Two articles I’ve written in the last 24 hours have gotten me thinking that we’ve already entered the post-implementation era of EMRs, even as implementation remains in progress at so many healthcare organizations. While the vast majority of hospitals and physician practices in the U.S. still don’t have full-featured EMRs in place, many are already looking well into the future.

As you may already know, HIMSS on Tuesday released its first-ever survey on “clinical transformation.” According to HIMSS and survey sponsor McKesson, “Clinical transformation involves assessing and continually improving the way patient care is delivered at all levels in a care delivery organization. It occurs when an organization rejects existing practice patterns that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes and quality care through process redesign and IT implementation. By effectively blending people, processes and technology, clinical transformation occurs across facilities, departments and clinical fields of expertise”

As I reported for InformationWeek, 86 percent of organizations surveyed had a plan for clinical transformation in place or at least under development, and just 12 percent of respondents called organizational commitment a barrier to reporting on quality measures. And though nearly 8o percent indicated that they still gather quality data by hand and 60 said they don’t capture data in discrete format, more than half already had software specifically for business intelligence. This tells me that analytics is here to stay.

I kind of knew that anyway, since the bulk of the program at last week’s Wisconsin Technology Network Digital Healthcare Conference was devoted to BI, data governance and advanced analytics tools, even in the context of Accountable Care Organizations. (My story about this for WTN News appeared this morning.)

“I’m ready to declare the era of business intelligence,” said Galen Metz, CIO and IS director for Madison-based Group Health Cooperative of South Central Wisconsin. Though he criticized the proposed ACO rules for being too “daunting” for the average provider, Galen and other speakers said that it’s time to harness all the new, granular data being generated by EMRs and, soon, ICD-10 coding.

It may seem “daunting” now in the midst of all the preparations for ICD-10 and meaningful use, but it’s good to know that many healthcare organizations see a light at the end of the tunnel and know that the future bring better healthcare information in exchange for all the hard work and investment today.

I was witness to an interesting discussion earlier this week at the Wisconsin Technology Network’s Digital Healthcare Conference in Madison, Wis.: Is meaningful use a floor or a ceiling?

One panelist, Judy Murphy, VP of information services at Aurora Health Care in Milwaukee, said Stage 1 meaningful use has caused the health system to alter its own IT plans by activating a patient portal and moving more toward interoperability sooner than intended. “We wouldn’t have decided to give electronic copies of clinical summaries at discharge [without meaningful use],” Murphy said.

But Murphy believes it’s a floor for many of the criteria, such as the requirement that 30 percent of patients have at least one medication order entered electronically. “No one would go into an implementation shooting so low,” she said. As a member of the Health IT Policy Committee as well as the Meaningful Use Workgroup of the Health IT Policy Committee, Murphy actually had a hand in shaping the standards. (Remember, though, the original proposal called for 10 percent for hospitals and 80 percent for physicians. The final Stage 1 rule set the threshold at 30 percent for both.)

Gartner analyst Vi Shaffer offered a counterpoint. “Meaningful use is not the floor,” she said. “All the existing quality measures that have been out there so long should be considered the floor.” Shaffer expressed frustration that so many 12-year-old National Quality Forum performance measures still haven’t been met.

According to Shaffer, the idea behind meaningful use is to “lift people up,” particularly when it comes to safety-net providers like critical-access hospitals. Shaffer said policymakers didn’t want to see “oligopolies” in local markets because smaller providers were forced to merge with large health systems because of EHR requirements.

Session moderator Dr. Barry Chaiken, chief medical officer at Docs Network Imprivata, and a former HIMSS chair, said he believes health IT will raise the norm for all providers and “lock in” better behaviors, suggesting that in some ways, meaningful use could be a floor.

By holding the conference in Madison, WTN was able to land the publicity-shy Judy Faulkner, CEO of Epic Systems in nearby Verona, Wis. Faulker noted that Epic shows a simpler version of its core EHR in overseas markets because the company had to add some functions for regulation and liability purposes in the U.S.

While plenty of providers are viewing meaningful use as a ceiling right now–perhaps an unattainable one–Murphy believes acceptance will come rapidly. “I think in 2015, we’re gonna look and say, ‘How did we even have healthcare without computers?’” Murphy said. She then said she had heard that HCA would attest this year to meaningful use at all of its U.S. hospitals.

Being the occasionally motivated reporter that I am, I tweeted this statement, asking for verification. Wouldn’t you know, HCA replied with this tweet: “Nearly all HCA facilities should achieve requirements 4 Stage I this yr. An exciting, important step for high-performance hcare!”

So maybe meaningful use is not a floor or ceiling, but the new norm.

What are your thoughts?

CORRECTION, June 13: Chaiken’s one-year contract with Imprivata is over, so he’s no longer affiliated with that company.

I’m beginning to see a pattern here. Two weeks ago, I wrote about clinical decision support in context of Dr. Larry Weed’s new book. Two weeks before that, I commented about physicians worrying that patients would perceive them as being incompetent if they relied on CDS. Today, I’m back to the same topic.

Deny the obvious all you want, physicians, but clinical decision support is coming, and once it’s here, it’s not going away.

I just got back back from the new IBM Healthcare Innovation Lab in downtown Chicago, the company’s third such center in the U.S. and eighth worldwide. While kickoff included a “healthcare leadership exchange” with such thought leaders as HIMSS CEO Steve Lieber and Allscripts Healthcare Solutions Chief Innovation Officer Stanley Crane, the real star was not a person, but a computer. IBM’s Watson, to be specific.

People stayed after lunch mostly to see a demo of Watson processing healthcare data—and IBM Chief Medical Scientist Dr. Marty Kohn said this was the first audience to see this demo. Make no mistake, IBM is positioning Watson as a clinical decision support tool, particularly for the much-ignored area of diagnostic decision support.

Saying that perhaps 25 percent of all healthcare errors are errors of diagnosis, Kohn noted how getting the diagnosis right can prevent all kinds of unnecessary complications and spending. “Of course, if you’ve made the wrong diagnosis, picking the right course of treatment becomes a challenge,” Kohn said.

And after the diagnosis, Watson can prevent treatment errors by, say, scanning EMR data for patient allergies to recommend against a drug that might cause a harmful interaction, then suggest alternative therapies. Kohn presented the case of a 29-year-old pregnant woman who was diagnosed with Lyme disease. A common treatment is the antibiotic doxycyline, but Kohn noted that it’s contraindicated during pregnancy.

Watson, according to Kohn, draws preliminary conclusions according to presenting symptoms, then scans multiple sources of information to present recommendations. Watson does look at the notoriously incomplete and inaccurate Wikipedia, Kohn said, mostly because that user-edited site covers so many topics, but then verifies information from other sources.

Watson then displays reasons why it believes the diagnosis may be correct so the doctor can make an informed decision. “It won’t let you ignore all the possible diagnoses,” Kohn said. But it won’t actually make the final call. “Watson is going to be in a supportive role rather than actually making decisions.” Kohn added.

What the supercomputer does is process vast amounts of data in a short amount of time., something that even the sharpest human mind could never do. And that’s what clinical decision support is supposed to be all about.

A blog post today by Microsoft’s Dr. Bill Crounse got me thinking again about the cloud.

Crounse cited a new CDW poll showing that 30 percent of healthcare organizations could be considered “cloud adopters,” and for good reason. “The flexibility, scalability and lower costs associated with moving certain line of business applications to the cloud are compelling, especially for an industry like healthcare. After all, the primary focus of hospitals and clinics is caring for patients, not running an IT empire. There’s not a CIO, CFO, CEO, COO, CNO, CMIO, or CMO who wouldn’t love to shift some of their IT spending to delivering better care to the communities they serve,” Crounse wrote.

They were more likely to turn to the cloud for “commodity” services such as e-mail, file storage, videoconferencing and online learning. “Moving your ‘commodity’ applications to the cloud is an excellent place to start,” Crounse said. “I’d suggest first reaching out to your health industry peers and professional organizations to get a better sense of who’s doing what. I think when you’ve learned about some of the best health industry practices in cloud computing, you’ll be ready to explore what might be possible in your own organization.

But the fact that 30 percent of healthcare organizations use the cloud means that 70 percent do not. I suspect a lot of hospitals and physician practices still run aging, legacy client-server management systems in-house, just because that’s how people did things when those systems were first installed. As they replace their legacy technology, expect more healthcare organizations to opt for cloud services for these commodity-type services.

And what about clinical services?

At HIMSS11 back in February, Athenahealth honcho Jonathan Bush, a longtime fan of the cloud, told me he wanted to lead the “Cloud Cavalry” into Las Vegas (there’s no better place for an over-the-top spectacle, of course) next winter for HIMSS12. (See the second video for that.) Athenahealth, which has a certified, cloud-based EHR, straddles the line between clinical and administrative, and it’s not alone. I can’t think of a single ambulatory EHR vendor that doesn’t offer at least a cloud option if not a full-fledged SaaS product.

But is the cloud truly reliable for critical applications such as inpatient EHRs? In the wake of April’s Amazon EC2 cloud outage, I can imagine more than a few CIOs, practice managers and, especially, physicians are a bit skittish now.

What do you think?

Sometimes it’s better to be lucky than good.

Last month, in my very first post for EMR and HIPAA, I mentioned Dr. Larry Weed in my commentary about the general public’s perception of clinical decision support. I referred to a 2007 study in the journal Medical Decision Making, which said, “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.” I then noted that Weed has been saying for more than 50 years that physicians shouldn’t have to rely on their memory to make clinical decisions when computers can help them process an increasingly voluminous knowledge base.

As it turns out, Weed read my commentary. (I’m guessing that a computer, i.e., Google Alerts, led him to the post. See, computers really can help find the information we’re looking for. Who knew?) And, as it also turns out, Weed and his son, Lincoln, a Washington, D.C.-area attorney who now consults on health privacy issues, just had their latest book, “Medicine in Denial,” published. They both contacted me last week to share this news.

“A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information,” reads the book’s opening paragraph.

Yep, that sounds like clinical decision support to me.

“Deep disorder pervades medical practice. Disguised in euphemisms like ‘clinical judgment’ and ‘evidence-based medicine,’ disorder exists because medical practice lacks a true system of care. The missing system has two core elements: standards of care for managing clinical information, and electronic information tools designed to implement those standards. Electronic information tools are now widely discussed, but the necessary standards of care are still widely ignored,” reads the book’s description.

The Weeds believe current EHR systems don’t measure up, and they said so in comments submitted in response to the December 2010 President’s Council of Advisors on Science and Technology (PCAST) report on health IT, which recommended against standardizing EHR formats. “Sound standards for the structure of medical records provide essential standards of care for managing clinical information.  Medical practice needs these standards no less than the domain of commerce needs accounting standards for managing financial information.  Failure of recognize this principle is a root cause of health care’s failures of quality and economy,”  the Weeds said in their comments.

It’s a principle that Larry Weed, 88, has been advocating since he developed the problem-oriented medical record in the 1950s. In 1991, the Institute of Medicine report, “The Computer-Based Patient Record:  An Essential Technology for Health Care,” (revised 1997) said that the problem-oriented medical record “reflects an orderly process of problem solving, a heuristic that aids in identifying, managing and resolving patients’ problems.”

And 20 years later, medicine hasn’t changed much. Perhaps, though, it takes longer than that. Lincoln Weed also referenced a story I wrote for InformationWeek on May 10. I noted that the Consumer Partnership for eHealth’s Consumer Platform for Health IT referred to consumers as “”the most significant untapped resource” in healthcare.

Well, wouldn’t you know, Larry Weed has written the following: “patients are the largest untapped resource in medical care today.” That was from his book, “Medical Records, Medical Education, and Patient Care”. That book was published in 1969.

Instead of ending this post on a down note, let me just add that I would have had an interview with Dr. Weed this week, but he just left the country for a speaking engagement. He’s 88 and still traversing the globe, fighting for what he believes in. Don’t we all wish we had that kind of passion?

Healthcare and health IT are plagued by conundrums. Providers long have been the ones asked to make hefty investments in EMRs and other IT systems to help remove costs from the healthcare system, but payers and plan sponsors tend to enjoy most of the financial benefits. Clinicians wish their organizations would share data with others, but those in the executive suite have been reluctant to cooperate with competitors for fear of losing revenue. And, let’s face it, medical errors can be profitable if a routine procedure turns into an expensive inpatient admission.

Portions of the American Recovery and Reinvestment Act and the Patient Protection and Affordable Care Act are intended to address these problems by providing financial incentives for “meaningful use” of EMRs (including health information exchange) and by encouraging the creation of Accountable Care Organizations

I’m just back from the Institute for Health Technology Transformation health IT summit in Fort Lauderdale, Fla., where I moderated panels on how health IT underpins ACOs and how business intelligence can create a framework for health information exchange.

The panelists did great job of articulating some of these conundrums and strategies to overcome them, but none better than Kevin Maher, director of clinical innovations for Horizon Healthcare Innovations, a new affiliate of Horizon Blue Cross Blue Shield of New Jersey tasked with testing new care models, and Victor Freeman, M.D., quality director in the Health Resources and Services Administration‘s Office of Health IT and Quality.

The patient-centered medical home is a great idea for managing care, promoting prevention and, ultimately reducing costs. “We view the base of the ACO as the patient-centered medical home,” Maher said. But what exactly does an ACO look like? “An ACO is like a unicorn,” Maher said. “We can all describe it, but we’ve never seen one.”

He noted that Horizon has started paying some physicians a care coordination fee to manage populations that potentially could add $60,000 or more to a doctor’s annual income. But there are plenty of factors outside a physicians’ control.

“Potentially the No. 1 focal point of a patient-centered medical home or an ACO is patient behavior,” Maher said. A doctor can’t force a patient to exercise more, quit smoking or get a mammogram or PSA test. There’s pay-for-performance for doctors, but what about paying for patient performance?

In January 2012, Horizon will launch a pilot to offer incentives to members who get recommended tests and choose providers that meet the health plan’s quality standards. That’s right, the Blues plan in New Jersey will pay people to go to the doctor and to make informed choices about which doctors they see. (“Everyone says she’s a great doctor” won’t cut it as an informed choice anymore.)

Freeman called the Horizon experiment “P4P that makes sense.”

Let’s just hope the technology can support making the right choices. “People in government get more involved in quality measurement, not necessarily quality,” Freeman said. Incentive programs these days still tend to be more pay-for-reporting than pay-for-quality, and the technology hasn’t fully matured in that area.

“EMRs were designed for billing, not quality reporting,” noted Freeman, who has a background in public and population health. Information often isn’t stored in discrete form, such as with images generated by specialists flagged as being abnormal, so even with HIE, it’s hard for primary care physicians to identify patients who might be candidates for early interventions before they actually exhibit symptoms of a disease.

“My biggest interest in HIE is how clinicians communicate with each other,” Freeman said.

But is the technology ready to help them do so? “HIE now reminds me of what EMRs were five years ago,” said another panelist, Bruce Metz, Ph.D., newly hired senior VP and CIO at the Lahey Clinic in Massachusetts. It’s viewed as an IT project that’s not necessarily linked to a business or clinical strategy. “You can’t force the technology to mature that fast,” he added.

And so the ride continues on what Metz called “a fast-moving train.” Have we even had time to see if the right people are on board?

One of my favorite conference speakers, Lexington, S.C., family physician Allen Wenner, M.D., who created Primetime Software’s Instant Medical History software, often jokes that many of his contemporaries “need to die” before we see much change in the way physicians practice medicine. I’m increasingly convinced that he’s right.

It’s, of course, older doctors, that seem to be the most resistant to change. They also happen to be the ones most likely to hold leadership positions, if for no other reason than their seniority.

That’s why I’m so troubled by the attitude of physicians such as Arvind Goyal, M.D., a family physician in Rolling Meadows, Ill., who’s on the faculty of Chicago Medical School/Rosalind Franklin University in North Chicago, Ill., and is a past president of the Illinois State Medical Society. Last week, the Chicago Tribune published a lengthy, scathing letter from Goyal, in which he thoroughly trashed electronic medical records based on a negative experience he had with “a popular brand of EMR” at a Federally Qualified Community Health Center.

Goyal brought up some salient points about what can go wrong with a poorly implemented EMR. “The system was slow generally, froze up a few times a day and crashed every few months, requiring us to reschedule patients. Pricey service calls, multiple system updates, periodic shutdowns, user training and hiring of a full-time IT expert at a significant cost helped some, but the dissatisfaction persisted,” he wrote.

He ticked off the standard laundry list of why physicians struggle with EMRs, including the argument that “documentation and accessibility of information in EMR is more time-consuming than paper records.” Forgive me if I’m wrong, but that sounds like a workflow problem more than a technology problem.

“Federal incentives for adoption of EMRs come with complicated bureaucratic requirements,” he added. Perhaps, but will you still be making that argument when Medicare and then private payers start requiring EMR usage as a condition of reimbursement?

“Data backup is a prudent need and often requires an additional investment.” Well, duh, but isn’t that true of your home computer as well? Your practice management systems?

But Goyal really stepped over the line when he repeated one of the greatest fallacies in medicine, that doctors know all.

“In my successful suburban solo family practice of several years, I did not use electronic medical records. Knowledge of each patient I served was on the tip of my tongue when an emergency-room doctor seeing one of my patients called in the middle of a night. I was available 24/7 with few exceptions. The paper records were organized such that I was able to access clinical details quickly when needed,” Goyal wrote.

How can knowledge of each patient be on the tip of his tongue if he’s woken up in the middle of the night and his precious paper files aren’t right there next to his bed? Is his memory that good that he knows every pertinent detail of every patient, even when still in a haze from an unexpected wake-up call? Yeah, nice try.

Furthermore, it’s great that Goyal is available to other doctors around the clock in case of an emergency, but is he available to patients? Medicine is changing. It’s supposed to be about patients, not physicians. But some physicians still wrongly believe they know everything and will do just about anything to cling to the status quo.

In case you haven’t noticed, the status quo isn’t so good.

I live in Chicago, a highly competitive healthcare market with some world-class medical schools (Northwestern, University of Chicago, Loyola, Rush) and a pretty decent record of EMR adoption. At least four major institutions/health systems run similar Epic EMRs: University of Chicago Medical Center, Northwestern Memorial Hospital, Rush University Medical Center and, in the northern suburbs, NorthShore University HealthSystem (formerly Evanston-Northwestern Healthcare).

Three NorthShore hospitals–Evanston Hospital, Glenbrook Hospital and Highland Park Hospital–were among the first in the country to reach Stage 7 on the HIMSS Analytics EMR Adoption Model.(NorthShore’s Skokie Hospital since has reached Stage 7). Several others, notably Rush, Advocate Lutheran General Hospital in northwest suburban Park Ridge, Mercy Hospital & Medical Center and  Swedish Covenant Hospital, have gotten to Stage 6.

But there’s been very little effort to interconnect these institutions and affiliated physician practices. Even during the RHIO heyday of 2004-07, I don’t recall much interoperability talk in the Chicago area. (In fact, one family physician, Dr. Stasia Kahn, in far west suburban St. Charles, got so frustrated that she formed her own group to promote EMR adoption and health information exchange, Northern Illinois Physicians for Connectivity. I had heard talk for a while of some south suburban hospitals joining in an HIE with counterparts across the state line in Northwest Indiana since Illinois was moving too slowly.)

All of that non-action at the state and regional levels happened under the not-so-watchful eye of one Gov. Rod Blagojevich, who apparently was more preoccupied with his own vanity and “giving healthcare to kids” (while also allegedly trying to blackmail the CEO of Children’s Memorial Hospital into donating to his campaign fund and also slowing Medicaid payments to pay for his All Kids program) than in, you know, actually improving healthcare for everyone by promoting HIE.

In February 2009, shortly after Blagojevich was removed from office and a couple weeks before the federal American Recovery and Reinvestment Act became law, new Gov. Pat Quinn signed a law allocating $3 million to the state’s Department of Healthcare and Family Services for HIE planning. That laid the groundwork for this week’s widely publicized announcement that the not-for-profit Metropolitan Chicago Healthcare Council had chosen technology from Microsoft, Computer Sciences Corp. and HealthUnity to build what could be the largest big-city HIE in the country, potentially serving 9.4 million people in nine Illinois counties and small parts of Indiana and Wisconsin.

I bring all of this up because I met yesterday with executives from the Metropolitan Chicago Healthcare Council, a 76-year-old coalition of healthcare organizations in and around the city. It just so happened that the 2011 Microsoft Connected Health Conference was in town this week, so it was the perfect time and location for Microsoft to drop the news. According to MCHC Vice President Mary Ann Kelly, more than 70 percent of the council’s 150-some members have made a commitment to participate, and they seem to have a plan to make the HIE effort sustainable.

The exchange will operate on a subscription model, with the vendors taking on some of the risk, Kelly said. “The subscription fee will be based on the benefit each member derives,” Kelly explained.

Initially, the exchange will involve 22 hospitals in nine organizations, said Teresa Jacobsen, the council’s HIE director. “We want to get one or two use cases running first,” she said. They will start by linking emergency departments to exchange clinical summaries and for syndromic surveillance, according to Jacobsen. Once that’s going, the HIE plans on adding medication and allergy lists, diagnostic testing results and Continuity of Care Document reports, as well as additional elements for public health, including immunization records.

It all sounds great, and it’s a good idea for them to start slowly, but I wonder when and if smaller physician practices will get involved. My own physician has had an EMR for a while, but not every doctor in the practice uses it. (The four-physician practice recently upgraded to the Meaningful Use Edition of Sage Intergy and has started the 90-day clock for qualifying for Stage 1 Medicare incentives this year, but there’s essentially zero interoperability with other healthcare entities, unless you consider faxing records to others straight from a computer interoperability. I sure don’t.)

My guess is that scenarios like this are playing out all over the country. I wish them luck, but I’m not counting on nationwide interoperability for many years. For one thing, the federally funded, state-chartered Illinois HIE Authority held its very first organizational meeting Wednesday afternoon. “That’s the biggest wild card we don’t know,” MCHC CFO Dan Yunker said.

It’s key to getting payers—particularly Illinois Medicaid—on board with HIE and linking metropolitan exchange networks across the state and beyond. “Our hospitals in Chicago are responsible for the snowbirds who are in Naples (Florida),” Yunker noted. They’re also responsible for patients who come from places like Rockford, Springfield, Champaign, Carbondale and the Quad Cities for certain specialized services only available in the big city.

Yeah, this interoperability thing isn’t so easy.

Yet again, someone needs to educate the general public about healthcare in general and health IT in particular.

HealthLeaders last week asked the question, “Does Decision Support Make Docs Look Dumb?” The story, apparently based on a 2007 study (not 2008, as HealthLeaders reported) in the journal Medical Decision Making, says: “Most clinicians would agree that evidence-based decision support tools have the potential to improve clinical quality. But patients’ perception of the tools—and the physicians who use them—might be yet another barrier to their adoption. The problem is twofold: Some patients are skeptical of docs who need a computer to help them make a diagnosis. And some physicians don’t want to be seen as being too reliant on technology.”

We’ve long known that physicians have resisted clinical decision support, for a variety of reasons. They trust their professional judgment. When they only have a few minutes with each patient, they believe it simply takes too long to look up information that might help reach a more accurate diagnosis or devise a better care plan. The technology simply isn’t up to snuff. Or there isn’t enough electronic data available on each patient for CDS to have a positive effect.

But to read the conclusion of that Medical Decision Making study is to see an entirely different excuse for shunning clinical decision support: “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.”

HealthLeaders interviews other clinicians and researchers who have found similar sentiments. “Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them,” Illinois State University information systems professor James Wolf tells the publication.

“Physicians are reluctant to adopt computer-based diagnostic decision aids, in part due to the fear of losing the respect of patients and colleagues,” Wolf adds.

If this is true, it represents failures on many levels. IT systems designers haven’t made their technology easy to use. Physicians and healthcare entities haven’t done a good job educating patients and journalists like myself have truly failed the public by continuing to feed them false expectations about healthcare.

First off, Wolf’s statement that patients feel like they wasted only a $25 copay perpetuates the myth that a physician office visit only costs $25. If patients think they may have wasted $25, how do you think insurance companies and employers must feel that another $150 of their money went out the window?

The part about losing respect is perhaps more troubling. Physicians need to put their fragile egos away and do whatever they need to do to provide better care. The status quo just isn’t cutting it.

I’ve had the distinct honor of interviewing Dr. Larry Weed on several occasions. Weed, the octogenarian inventor of the problem-oriented medical record and the SOAP note, has been calling for CDS and other IT for more than half a century. Yes, more than half a century. He’s been actively working on such technology since the early 1970s. In a 2009 interview with the Permanente Journal, Weed said:

Computer technology maximized access to voluminous data and knowledge, thereby exposing the limited information processing capacity of the human mind. Scientists cope with this limitation by controlling the research environment, defining the variables involved, and limiting the scope of their investigations. Practicing physicians do not have that luxury. The time constraints of practice and the enormous scope of information implicated by multiple problems in unique patients make it impossible for the human mind to function with scientific rigor. Physicians inevitably resort to dangerous cognitive shortcuts.

I realized that medicine must transition from an era where knowledge and information processing capacity resides inside a physician’s head to a new day where information technology would provide knowledge and the processing capacity to apply it to detailed patient data. The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible. Changing this requires that we recognize the crucial distinction between electronic access to information and electronic processing of information. This requires a rational standard of data organization in medical records. Yet, these points are still not recognized in most current discussions of health information technology.

As a result, I have been involved for the last 60 years in trying to design and develop a medical care system in which patients are no longer dependent on the limited, personal knowledge their caregivers happen to possess. The medical care system must resemble the transportation system, where consumers use knowledge captured in maps, road signs, computerized navigation devices, and the like at the time of need. Patients, like travelers, will be expected from childhood on to develop the necessary skills to navigate the system.

At all times, patients should be supported by caregivers who are highly trained in the necessary hands-on skills, like removing the appendix or listening to heart sounds, just as in the travel system there are pilots, mechanics, air-traffic controllers, and others who perform functions that travelers cannot perform.

Yet, few outside of academic medicine have ever heard of Weed and his pioneering work. Instead, we rely on shoddy reporting and sound bites designed to score political points to shape our opinions. Why do you think the debate around “healthcare reform” focused so much on insurance coverage rather than actual care? And why do you think patients still believe office visits and prescriptions really cost just $10 or $20 or $30? And why do so many people still expect their physicians to know everything?

We must do better.