James McGauley, M.D.

home

authors

james-mcgauley-md

Editor’s note: This article is the 10th in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

The term “medical home” was introduced by the American Academy of Pediatrics (AAP) in 1967 to describe a central source of a child’s pediatric records. It particularly emphasized the importance of centralized medical records for children with special healthcare needs. The concept was introduced to address the duplication and gaps in services that resulted from a lack of communication and coordination among the different practitioners who cared for special needs children.

To address these problems, the AAP advocated for three steps to spread the word about the importance of the medical home: “The first requirement is the teaching of all medical students that a medical home and a complete central record of a child’s medical care are the sine qua non of proper pediatric supervision. Second, the concept must spread from physicians to all agencies and people caring for children—schools, child guidance clinics, well-infant stations, surgical specialists, emergency departments and so forth. The third step is the indoctrination of parents.”

In 1977, the concept of a medical home as a central repository for medical records actually became a formal policy of the AAP. Its statement read: “Quality medical care is best provided when all of the child’s medical data are together in one place (a medical home) readily accessible to the responsible physician or physicians.”

Expansion of the Concept, but Elimination of the Core Principle

Since 1977, the concept of a medical home has evolved and expanded, but in the process, the original idea that a medical home is essentially a 

In 2006, the Patient-Centered Primary Care Collaborative, a multi-stakeholder advocacy organization, described a medical home as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety.

In 2007, a consensus statement on medical home principles was jointly endorsed by the American College of Physicians, the American Academy of Family Physicians, the American Osteopathic Association and AAP. It defined a medical home as a healthcare setting led by a personal primary care physician that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family members.

The 2010 Patient Protection and Affordable Care Act mentions medical homes in the context of new payment policies, Medicaid demonstrations and the creation of Accountable Care Organizations.  

Recent articles describe a medical home as a partnership between patient, family, primary provider, specialist and community support groups whose goals are to provide comprehensive care and minimize gaps in healthcare delivery. Other articles describe it in terms of a personal physician, a physician-directed medical practice, whole person orientation, integrated care across the lifespan, enhanced access to care and payment structures that reflect the value of care management.

The initial AAP definition of a medical home was focused and specific — a primary care physician plus a Coordinated Medical Record for every patient. It was remarkably prescient of the AAP to define a medical home in this way because 1967 was a time when all medical records were still on paper, making it virtually impossible to generate a single, comprehensive, coordinated lifetime record for any patient.

All of the subsequent descriptions of a medical home are laudable but vague. They essentially define what primary care physicians already do — coordinate care for their patients and communicate with other care providers and family members.

What’s missing in the recent descriptions is the specific requirement for the coordinated and comprehensive information that automatically ties all of these functions together. It’s unfortunate that this requirement is still missing at a time when it is actually technically and logistically possible to provide this information to the caring physicians.

The simplicity of what AAP recognized long ago was that the formula for providing the highest quality of medical care was simply to have all of a patient’s healthcare information readily available to the providing physician at the time of every healthcare encounter. They recognized that a Coordinated Medical Record was the necessary foundation of a true medical home.

None of us get all of our lifetime healthcare from a single physician. As we all move through space and time, a consistently available Coordinated Medical Record would allow all of our primary care givers to provide us with a top quality medical home without them needing to build the foundation of that home from scratch every time.

Get the best insights in digital health. 

A Coordinated Medical Record System Defines the Holy Grail of Healthcare IT

True Value-Based Healthcare Requires a Coordinated Medical Record System

A Coordinated Medical Record System Is 96% Outpatient Focused

Articles

A consistently available record would allow PCPs to provide patients with a top quality medical home.

A Coordinated Medical Record Is the Foundation of a True 'Medical Home'

Editor’s note: This article is the ninth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

 that produces a single, comprehensive, privacy-protected, automatically-updated patient record that is continuously available to the patient and to all authorized caregivers essentially defines a “Holy Grail” type of IT system.

Single, comprehensive medical records are the ultimate patient-focused records. The continuous availability of those records to all caregivers means that everyone is working with the same patient information all the time, and that is the core principle that leads to a significant increase in the quality of healthcare. And, it is the documentable increase in the quality of care that ultimately determines the appropriate cost of care.

A Coordinated Medical Record system is modeled after the credit card industry, which has proven that it is both technically and logistically feasible to establish a customer-centric data management system that captures and organizes billions of random transactions every day.

Groups of bankers founded the companies that developed and deployed the credit card systems. Currently, there is no comparable entity in the healthcare industry, so one needs to be established. It needs to be a new corporation in the middle of the healthcare industry whose sole purpose is the neutral management of medical records.

, the founding members would be a handful of activist physicians and representatives of major national corporations. These potential founders are currently sitting on the boards of national physician and employer organizations that are looking for ways to improve the quality and decrease the cost of healthcare.

The employers can easily fund the start-up of this entity and can subsequently use their collective power as the ultimate source of most healthcare dollars. These individuals can redirect insurance premium and healthcare tax dollars to fund the ongoing functioning of this information system.

Physicians are the ones who need to use this type of system and will only do so if they are the ones who can write the rules regarding the functionality of the system. This includes the rules regarding access to and ultimate uses of the data in the system. 

Ideally, this new corporate entity should be not-for-profit. The business of moving information around the healthcare industry obviously can be, but does not need to be, a profit center in itself.

The new entity only needs a thin corporate structure. The intellectual property and the IT team that maintains and enhances the system remain in the corporate entity, but nearly all of the data processing and communications operations can be outsourced to a first-tier, enterprise-capable, national data processing company.  

In our team’s second pilot project, we outsourced the data processing, communications and Service Center staffing functions to Electronic Data Systems Corporation (EDS, now DXC Technology). Four first-tier national data processing companies showed interest in providing these services, including IBM, which later provided a letter of intent indicating its interest.

The level of interest that these companies demonstrated shows that a Coordinated Medical Record type of system can meet the highest levels of data and system security, stability and scalability.

Our pilot projects showed us that physicians, patients and employers are all strongly supportive of a Coordinated Medical Record system. The pilots demonstrated the ideal size and configuration of a healthcare community that make it both logistically and financially feasible to establish the system in that community.

The projects showed us that primary care physicians are the key to establishing the system in any community because they are the only entities in the healthcare industry that care for a consistent group of patients. The pilots documented specifically how the system improves the quality of care and how that quality improvement is the driver for 

multi-billion dollars’ worth of cost savings

Statistics, Reports, AI and Risk Management

The central database of Coordinated Medical Records is capable of generating real-time, comprehensive, clinical and financial, standard and customized statistics and reports that are unparalleled in the industry. The comprehensiveness and real-time nature of the information in the database make it a uniquely powerful foundation for producing artificial intelligence analyses and risk management protocols that fragmented EHR systems cannot produce.

It is critically important that this type of database be neutrally managed with strict adherence to access and use criteria that are primarily patient-, physician- and quality-focused.

If a Coordinated Medical Record system, as described, does not fit the criteria of the healthcare industry’s IT Holy Grail, then what are the criteria? Admittedly, many might argue that it would be very difficult to get this type of information system established, but no one can say that it’s impossible.

Coordinated Medical Record System's Administrative Backbone: Service Centers

How a Coordinated Medical Record system could be implemented. 

Editor’s note: This article is the eighth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

The current initiative by healthcare payers to replace the traditional fee-for-service payment model with a “value-based” system is not likely to improve the quality or decrease the cost of healthcare.

The Centers for Medicare & Medicaid Services (CMS) specifically defines value-based healthcare as paying for services in a manner that directly links a provider’s performance on cost, quality and the patient's experience of care. It’s essentially a payment model that assumes that quality reports provided to CMS and private insurance carriers by healthcare providers are a good way to measure quality of care, and therefore a good foundation on which to base provider reimbursement. But there’s a problem with these quality reports.

There are more than 3,000 competing quality measures across all government and private healthcare agencies. CMS Administrator Seema Verma, MPH, has said “it’s not clear whether all of these measures are actually improving patient care.” 

Despite that uncertainty, she nevertheless said that “we need to move from fee-for-service to a system that pays for value and quality” even though “how we define value and quality today is a problem.”

To caregivers, trying to tie their reimbursement to parameters that cannot be clearly and universally defined seems counterintuitive. It’s quintessentially putting the cart before the horse.

 describes how a Coordinated Medical Record system can significantly improve the quality of healthcare by reducing the incidences of information-related problems. Decreasing the rates of misdiagnoses and inappropriate medications will decrease the incidences of duplicate tests, ER visits, hospitalizations and medical-legal issues. 

Collectively, these quality improvement measures have the potential to reduce healthcare costs by hundreds of billions of dollars — an effect that a “value-based” payment model cannot duplicate.

Despite the fact that no physician wants to make a wrong diagnosis or prescribe an incompatible medication, these problems are occurring every day at every care site across the country. It’s not because physicians are generating too few quality reports or because they’re being paid in a particular way. Payers could double their reimbursements to physicians or cut them in half and the problems would still exist because payment protocols are not the cause of or the solution to the healthcare industry’s problems.

The healthcare industry’s major problems are information-related and they need a proactive,

real-time information-based solution, not a retroactive financial solution. A Coordinated Medical Record system helps to resolve the industry’s information-related problems because it gives physicians the information they need to avoid these problems at the time of every healthcare encounter — the times and places where all of these problems are occurring.

Alternative Payment Models Aren’t Working

As of today, about 90,000 physicians who participated in CMS-sponsored advanced alternative payment programs in 2017 have still not received their bonus payments. The program’s participants typically had to make significant investments in IT systems and support staff in order to fulfill the program’s requirements, and some providers have indicated that they might actually have to make budget cuts if they don’t receive their payments soon.

To make things worse, CMS’s own analysis shows that these programs are not correcting any of the problems that it associates with the traditional fee-for-service payment model.

Because frontline physicians generate at least 80% of all healthcare activity, they are technically responsible for most of the industry’s information-related problems. By default, they are the only ones who can fix these problems.

In an environment where at least 50% of physicians are showing signs of burnout, primarily due to bureaucratic demands, long hours and EHR dysfunctionality, it seems unlikely that any initiatives that might decrease their reimbursement would be well received. Calling them “value-based” payments is not likely to convince or appease them.

A total of $35 billion was spent on an EHR incentive program that was well-intentioned, but not well-conceived. At some point there will need to be a policy shift in the healthcare industry based on the acknowledgement that fragmented EHRs are part of the industry’s quality and cost problem, not part of the solution.

Physicians, like most people, respond better to carrots than to sticks. Payer support for the development of a physician-friendly Coordinated Medical Record system that can actually solve many of the industry’s major problems is more likely to be well-received by physicians, than initiatives that threaten to decrease their reimbursement and offer no positive supportive measures in return.

The Credit Card System Is an Ideal Model for a Coordinated Medical Record System

Implementing a new record system could put more emphasis on quality of care.

Editor’s note: This article is the seventh in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative

A Coordinated Medical Record system is primarily designed to capture and organize outpatient data because 96% of healthcare encounters occur in the outpatient arena. There are about one billion outpatient visits every year compared to only about 36 million hospitalizations.

On a daily basis, there are about 2,750,000 patient-physician encounters in numerous outpatient settings across the country. By contrast, there are only about 98,000 daily admissions to hospitals. There are twenty-eight times more changes being made to patients’ ongoing medical records from outpatient encounters every day than are being made from hospital encounters.

Inpatient vs Outpatient IT and Data Management Requirements

Inpatient and outpatient healthcare settings have significantly different information technology and data management requirements.

The inpatient setting is a closed environment. All healthcare is delivered within the walls of the single institution. Massive amounts of data are captured in a short time span. Minute to hourly changes in a patient’s vital signs, temperature and medication regimen are recorded. Multiple laboratory, radiology, diagnostic and therapeutic procedure results are documented in a short time span. All of this data is technically available to all of a patient’s caregivers in the institution in real-time. It is only the discharge data that significantly alters a patient’s ongoing medical record.

By contrast, outpatient caresites are physically disconnected. They deal with a relatively small amount of data at the time of any particular patient encounter, but every change to that data significantly alters the patient’s ongoing medical record. Communication of data between caresites is delayed and inconsistent.

A Patient’s Clinical Profile: Diagnoses, Procedures and Medications

As complex as the healthcare industry seems to be, there actually is an underlying simplicity to it. The primary purpose of every patient-physician encounter is to arrive at a correct diagnosis and prescribe the correct treatment in the most expeditious manner possible.

From a medical record standpoint, the purpose of every encounter is to confirm, modify, add to, or delete the information in three specific categories — diagnoses, procedures, and medications. This is the information that populates the Face Sheet/Summary Sheet that sits in the front of every patient’s medical record. This is the baseline information that every caregiver is working from at the time of every healthcare encounter.

If this summary information is not exactly the same at every caresite, then there must be missing, incomplete or inaccurate information in the medical records at the various caresites that a patient visits. It is these disparities that lead to misdiagnoses, inappropriate medications, duplicate tests, unnecessary ER visits and hospitalizations, and medical-legal issues.

In outpatient settings across the country, the medical summaries of about 2.8 million people are being updated every day. Every time new diagnosis, procedure or medication information is entered into a patient’s record at any caresite, that information becomes the new reality for the patient, and it negates the accuracy and the reliability of the information that sits in the medical records at all of the previous caresites that the patient has visited.

By contrast, an average of only 98,000 people are being discharged from the nation’s 6,200 hospitals every day — that’s an average of only 16 patients per hospital per day. Despite the massive amount of data that is collected in these hospital IT systems, it is only the discharge diagnoses, procedures and medications that actually update a patient’s summary sheet. Because the ratio of outpatient to inpatient encounters is 96% to 4%, a hospitalization summary bears no more weight than any other single caresite encounter from the standpoint of a patient’s ongoing medical care.

The Inpatient-Outpatient Communication Gap Is Bidirectional

The problem of getting hospital discharge data into the hands of a patient’s outpatient caregivers is well documented and bemoaned, but little attention is given to the problem on the intake side — how do you get comprehensive and reliable outpatient data into the hands of hospital-based physicians?

Every emergency room physician, hospitalist, anesthesiologist, radiologist and pathologist knows that there are many instances where having access to the information in a patient’s comprehensive outpatient record would significantly improve the quality of their hospital-based care.

Based on the 96:4 ratio of outpatient to inpatient encounters, it is much more likely that hospital-based physicians would need information from a patient’s outpatient record in order to provide the best care, than outpatient physicians would need information from a patient’s relatively rare hospitalization record.

A Coordinated Medical Record system serves as a single point-of-contact for updating every patient’s medical record, whether the updates come from the high volume outpatient or the low volume inpatient side. In this capacity, this type of system assures that all caregivers are always working from the same baseline of clinical information, thus avoiding the disparities that invariably exist among fragmented information systems, and the resulting clinical and financial problems that the disparities causes.

Incentive to Establish a Coordinated Medical Record System

Despite the best patient-focused intentions of its executives, a hospital’s financial picture benefits by default from the very problems that a Coordinated Medical Record system is designed to alleviate. Misdiagnoses and inappropriate medications invariably lead to additional tests, procedures, ER visits and hospitalizations — all to the financial benefit of the hospital and its affiliated diagnostic and therapeutic services centers.

The establishment of a Coordinated Medical Record system in any healthcare community across the country is more likely to be 

driven by the community’s physicians and employers

 rather than by the C-suite executives of the local hospital-based systems.

Navigate the digital transformation with confidence. 

Making the Case for a Coordinated Medical Record System

The seventh in a series on a hypothetical CMR system to fix American healthcare. 

Editor’s note: This article is the sixth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

If the healthcare industry is truly interested in being patient-focused, then its information system should reflect that fact. A Coordinated Medical Record system is by definition the ultimate patient-focused system.

If one was going to develop a patient-centered information system from scratch and had to decide whether all of a patient’s clinical and financial information should be in a single record or scattered among hundreds of different records, Occam’s Razor would definitely point to the single record — the simplest explanation is usually the correct one.

If a single record is indeed the ideal patient-focused record, and it is also the type of record that will do the most 

to increase the quality and decrease the cost of healthcare simultaneously

, then it seems reasonable to vigorously pursue the deployment of this type of record system both for the benefit of the patient and the industry as a whole.

Every current electronic medical record system contains its own unique view of a patient’s clinical picture. Even caresites that use the same medical record system can have significantly different information about the same patient. Some of the major EMR systems that contain numerous modules don’t even install their modules uniformly at every caresite.

Every time information is entered into a patient’s medical record at any caresite, that information becomes the new reality for the patient, and it negates the accuracy and the reliability of the information that sits in the medical records at all of the previous caresites that the patient has visited.

In the web of hundreds of unconnected electronic medical record systems, health information exchanges, new and old code sets, new and old standards, and technical middleware, where is the truth about any given patient. Where is the single medical record that everyone can rely on for its comprehensiveness, accuracy, and availability? Where’s Waldo — where is the accurate and reliable picture of the patient?

Every Healthcare Information System Is Flawed

From the standpoint of the patient, every current healthcare information system is flawed. As a patient moves through space and time, every system will eventually contain incomplete, inaccurate, or conflicting information about that patient. And, these are the very problems that lead to misdiagnoses, inappropriate medications, duplicate tests, frequent emergency department visits and hospitalizations, nursing home care, and even death.

Documentation of Information-Related Problems Is Both Sketchy and Scary

Because there is no central database of longitudinally reliable patient records anywhere in the healthcare industry, no one really knows the full extent of information-related morbidity and mortality.

However, the medical literature does suggest that 10-20% of all medical cases are misdiagnosed, and that most people will experience at least one diagnostic error in their lifetime. If this information is correct, it means that between 275,000 and 550,000 people could be misdiagnosed every day in this country.  

 estimates that inappropriate medication problems in this country result in about 160 million repeat physician office visits, 24 million emergency department visits, 12 million hospital admissions, 4 million long term care stays, and 276,000 deaths each year.

If these numbers are anywhere near correct, it means that every day in this country 440,000 people are returning to physician offices specifically for treatment of an inappropriate medication problem. 66,000 people are going to emergency rooms, 33,000 are being hospitalized, 11,000 are entering long term care, and 800 are dying -- all for the same underlying reason.

All of the people that are suffering these information-related problems have faces — they are us.  Hardly anyone gets all of their lifetime healthcare at one institution. As we all move through healthcare’s space and time, we invariably interact with information systems that have incomplete, inaccurate, or conflicting information about us. We experience these problems as different degrees of inconvenience, discomfort, disruption and tragedy in our lives.

If fragmentation of information is the underlying cause of most information-related problems, then coordination of information must be the solution. For every patient, there is only one clinical picture that is both currently and historically accurate, and 21st century technology is capable of generating that Coordinated Medical Record picture.

Unless every caregiver is given the opportunity to work from the same comprehensive and reliable medical record for every patient, it is likely that all information-related problems with their attendant morbidity and mortality will continue unabated.

We are Both the Victims and the Problem Solvers

We are all in the same boat. We are all potential victims of information-related problems. But, 

 are with us in this boat. An amazing number of people know from personal experience how inaccurate or unavailable information has caused a significant problem for them or a family member. Among these people are the activist physicians, business executives and government decision makers who can be the drivers and the instigators of making a Coordinated Medical Record system a reality.

Part six in an ongoing series on the concept of a Coordinated Record System by James McGauley, M.D.

A Coordinated Medical Record System Is the Ultimate Patient-Focused System

Editor’s note: This article is the fifth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative

A Coordinated Medical Record (CMR) system is based on the concept of organizing information in a complex virtual network. In our configuration of a CMR, Service Centers are regional hubs that provide the administrative services that support the system’s network architecture. The software, policies and procedures of these Centers are fully integrated with those of the system’s 

Point-of-Service and Data Center components.

Each regional Service Center is staffed by 6-8 data entry and data management personnel. Their basic functions are to generate and maintain a number of network-centric administrative databases.

When a contract is made with a group of physicians to establish a Coordinated Medical Record system in their healthcare community, a Service Center is established. The initial task of the staff is to generate individual but interconnected databases that collectively paint an administrative picture of the entire community. It is a picture of the people, places and tools that define the network structure of the community.

The profiles of the contracting physicians contain demographic information, specialty designation, group affiliations, practice locations, hospital affiliations, accepted insurance, patients affiliated with their practice, short lists of diagnoses, procedures and medications, customized templates, and standard and customized quality report requirements.

Profiles of the patients of the contracting physicians include demographic and insurance information, and a list of the healthcare providers that are authorized to access the patient's clinical record.

The community profile includes information about all physicians, hospitals, emergency departments, labs, pharmacies, diagnostic and therapeutic treatment centers, nursing homes, home healthcare agencies and ambulance services in the contracting physicians’ geographic service area. All of these entities are included in the community profile whether they are currently being connected to the system’s network or not. Active or inactive status is simply indicated with a toggle switch. Generating this baseline information at the outset makes it easy to activate care providers and caresites as the system expands locally and regionally.

All caregivers and support staff that have any access to the system are profiled and assigned security level access designations.

Databases are created for all of the insurance carriers and employers in the area, and for all of the clinical code sets that are used in the community, such as CPT, ICD, HCPCS and NDC.

All of the data elements in all of these databases are maintained 

. If an original file, such as a CPT file, is in a comma-delimited format, it is converted to an object-oriented format. This means that every piece of data in the care provider, caresite, personnel, and code set databases can easily be modified, edited or distributed individually.

Transition from Data Entry to Data Management Functions 

After all of the initial databases have been generated, the primary function of the Service Center staff turns to maintaining those databases. This is essentially a modify-add-delete function. Because most of the system’s database update functions have been automated, the staff usually needs to manually deal with a relatively small number of modifications at any given time.

For example, every year the Centers for Disease Control and Prevention (CDC) make minor changes to the ICD-10 code database. This year, there were 473 changes, including 279 new, 143 revised, and 51 deactivated codes.

Whenever Service Center personnel receive the details of these changes, they reconfigure each individual code from its comma-delimited format to 

 This means that each individual code has a tag attached to it that includes information that tells the destination databases whether this particular code change is a modification, an addition or a deletion.

These changes are then broadcast through 

 to every caresite in the system, thereby automatically updating every point-of-service database within 24 hours of the Service Center receiving the notice of changes. Employing this type of technology, would have made the process of transitioning from 13,000 ICD-9 codes to 68,000 ICD-10 codes a few years ago much more efficient and less stressful than it was for healthcare providers

As the primary function of a Service Center gradually changes from data entry to data management, staffing requirements do not need to significantly increase because the original personnel have the skill sets to handle both functions.

For example, in our pilot project, one Service Center staff member was tasked with generating a database of all of the insurance carriers in the area, and then reverse engineering their code sets to make their internal processing functions transparent. As the carriers made changes to their benefit packages over time, it took only a small amount of that same staff members work-time to make the necessary modify-add-delete revisions to the database and broadcast the updates to all of the system’s affected caresites.

The highly leveraged internal staffing efficiency of a Service Center is magnified by its once-for-all effect on the entire healthcare community. The insurance information that the Service Center personnel capture and organize is the same information that the billing personnel at every caresite in the entire healthcare community are redundantly attempting to capture and utilize every day in their attempts to avoid claims rejections.

Billing and Insurance Related Implications

One particular piece of information that the Service Center staff watches for very carefully is a new rejection of a previously accepted claim by any insurance carrier. The staff immediately passes that type of information along to all of the providers and caresites in the community that could potentially receive that same rejection, allowing them to proactively take corrective action. This process can eventually lead to 100% clean claims processing in the entire healthcare community.

Currently, billing and insurance related expenses for all of the healthcare providers in the country are reported to be a staggering $282 billion, with the costs for the insurance carriers being an additional $214 billion. By serving as a single-point-of-contact for gathering and organizing the common and critical information that is needed for claims processing at every caresite, and then serving as the once-for-all dispenser of that information, these Service Center functions can significantly decrease billing related expenses across the entire healthcare industry.

Unique Comprehensive Statistics and Reports

With secure access to the records in the Coordinated Medical Record system’s central database, Service Center personnel are able to generate near real-time, comprehensive, clinical and financial statistics and reports that are unique in the healthcare industry.

Because the system’s data elements are in an object-oriented format and the information in every patient record is reconciled within a 24 hour period, the report generators can see all of the diagnoses, procedures, prescriptions and referrals that were made in the entire healthcare community on that very day.  They can selectively mix and match the details from any of the day’s healthcare encounters to generate standard and customized statistics and reports.

Quality-of-Care Reports vs. Actual Quality-of-Care Improvement

Currently, physician practices spend about $15 billion and 785 physician work-hours annually to report quality measures. Service Center personnel can produce any of these reports in minimal time and at minimal cost. It is reported that there are over 3,000 competing quality measures across all government and private initiatives. This is an industry problem because having so many competing measures just doesn’t make any sense, but it is not a technical problem that a Coordinated Medical Record system has any trouble dealing with.

The healthcare industry’s obsession with reports being the benchmark by which quality of care is measured is definitely a misdirection.  Although a Coordinated Medical Record system can easily generate any report that is needed, that is not where the system’s quality improvement value comes from. It is the ability of the system to put a comprehensive longitudinal patient record in the hands of every healthcare provider at the time of every encounter,

It is this type of record that proactively helps decrease the incidences of misdiagnoses, inappropriate medications, duplicate tests, unnecessary emergency department visits and hospitalizations. And, it is the central database of all Coordinated Records that can spot an epidemic in its infancy, help identify ground zero, and track its spread in real time. 

All kinds of reports can document these benefits sometime later, but the good will have already been done.

The Multibillion Dollar Consequences of Fragmented Healthcare Information Systems

Fifth in an ongoing series proposing CMR model based on credit-card industry.

Editor’s note: This article is the fourth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

In a previous article, I described how a Coordinated Medical Record system could significantly reduce the pain, suffering and multibillion-dollar costs of the healthcare industry’s information-related problems — misdiagnoses, inappropriate medications, duplicate tests, billing issues, quality reporting requirements, medical-legal issues and fraud. 

 is the underlying cause of all of these problems and coordination of information is the solution.

Establishing a Coordinated Medical Record system is obviously a major undertaking. It is essentially a complete reshaping of the healthcare industry’s information infrastructure. The necessary technology is available, but tech does not solve problems, people do. So, the question is, who wants this type of information system and who can make it happen?

Patients and Physicians Want Coordinated Medical Records

 In the several years that I have been working on and talking about a Coordinated Medical Record system, I have never come across a single person who has openly stated that the concept of a Coordinated Medical Record, as I describe it, is a bad idea.

Some people ask about data access and privacy safeguards, but most people immediately home in on the system’s ability to eliminate the need to rely on memory, repetition and guesswork at the time of every healthcare encounter. Frequently, people launch right into their own personal stories about how missing, conflicting or inaccurate information has caused some clinical or financial problem for them or a family member.

I have never met a physician who would not like to have access to Coordinated Medical Records. Frontline internists and family physicians, specialists, emergency department docs, hospitalists, radiologists, anesthesiologists and even pathologists know how access to comprehensive and reliable patient records would improve their lives and the lives of their patients.

No physician wants to miss a diagnosis, prescribe a wrong medication or duplicate a test without a reasonable cause. But there is no way to avoid these problems without real-time access to the specific information that is needed to proactively prevent these problems.

The problems caused by fragmented medical records were understandable when everything was on paper, but they should not continue to exist for patients and physicians in the digital age.

Physicians and Employers Can Drive the Establishment of Coordinated Medical Record Systems

Because physicians generate at least 80% of all healthcare activity, they are technically responsible for most of the industry’s information-related problems. By default, they are the only ones who can fix these problems. Physicians are the ones who have to use a Coordinated Medical Record system in order for anyone to appreciate its benefits.

 Employers are the ultimate sources of most healthcare dollars. They sit alone at the top of the healthcare industry’s financial food chain. Using their collective financial power and influence, employers have the ability to impel major changes in the healthcare industry, including a reshaping of its information infrastructure.

Employers have the collective power to influence the way insurance premiums and healthcare tax dollars are spent. A reallocation of a portion of that money could fully fund a Coordinated Medical Record system, which would both improve the quality of healthcare and produce documentable multibillion-dollar savings — a pretty good return on investment.

The $35 billion that were spent on incentivizing the purchase of more than 2,000 fragmented electronic medical record (EMR) products came from our tax dollars, and they have not produced significant quality or cost benefits. Collectively, employers are the only ones who can prevent these types of problems from recurring.

During our pilot projects, we put some local employers who were concerned about healthcare costs in the same room with our pilot physicians. The two groups bonded rather quickly around their common goals: their concern for the health and well-being of their shared patients/employees and their desire that healthcare costs be transparent, equitable and justifiable.

The healthcare industry’s information-related problems were discussed as if they were a fairly straightforward business school case study. A successful business just doesn’t spend 30% of its operating budget on hundreds of different internal information systems and services that don’t talk to each other, and thereby directly cause billions of dollars’ worth of company losses.

It didn’t take much discussion for the employers to realize that physicians, using a Coordinated Medical Record system, could improve care quality and decrease costs in ways that were unattainable for insurance companies, hospital systems and companies that simply negotiate discounted physician fees.

Physicians and employers have compatible goals and complementary strengths. Each one has the capacity to exert their particular influence at different pressure points in the healthcare industry.

We formed these employer-physician coalitions in three geographically separate healthcare communities. The interactions were nearly identical in all three. They all demonstrated a broad appeal for the concept of a Coordinated Medical Record system, and they all highlighted the potential for direct employer-physician alliances to effect major changes in the healthcare industry and possibly even completely change the power dynamics.

Although we formed these coalitions in individual healthcare communities with local physicians and local employers, the model and the format are easily reproducible on a national scale.

There are dozens of physician organizations — like the Medical Group Management Association, the American College of Physicians and the American Academy of Family Physicians &mdash; who could be sitting down at a table with their counterparts from the dozens of employer organizations that are focused on healthcare issues &mdash; like Haven, the Amazon-Berkshire Hathaway-JPMorgan Chase project, the Leapfrog Group, the National Business Group on Health, the National Transformation Alliance and the National Federation of Independent Businesses &mdash; to discuss the concept of a Coordinated Medical Record system.

Based on my experiences, it is very likely that a meeting that included a representative from each of these groups would at least be interesting and possibly even productive.

Coordinated Medical Record system technology is available. If such a system is ever to become a reality in either individual regional healthcare communities or on a national scale, the driving forces are likely to be employer-physician coalitions. In a subsequent article, I’ll describe what our pilot projects taught us about the logistics of deploying a Coordinated Medical Record system.

Billions of dollars are at stake. It’s time for leading physician organizations and forward-thinking employer groups to collaborate.

Employer-Physician Coalitions Can Fix the Healthcare Industry's Information Related Problems

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

Fragmentation of information is the major underlying cause of most of the healthcare industry’s information-related problems. These problems include misdiagnoses, inappropriate medications, duplicate tests, medical-legal issues and fraud. The range of clinical issues that these problems cause runs the gamut from diarrhea and skin rashes to hospitalizations, long-term care and even death. The financial cost runs into the hundreds of billions of dollars.

Each of these problems cause enough trouble on their own, but the damage increases exponentially when they interconnect and feed off each other. A missed or delayed diagnosis can easily lead to inappropriate medication issues, duplicate tests and lawsuits.

However, the story isn’t all gloom and doom. All of these problems are potentially preventable. Because fragmentation of information is the identifiable underlying cause of all of these problems, then coordination of information must be the common solution.

, I led a team that developed and beta tested a Coordinated Medical Record system that literally produces a single comprehensive medical record for every patient. Each record contains all of the patient’s clinical and financial healthcare information over space and time. The records are continuously available, in whole or in part, according to privacy and need-to-know protocols for all of the clinical, financial and administrative purposes required of any medical record.

Because this type of information system enables all caregivers to work from the same comprehensive medical record for every patient encounter, it eliminates the problems of missing, conflicting, inaccurate or unavailable information — problems that are inherent in all fragmented electronic medical record (EMR) systems.

The consensus in the medical literature is that the prevalence of missed, inaccurate or delayed diagnoses is 10 to 20% of all patient encounters. Some studies indicate that most Americans will experience a diagnostic error at least once in their lifetime. The most frequently cited cause of this problem is the unavailability of some critical information at the time of a patient encounter.

A lot of industry and political attention focuses on the $330 billion cost of prescription medications, but very little attention centers on the $530 billion spent on the problems that arise from inappropriate medication prescriptions and usage. These problems include additional medications, physician visits, emergency department visits, hospitalizations, long-term care and death.

There are thousands of different prescription and over-the-counter medications. There are more than a million healthcare workers who can prescribe, alter or dispense these medications. And there are hundreds of fragmented EMR systems that contain different medication profiles for any given patient. With all of these variables in play, the only way to even begin to solve the inappropriate medication problem is to assure that all caregivers are working from the same data set, the same medication profile for every patient.

The cost of duplicate healthcare services is estimated to be at least $200 billion a year, with a significant percentage attributed to the difficulty or inability to access the results of previous tests or procedures during a patient encounter. Recent studies have documented the fact that incidences of duplicate services have actually increased since the widespread deployment of fragmented electronic medical record systems.

Healthcare providers and payers spend about $500 billion a year on billing-related services, primarily because patient, provider and payer information is fragmented. During our pilot projects, we demonstrated how a small number of data management personnel working with a comprehensive and coordinated database of patient records can reverse-engineer the specific processing rules of every insurance carrier. This information, coupled with the system’s automated feedback loops and data distribution channels, can lead to 100% clean claims processing for all of the system’s participants. The system can also provide expected charges and payment information prior to making treatment decisions, thus avoiding surprise billing.

The cost of reporting quality measures has been put at about $15 billion and 785 work hours per physician. Because a Coordinated Medical Record system contains comprehensive clinical and financial healthcare information that is automatically updated, synchronized and organized within every 24-hour period, it can produce standard and customized clinical and financial statistics and reports in near real time and at minimal cost, in ways that fragmented EMR systems can never do.

Healthcare fraud is a $68 billion problem. Because all of the data elements in each patient’s record in a Coordinated Medical Record system are reconciled within a 24-hour window, this type of information system can use artificial intelligence, algorithms and alert notifications to both recognize and deal with fraudulent activity in near real time, in a manner that’s impossible to achieve with fragmented information systems.

The processing costs surrounding medical liability issues are around $10 billion annually. About 45% of all malpractice claims are related to misdiagnoses, and about 10% are related to inappropriate medication problems. An information system that can help reduce the frontline real-time incidences of these two problems will make a major contribution to reducing the incidences and costs of more than half of all malpractice claims.

Overcoming Healthcare Information Systems Fragmentation

Because fragmentation of information is the problem that underlies all of these issues, none of them can be solved unless every caregiver receives the opportunity to access and work from medical records that are comprehensive and reliable, meaning that they are complete, accurate and continuously available.

Technology is not the barrier to producing this type of medical information system. The technical tools that can generate a single comprehensive patient record, and then automatically update, organize and distribute the data in that record, are readily available. These tools are already being used in other industries to make them more efficient and cost-effective.

In an effort to rapidly digitize itself, it seems that the healthcare industry took the wrong fork in the road with its $35 billion EMR incentive program, and its current initiative to interconnect more than 2,000 fragmented EMR products with new industry standards or middleware is heading down a blind alley.

It’s still possible to head back to that fork in the road and take a path that would lead to the type of information system that would produce comprehensive and reliable medical records for all. The technology is available, and in a subsequent article I’ll explain why physician-employer coalitions could become the driving forces to make that type of information system a reality.

If you wish to contact James McGauley, please reach out to the 

Epic Parody Twitter Account Spotlights Deep Flaws in EHR

Podcast: Nuance, Tech & Fighting Physician Burnout

But a Coordinated Medical Record system could help solve critical financial and clinical problems.