L.A. physician sees electronic medical record as key to better public health. (Profile).

ACCORDING TO A recent Los Angeles Times editorial, (1) Tom Garthwaite, MD, faces an impossible task.

As director and chief medical officer of the L.A. County Department of Health Services (LACDHS), Garthwaite oversees one of the largest county health departments in the U.S.-one that is struggling with rapidly increasing operating and health care costs and mounting deficits.

The situation for LACDHS is serious. The California state auditor published a status report on LACDHS in May 2002, that stated that "current proposals will not resolve its (LACDHS) budget crisis, and without significant additional revenue it may be forced to limit services." A budget deficit is predicted for fiscal year 2003-2004 of $365 million and it's expected that the deficit will grow to $628 million in fiscal year 2005-2006.

The financial problems largely stem from fixed or decreasing funding for the uninsured and inadequate information systems, a summary of the audit stated. "The department lacks the clinical or financial information systems needed to effectively manage a multibillion-dollar health care system."

Garthwaite agrees. He believes improved information technology, specifically an electronic medical record, is one key to solving many of the problems facing LACDHS and other county health departments across the U.S.

His agency provides the medical facilities and the personnel to deliver health care services to the least advantaged citizens of L.A. County. Coordinating the gigantic system is difficult. Garthwaite hopes he can implement an electronic medical record system that will significantly improve patient care, reduce paperwork and speed the operations of LACDHS facilities.

He wants to design a system of care that is better than the fragmented, chaotic, expensive status quo. Among the problems he cites with today's record keeping systems:

* Since health care records are owned and organized by institutions, hospitals and medical groups, most Americans have many medical records.

* Most medical records are written by hand and illegible to everyone but their authors.

* Paper medical records cannot be searched for keywords and do not have indices.

* Paper medical records cannot be aggregated for study, but must be examined one by one.

* Garthwaite predicts that performance and cost-effectiveness of the American health care system will not improve and the value of health care services will not increase until most providers share standardized computer-based medical records.

Experience with EMR 

Garthwaite has seen what electronic medical records can accomplish firsthand. Before taking charge at LACDHS, he spent seven years helping the U.S. Veterans Health Administration automate. When he started, the VHA was known for poor quality clinical care and a stultifying bureaucracy. But just before he left, the VHA won several prestigious national awards for quality of care and innovation in management.

Much of the credit goes to VISTA, the VI-IA's electronic medical record that improved operating costs of facilities and clinical outcomes for patients.

Garthwaite wants to bring the same sort of results to L.A. County, particularly to people living in poorer neighborhoods who often suffer medical neglect. With a shared electronic medical record and shared data warehouse of clinical and administrative transaction data, he says health care for LA County's most vulnerable people would improve dramatically.

Shared data mean physicians will have the information they need to do the right thing for patients, Garthwaite says. He bases some of his ideas for EMR on the work of business luminary Dee Hock.

Hock is credited with coming up with a plan in the 1970s to save BankAmericard and transform it into a global business for the most efficient exchange of value between consumers and producers of goods and services. The result is today's VISA.

Garthwaite recommends Hock's book, Birth of the Chaordic Age, (2) published in 1999. He points out that most business and health care firms are based on hierarchical command and control models of organization. But Hock's plan for VISA did not rely on hierarchical structure. Despite the flat structure, it is a network of data centers and banks transacting 53 percent of the world's credit card business and exchanging nearly $2 trillion in goods and services each year.

No hierarchy

Garthwaite wants to create an EMR based on a similar structure. He says most organizations have hierarchical management structures, but the health care system behaves more like a biological system, which is not hierarchical. Living things retain in themselves-in their instincts and memory-the knowledge of what they need to do to survive in most situations. Currently, organizations are about command and control, Garthwaite says. They impose rules of behavior on people.

But if health care rids itself of hierarchy, Garthwaite explains, clinicians will be able to practice medicine armed with the latest information about their patients and will be informed by automated alerts and reminders that guide them to best practices--just as VISA created a nearly global community for the exchange of value between people.

He says a critical step will be the conversion from a competitive to a collaborative model in health care--where competing providers in a community learn to share information about patients, especially electronic medical records, just as competing banks learned the enormous value of sharing VISA.

Garthwaite believes medical records ought to be owned by patients, not by the medical practices, hospitals or diagnostic centers where they receive care. He hopes a shared electronic architecture for medical records will evolve, with the patients holding the IDs and passwords to access their records. Patients would grant permission for physicians to see their records, just as consumers control access to VISA cards.

In 2000, Garthwaite attended a planning retreat for experts in health care policy, industrial development and change management that included Hock. He left convinced the VISA model of shared standards for information exchange would support a community-based electronic medical record.

He wants to produce immediate financial benefits from electronic medical records by simplifying registration of patients and reducing some of the administrative costs of caring for patients.

He believes if patients can control access to medical records, it will ease the burden of documentation and security that HIPAA places on providers and vendors who store medical record data on their patients.

No waste

L.A. County manages six medical centers, more than 40 clinics and generates revenue of $2.9 billion dollars. Big shortfalls will arise in the next few years, Garthwaite predicts, unless dramatic changes take place in the way care is delivered.

When patients see physicians, they often do not have the paper records of the medical histories, so physicians repeat diagnostic tests that might not be necessary.

Similarly, administrative review of paper records for coding and billing consumes thousands of dollars per year for each occupied hospital bed in the United States, and hundreds of dollars per active chart. A shared, national electronic medical record could eliminate many of those costs.

Garthwaite adds that paper records cannot:

* Alert physicians to diagnoses they have not considered or treatment guidelines unfamiliar to them

* Reduce a delay in the clinician reaching the correct diagnosis

* Guide a physician to the most modern medical treatment

* Improve health care services

The electronic medical record can.

Garthwaite knows he'll need help to successfully create an electronic medical record system. He's thinking about seeking corporate partners who might see L.A. County as a laboratory for integrating health information. He'll also consider philanthropic support and community involvement.

And if he succeeds in mounting a strong effort with solid financial backing, perhaps the next L.A. Times editorial will praise Garthwaite for overcoming impossible odds.

References:

(1.) Los Angeles Times, Feb. 4, 2002

(2.) Hock, D. Birth of the Chaordic Age. San Francisco, Berrett-Koehler Pub., November 1999.

RELATED ARTICLE: Tom Garthwaite MD

Age: 55

Schools:

Medical: Temple University School of Medicine 

Specialty: Internal Medicine

Undergrad: Cornell University

Hobbies: Reading, Home Improvement, Golf

Marshall Ruffin, MD, MPH, MBA, CPE, FACPE, is president and CEO of Ruffin Informatics, Inc., Charlottesville, VA, He consults to health care organizations on the selection and implementation of information technologies. He can be reached by phone at 434-244-7980 or by e-mail at [e-mail].