Dr. Richard M. Hamrick recalls a simpler time in his profession — a time when doctors knew their patients, knew their illnesses and could count on training, relationships and a pretty good memory to treat them.
Those days, like a Happy Days rerun, are gone. The era of medical specialization — in which doctors still know their patients, but the breadth of medical knowledge has outpaced the ability of most doctors to know a lot about everything — means patients are likely to see their primary care physician only for a referral to the next doctor who is trained to deal with their specific malady.
Still, rather than losing close doctor-patient relationships to time and technological innovations, Hamrick says, the same march of progress might help revive medicine's focus on the importance of those bonds to achieving quality care.
"In the old days, you had to rely on your memory — and when there was less to remember, that might have been a little more feasible," says Hamrick, chief medical officer for the HCA Virginia Health System. In his role as a member of Gov. Bob McDonnell's Virginia Health Reform Initiative Advisory Council, Hamrick is deeply involved in the state's efforts to prepare for major changes — both legal and economic — coming to the health-care industry.
"I think we're entering this amazing age of information technology," he says, predicting that "the mass computing that's available to manage, store and use information" will allow much closer relationships between doctors, more efficient use of the nation's medical resources and better overall patient outcomes. He points specifically to the health care industry's efforts to implement and streamline the use of electronic medical records.
The upswing of electronic records on Richmond's health-care landscape will have more impact than the addition of any new piece of microsurgery technology or revolutionary testing procedure, Hamrick says.
"If you're a guy who has an opportunity to undergo a da Vinci [robot surgical] procedure, we also have to think about after the da Vinci operation: How do we create value all along the continuum of care?" he says. "I think the important thing is [that] the electronic medical record is the thread that knits it all together."
Already, Richmond's major hospital groups — Bon Secours, VCU Medical Center and HCA — have made the leap to internal electronic medical records systems that have helped revolutionize care, he says.
A patient, for instance, who sees a physician at St. Mary's Hospital can expect another doctor about 12 miles away at Memorial Regional Medical Center to have access to records of tests, results, procedures and prescriptions instantly.
Dr. Mark Bladergroen, chief medical information officer of Bon Secours Virginia, oversees Bon Secours' ConnectCare e-records program. "I think in the big picture only about 5 percent of health systems have an [integrated] electronic medical records system," says Bladergroen, "We do all our documentation, all our results forms, all our ordering is done electronically — and not just [at] our acute-care facilities."
Patients' access to their records also stands to improve through initiatives such as the Virginia Health Information Exchange. This central hub will enable hospital systems and other health-care providers to share patient records, while providing patients with better access to the same information. In the case of some health systems — for instance, Bon Secours and its MyChart online portal — patients have abbreviated access to their lab results, medical imaging and office visits.
"Within one month [VCU plans] to launch our patient portal to allow our patients to interact with their own record, results, and our providers in an electronic fashion. We are also actively involved with MedVirginia (the statewide health information exchange) so that our patient's data can be available to other outside providers in a safe and secure manner," says Dr. Colin A. Banas, chief medical information officer for VCU Health System.
And with federal funding available, many smaller medical practices are making the same transition. The council that Hamrick sits on is tasked, in part, with giving advice on how best to ensure communication between electronic-record systems. The state's opt-in Health Information Exchange will rely on provider buy-in — there will be a fee to participate — as well as patients' permission to share their records through the hub.
But once the exchange is fully implemented, Richmond-area patients stand to reap big benefits, Hamrick says.
Perhaps the biggest recent driver of the move to electronic records management is passage in 2010 of the federal Patient Protection and Affordable Care Act. Though currently the subject of a torrent of legal challenges, much of the act is undisputed by the health-care industry, including the portion mandating what had been happening piecemeal for a number of years, says Michael Matthews, CEO of Central Virginia Health Network and MedVirginia. Both entities are efforts at improving preventive care by means that include the use of electronic records. They operate as a partnership between a group of Virginia not-for-profit health-care providers. Matthews is among the experts on state and private efforts to tie together the many disparate electronic records systems that doctors and hospitals currently use or that they are adopting.
"A lot of clinical data in health care has historically been paper-based," says Matthews. "When it has been electronic, oftentimes those data are housed in information silos that don't communicate with each other."
Part of this electronic communication breakdown can be chalked up to the industry being in the early stages of adoption. Systems are still being developed.
But part of it also is simply the proprietary desire of any business to encourage customers not to shop at the competitor's store. New regulations, and some emerging industry trends, seem aimed to at least partly push past the use of proprietary technology that might inadvertently discourage important life-saving — and cost-saving — communication between doctors.
Many experts say that communication between these systems will result in improved treatment for patients, fewer medical errors and, in the end, lowered health care costs nationwide.
And with many health-care experts citing concerns about a future shortage of doctors even as the system faces an aging baby boomer population likely to bring a huge increase in need, the efficient and effective use of electronic records to streamline costs and to improve the delivery of care becomes all the more urgent.
Both the law and real-world needs are pushing the industry to knock down the silos between electronic record systems, or at least to create ways to allow communication between them, Matthews says.
"Historically, health care has way underinvested in electronic records infrastructure, in having those systems communicate," Matthews says. He suggests one way in which universal use of electronic records can improve care: "If you're a specialist, you need to see what else other specialists or physicians have done for a particular patient. No patient lives with just a single provider and ... providers rely on having a complete medical record to understand everything a patient needs and has had done."
Other ways that electronic records change the landscape are equally fundamental. For instance, with more patients relying on medications prescribed to control or prevent chronic conditions, electronic records that compile all of a patient's prescriptions into a single history help to minimize the risk of dangerous interactions.
And health insurers — who may find their roles drastically altered if the new health-care law withstands legal challenges — are eyeing ways to use medical records to provide preventive services and programs such as diet counseling or smoking cessation that get measurable results for employers seeking innovative ways to control healthcare costs within their employee ranks.
Or in cases when a patient has a chronic illness requiring regular tests or procedures, automatic prompts could help to decrease the risk of missing routine doctor appointments that could prevent costly hospitalizations or negative outcomes for patients who otherwise might have kept their condition in check and remained healthy.
Continuum of care — in which proper treatment of patients while they are well is perhaps more valuable than the expensive acute care they receive when they are sick — is the focus of future health care, facilitated by electronic records that follow patients wherever they go.
The future of health care, in the Rich-mond region and beyond, relies on developing platforms for the effective use of electronic records, says Deborah Love, executive director of the Richmond Academy of Medicine. The reason is simple: As the cost of health care soars, good management of patient care — both before and after illness — is key to controlling those costs.
"The message is clear: You can't continue to have cost just continue to climb and climb and climb," says Love. "The answer to the question is not reduced quality — we do have high-quality health care in this community — so the issue is pushing down cost."
And to do that, a streamlined electronic patient record that allows physicians and specialists to act as a team will be essential.
"It's the lack of coordination within health care that's been a key driver [of spiraling expense]," Love says, pointing to something as seemingly mundane as an X-ray for a knee problem ordered by a general practitioner. It's not uncommon, she says, that that same X-ray will be administered again and again by specialists, because often those specialists don't have access to or don't know about the X-ray that already was done.
It may seem like a small thing, but when that mistake is repeated over and over again across an entire system — and in an industry that in the past has lacked incentives to hospitals and insurers to avoid such overlap and waste — the net effect is staggering.
In a 2010 report comparing U.S. health- care quality and cost with five of its large trading partners (Canada, France, Germany, Japan and the United Kingdom), The Business Roundtable, a corporate public policy think tank and lobbying organization, found that for every dollar spent on health care in the United States, other countries spent half that amount on average. The report also determined that the higher cost did not translate to better care.
"There are all sorts of things that crop up that can be streamlined — and by doing so reduce the cost that's associated," Love says.
An even more significant way that electronic records stand to change the face of health-care will be — at least on a day-to-day basis — invisible to patients. Quality metrics, another mandate built into the nation's new health-care law, will be used to hold doctors and hospitals to their mission to provide quality care to patients.
In part through the use of electronic records, and the big-picture view that can be assembled using the data contained within them, Hamrick says, "We're able to measure things in ways we weren't before."
Those records, along with patient surveys and real-world patient outcomes, will provide the measure that demonstrates value — and that determines the rate at which doctors and hospitals continue to receive the federal dollars that long have flowed to them in the form of Medicaid reimbursements.
"If you score poorly, you're going to fall behind financially," says Hamrick. "The government is saying, ‘If we're spending the money, you'd better show you're delivering great care.' " That kind of care will be accomplished only by re-envisioning how doctors interact with doctors and how patients are once again made a part of the team. After all, the patient is the only member of the team who goes home from the hospital or from the routine checkup, and in a world driven by data, the data they provide is critical not only to their health, but also to the system's health.
"The world is changing really quickly," Hamrick says. "At the hospital system, we are having to think a lot about the quality of care that happens beyond the four walls of the hospital. It's about how you manage change carefully, thoughtfully ... and how you help the patients navigate these systems."