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Better Care Through HCIT 101: Part Two, What Problem Does the EMR Address?

March 4, 2009
by Joe Bormel
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Better Care Through HCIT 101: Part Two, What Problem Does the EMR Address?

In this crazy era where we’re going to “fix healthcare” by driving investments into adoption and meaningful use of an EMR, there’s a vague fog about what exactly this will fix. When the certification criteria become established for ARRA, we’ll be in a better position to clear the air. In any event, it will help, both before and after these are defined to have a framework to think about fixing healthcare.

Why a framework? A framework can help sort issues into a succinct, manageable package, allow priorities to emerge, required sequences to become apparent, and allow for a complete argument to be constructed. The kinds of frameworks I’m talking about are simple and elemental. For example, a

SWOT analysis or applying

Michael Porter’s “Five Forces of Business Competition” come to mind. They allow an intelligent person to quickly and succinctly organize an argument and have an assurance that it’s reasonably complete, at least in terms of the framework.

Are there commonly accepted frameworks for fixing healthcare? Frameworks that are useful, especially with respect to contextualizing the impact EMRs will have on healthcare? Well, here’s a brief story to illustrate one framework and help make it memorable. I call it

The Vowels of Healthcare Improvement.

A few years back, the U.S. Surgeon General at the time, C. Everett Koop, said that healthcare problems, and the solutions to those problems, could easily and succinctly be summarized. Using some literary license, I organized those problems (issues) as follows:


costs are too high.

Effectiveness is not a focus. We over use, under use and misuse resources.

Incentives are aligned for the volume of care, not the value of care.

Outcomes are not systematically captured and used for learning.

Uninsured care causes very irrational behavior, cost shifting, overall waste and suffering.

The vowels A, E, I, O, and U are easy to remember and easy to remember in order, thereby serving as a memory aid to discuss these issues. I generally don’t disclose that the

mnemonic device is there until after the audience has agreed that the five issues are generally recognizable and probably the most important.

The vowels also closely correlate to the natural sequence of healthcare improvement. This sequence starts with reducing Administrative costs by becoming focused upon finding and moving information electronically. Whether that’s reconciling a patient’s identity, viewing an electronic medical record, ensuring adequacy of the record (medically, financially, legally), or submitting a bill (claim), EMRs and the associated transaction solutions drive down administrative costs dramatically.

The comparative costs, for example, to pull a patient’s record, find the information required, and re-file the chart typically costs institutions $10-$30 per paper chart pull, and introduces 15-30 minutes of process delay waiting for and handling the chart. Waiting for a paper chart to be delivered, or walking to radiology to see a film, were common frustrations for me. But with strong EMR solutions, these costs become pennies and the delays are measured in seconds, usually less than ten seconds.

What’s amusing is that most of us complain that waiting ten seconds for an electronic document to open is an eternity, even though the processes being replaced were measured in tens of minutes!

EMRs play a comparable role to improve, once decision support is applied, Effectiveness, Incentives, and Outcomes. And, until good and appropriate processes are made more automatic, we won’t be able to systematically plan, deliver and cost care effectively enough to develop a sustainable economic model that addresses the Uninsured.

There are other components of the sequence that have obvious sequential aspects to them as well. For example, we cannot assess Outcomes effectively if they don’t reflect repeatable processes. Call those processes guidelines, order sets, knowledge management or workflow. Yes, we know those are all different, yet they each reflect program components we all recognize as essential to ensure

the care provided reflects what the best of us know about diagnosis and treatment.

Notice that




certification, and other important elements are secondary to the EMR and transaction machinery addressed by the Vowels.

Conclusion and Lessons? When looking at the stimulus package, or any other improvement initiative, you can now ask: Specifically, how does this lower Administrative costs? Will these Incentives, for example, improve Effectiveness of care, or merely automate existing practices? Will these Incentives have a direct impact on Outcomes? Will they, through the earlier vowels, better position us to improve Outcomes in the future? And how will these measures impact the Uninsured, and when?




This post is classic! You've given me information on a topic I work with that's concise, easy to understand and remember, and therefore, easy to communicate with others. The "Vowels" are a big hit with me.

I went back to your Armstrong/PHR post because I felt as though there's something that links it with this post. I noticed you added a comment earlier today, so maybe I'm traveling down the right path in saying that PHRs appear to have a huge potential to deliver your Vowels.

Putting my PHR privacy/security concerns aside for the moment, I really do think that individuals have a certain responsibility for their own care. Being able to track specific information about oneself in a simple, organized manner using a PHR is a good idea. And it seems to me that a PHR should then, logically, work in concert with an EMR. For instance, I can see here an opportunity for individuals to inform their docs about the outcomes of various treatments in a timely manner, with notes about progress - all of which could prove to be valuable input for the EMR.

I don't know that I've sufficiently organized my thoughts on all this, so it's time to ask you what you think and request a little guidance. Can you add to the framework?


Health-Care Battle Set to Focus on Public Plan by LAURA MECKLER (3/24/2009).

This is a great little article, hidden away on page A4. It focuses on the issue of coverage of the uninsured.  This "Better Care... HCIT" blog post positioned Coverage of the Uninsured as one of the five key benefit areas for EMRs (aka Vowels framework).

After reading this WSJ article, I realized that, in terms of provider business strategy, ARRA-2009 is a distraction from this larger issue: options for structural change to the care delivery system itself to address the Uninsured.

As is often the case, the comments are rich.

I think I'm going to parse this into more than one comment.

First, thanks for the kind words. These days, I'm especially appreciative of positive comments. I'm not getting negative ones, but the world pendulum has been swinging back toward very critical thinking which can feel that way.

The 'The Vowels of Healthcare Improvement' as a framework is best understood by looking at the competing frameworks. The issue with frameworks and accounting systems in general is that they should cause you to start off by creating clarity on your goals.

There is no correct way to do accounting (i.e. no single correct framework). You must start with a statement of your purpose. And, you may need several frameworks to address your goal. Hence, the need for balance sheets, income statements, cash-flow analysis for example, to characterize assets and performance. Gee, did you notice that the cash-flow analysis for the ARRA incentives is negative for providers for several years?

Common frameworks for healthcare start with stakeholders, and look like this:

1) Payers 2) Providers 3) Patients 4) Policy Makers 

Historically, the problem with this framework is that the big investments in information systems were by and for the first two stakeholders. Not surprisingly, the clinical issues lagged the financial ones by 10 to 30 years.  Costs were passed on, rather than rationalized, leading to spiraling healthcare costs. This is a simplification, of course, but it's correct as a first-order explanation of what we see in the US.

The coordination and collaboration between Payers and Providers is best summarized as competitive.  (Without financial risk assumption, that's unlikely to change.  We all know how well that worked out last time we tried that.  It didn't.  Read JD Kleinke's work, specifically Oxymorons, for a fabulously articulate depiction of the demise of risk assumption.)

Not until very recently, say the past decade, has there been an understanding that the pie is not fixed. For example, we've dramatically reduced the CABG (coronary artery bypass graft) rate (and costs) with drugs. The incidence of MI has fallen. One of the leading drugs is all but free, aspirin!  The next biggie is available in generic.

The other messy thing about this common framework is that the biggest Payer is also the biggest Policy Maker; they're also the Government, so they've got a phenomenally diversified constituency and mission.

This framework is extremely helpful in sorting out the money flow it does very little if anything to get at coordination of care, waste, etc. There are clearly examples where this framework helps understand where we're making coordination of care worse.

A quick common example: I was just started on a six-week trial of a drug, and given a prescription for 4 weeks. Purely in industrial engineering terms, this doubles my setup costs (obtaining the drug). It raises the opportunity for errors (patient safety violation). And, it's anti-satisfaction (fails the consumerism test).  It's only going to lower my compliance.  It also lowers my level of confidence in the healthcare system to truly care for me. 

In short, the The Vowels of Healthcare Improvement is a very useful framework, if healthcare improvement (with improved cost management) is the ultimate solution we're really solving for.

I'd be very interested in other frameworks we should be explicitly kicking around. (Hint: The most recent CBO reports, December and February are telling.  Another very useful framework, an economic one, is the components of the MLR, medical-loss-ration, which looks at person costs in a population for in-patient care, ambulatory care, pharmaceutical, administration of benefits, etc.)

Dr. Joe,
Thanks for both of your replies. I want to tell you that just yesterday I used your initial post and first reply to my comment to formulate questions I posed about the successes achieved by two customers of a healthcare organization I work with.

By asking them about the framework they used for success, I was able to gather much more information from them in more succinct responses. What appeared on the surface to be rather mundane processes proved to be quite interesting and valuable. And lo and behold, one of them really did use more than one framework! What I took away from the conference calls was a richer appreciation for what these two hospitals had accomplished, because I learned more about how they planned for success.

To say the least, Friday was one of the best days I've had in several months. In the end, as I explained my findings to the client (before issuing a detailed report), I found that the execs on this call were learning, too. That's what I call making progress!

As to your second reply, yes, you did address the spirit on my question. Let me give you just one important example, because there were multiple, diverse items I consider important.

Your paragraph about lab results, once again, underscored the importance of clear, concise, and consistent communication. Stay away from the minutia, particularly when constructing a framework from which to move forward. By the way, I am a vet, although not eligible for VA health benefits. But I'm familiar with the site you mentioned as I'm active with several veteran groups. Too bad the folks at VA don't get more credit for all this agency has accomplished in the past decade or so.

In closing, I do understand how, for instance, the value of a PHR can be diluted. In fact, I think you've changed my mind about them. But more important is that I understand how your Vowels as a framework, alone or with others, can have a positive impact ... and the importance of "meaningful use." That's progress, too.


So, Jack, with the above as background, where do PHRs fit in?

Let's follow the guidance of Pam Arlotto, who, last month, encouraged us to 'think in different terms' about value.  Switching between frameworks while looking at PHRs will help us do exactly that.

From the Vowels framework, PHRs dramatically reduce the information management and transaction burden on consumers.  It's huge.  (see My HealtheVet and Partners links below.)   The potential power of PHRs are obscured and/or nullified by the stakeholder analysis framework (see prior comment).  Given that Netscape was in use in 1994 and public in 1995, and PHRs are not readily available to most of us, the stakeholder analysis correctly portended the low penetration of PHRs.

It's still a messy hassle for most of us to walk out of a doctors visit with our management plan, coherently assembled.  If we do get it, it's likely on paper.  Substantial parts of mine were hand-written in the margins during my last visit. 

Getting our lab results has control issues, some a legacy from the paternalistic doctor model.  Some of it is legitimate.  Do I really want to learn that my HLA-B27 titer is positive at 1:160, alone, when I'm tired.  What the heck does that mean?  The context will most likely come from a random Yahoo chat board?  Is that a professional way to disseminate results? 

With a PHR, combined with thoughtful use case modeling, this has been dramatically improved for some early adopters, typically of relatively large healthcare delivery systems whose investments are measured in Billions..

The clarity of getting the basic information, the same stuff of Medication Reconciliation, by the way, leads to huge opportunities to create clarity and a better consumer experience regarding effectiveness, contextualizing options related to incentives (critical for health spending accounts, and conditions with significant disparate treatment options, like prostate cancer).  PHR's also make Outcome data available in context. 

Last week, my doctor walked me through my Framingham risk data, using a template from UpToDate.  This was and is fantastic.  Can I easily track this overtime, with treatment and lifestyle interventions?  No.  With a PHR?  Yes.

If you use the Vowels' "Uninsured" as a proxy for expanding coverage under the administration's Healthcare Vision Statement, you need look no further than the VA's My Health-e-Vet program to find a market-tested, proof-of-concepts (slide 8 - half a million vet users). 

Others, like Partners HealthCare in Boston having proven real benefits to commercial populations.  See Dr Jon Wald's comments at the end of this article.  The point?  For patients with chronic medical conditions, i.e. those with the relatively high PMPM costs, PHRs are very effective, for Quality, Cost and Access to care.

When you look at PHR's from other frameworks, like the stakeholder analysis framework in my previous comment, the value of PHRs gets heavily diluted.  It becomes a marketing tool for Payers (and becoming a commodity since the top Payers all offer them.)  They also shift to a view a health-plan utilization tool, rather than a health tool, or an effective chronic condition tool, per Dr Wald's observation.  Yes, I know that the payers are striving to make PHR something greater.  To my knowledge, none can show the adoption, utilization, and consumer satisfaction data that the VA has.  Nothing close.  (I have looked in some detail in 2008.)  Paid claims data is great.  It's low cost.  It's codified (see my post on ICD-10).  It's real time.  Today, however, it tends to be poorly integrated with disease management, case management, predictive analytics and member services systems.  At the end of the day or year, my goals and my payers goals aren't always aligned.

Using the stakeholder analysis framework for health system providers, PHRs get a little more effective.  They can be a superb results delivery tool, with a substantially positive ROI.  This has been documented in Regenstrief and presented by Dr. Mike Barnes in a national meeting. It's also allowed some RHIOs that I know about to be financially viable.  The other transactional capabilities, like web-scheduling are terrific parts of PHRs. There too, there's a very real ROI opportunity to be managed to.

You look at those same 2 examples, results delivery and web-scheduling from the Vowels' framework perspective, and PHRs have considerably more value than from the Providers-angle of the stakeholder framework.

So, I'll end with this.  The Vowel's framework is a more powerful tool to look at the positive health impact of the any initiative package (be it ARRA, an organic corporate strategy or other business-oriented investment thought.)  It can eliminate the proxy, i.e. adoption of EMRs, replacing it with concrete, measurable improvements in the US healthcare system.  Now that's "Meaningful Use."  Let the definition of certified and qualified provider follow that!

Jack, did I address the spirit of your question?