolled out. We know why the equally ill-conceived standards/interoperability initiative is not going to work. And we know how to head in a different direction.

In a series of articles, I will describe the technical, functional and logistical criteria that are needed to develop and deploy a Coordinated Medical Record system. I will explain the clinical, financial and social implications of establishing such a system. I will show how the system impacts almost every aspect of the healthcare industry. And I will show how this type of system will significantly improve the quality and reduce the cost of healthcare simultaneously — something that many people say can’t be done simultaneously.

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