Daniel Essin, MA, MD

To implement EHR nationwide, it could cost $168 billion - it boggles the mind, but where does it come from?

Certification is good for large, legacy companies. It anoints what they have already done thus minimizing the need to innovate in the future. It is in their interest to flex whatever political muscle they have to insure that certification is required.

In our democracy, the objective of law should be to ensure maximum freedom for the largest number. In one sense, laws and regulations restrict freedom but in a more basic sense, freedom is more damaged more seriously by the abuses which engendered the laws.

Provide the same amount of care with less money and there is less available for profit. Eliminating the profit could allow the same amount of care to be provided at less expense but you would be left with the dreaded "government-run healthcare system."

Even if the cloud was perfect from a technical perspective it raises some important questions and now is the time to think about them before many have taken the plunge. Is the cloud approach and everything that it implies good for the individual? Is it good for your practice?

Itinerant practitioners, of any sort, pose a challenge to the organizations that use them and present a challenge. They may work at several different facilities during a single week. Each facility has its own policies, procedures and data systems, all of which are notorious for being arcane and highly detailed.

The medical profession exists precisely because of ambiguity and uncertainty. If patients knew intuitively and precisely what was wrong with them or if there was a one-to-one correspondence between signs, symptoms, and specific diagnoses, the practice of medicine would be a trade, not an art.

When "slow adoption" is questioned, what is being asked is why ordinary doctors haven’t done what the superstars have done.

The computer era changes the ground rules for what constitutes useful content in a note. The goal is to get information committed to computer storage in a way that will be useful to both the computer and the practitioner.

Do you need to speed up the process of finding an EHR solution that is good enough? Eberhardt Rechtin, in a wonderful little book called "Systems Architecting: Creating and Building Complex Systems," lists a number of heuristics that I find useful.

Practices need to develop an informed consent policy relating to data practices that tells patients its intentions regarding unencrypted e-mails, faxes, and social media sites.

Medical care is delivered in four distinct settings. They differ in many ways: who is in charge, what the immediate goal is, what information must be accessed or created, and what types of action are taken.

When it comes to EHRs, vendors are quite happy to offer products that are inefficient, awkward, and uncomfortable to use and to do so with aplomb. Customers, for their part, are apparently quite willing to ignore performance requirements, and perhaps never define them; something they rarely do when purchasing other items.

Everything was referred to as an order because it was written on an "order" sheet and because, in those days, doctors issued orders and nurses followed them. This is a new era. We all work as a team for the benefit of the patient.

Good longitudinal medical care requires a good medical record but most emergency situations don't. In an emergency, a computer won't save the person,

The current ballyhoo over EHR has interrupted what would have otherwise been a gradual evolution of EHR with the most effective, easiest to use products winning out over time. A fork in the road has developed and two possible futures for EHR are now before us.

Today, the expectation is that the patient's history, along with all that subtlety and detail will be recorded in the EHR. To the physician, details are additional information about the patient; the computer expects precise bits of data that will fit nicely into ready-made slots like antigens into receptors. Thus, the computer does not lend itself to recording subtlety as data.

Windows (in the generic sense) provide an organizing theme (a metaphor if you like) that takes multi-tasking out of the geek realm and makes it more understandable to the general public, thereby helping them to unlock the power of the computer.

Opportunities to standardize were missed; while technically straightforward they were not considered important or were perhaps operationally too expensive. Even today, as development begins on new systems, there are decisions to be made.

This week continues the discussion of how a computer’s basic design can influence how an EHR behaves.

How an EHR behaves is highly dependent on design and other technical properties of the underlying hardware and software. These basic properties are essentially unalterable and can have lasting, and often negative, effects on what a product can do today and whether physicians will find it easy to understand and pleasant to use.

One of the most important decisions that must be made when designing a new system is what elements will be implemented internally and which will remain external. Decisions of this type are common and familiar to everyone. Do you buy a Swiss Army knife or separate knife, fork, spoon, screwdriver, etc?

Each person has likes and dislikes, things they do well, things they do with difficulty, and things they are simply unable to do. So it is with technology.

The typical EHR looks and feels like a transaction processing application found in a bank. They are, after all, built out of the same raw material, by people who think that is how computer software should look and function. Unfortunately, when you put the end product in the hands of physicians, most of them find it awkward, illogical, constraining, and generally unpleasant to use.

Whether we like it or not, healthcare is a business. In the past, practice was sufficiently remunerative and it was possible to be a bit sloppy with the business end of things. These days money is tight and, at the same time, practices are under pressure to spend on technology.

The technology that is readily available today is simply too rudimentary and ... today's practitioners lack the training and experience to make full use of it. If the inventive powers of developers and medical informaticians are not stifled by federal incentives that favor the persistence of obsolete technology, it will take another 10 to 20 years for the next generation of systems to emerge and mature.

What was it that induced healthcare institutions to accept and implement products that actually impair efficiency? This is, or should be, a recurring question. It has many facets, but an important one is whether government regulation can result in "meaningful use" of EHR.

Governments, that is to say people with a taste for politics and power, love to make regulations - but what kind? Regulate the means or regulate the ends?

Interoperability is a lot like the elephant. The government and various groups have each seized a different part of the elephant but have not yet reached the king's level of understanding. Rather than rehash the arguments, let's simply consider what it might mean to a practicing physician.

Judgment is essential for good patient care. There are many diagnostic and treatment options. Some are better than others, but who knows for sure? Many medical conditions are as yet understood poorly or not at all.