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An integration tax that every adult in the US pays

  • Alan Morrison 
An integration tax that every adult in the US pays
Image by PublicDomainPictures from Pixabay

I live in Northern California and have a new primary care doctor now. My previous primary care doctor, who has since retired, was part of the Stanford Health Care (SHC) system. My new doctor is merely in a different SHC office. 

The new doctor has a very nice office, and the doctor and staff I’ve met are quite helpful. He was meticulous about noting down answers to questions he asked me during my visit in October. His notes were in addition to information his staff had collected from a comprehensive battery of forms I’d filled out and submitted online when I switched doctors within SHC. 

I learned during the visit that SHC doesn’t have many recent records for me because my previous employer offered a physical exam benefit through a third party called Executive Health Exams (EHE). Fortunately, I’ve been healthy for a good long while, and I was really only going to the doctor once a year for the annual physical. So I’d just go to EHE instead of SHC, taking advantage of the benefit my previous employer was providing in the process.

A vaccination records integration tax example

The doctors and staff at EHE would also monitor my vaccination status and update my vaccinations when necessary. For example, EHE staffers gave me the Shingrex vaccine to prevent me from getting shingles, which I was at risk for because I am now in my 60s and had chicken pox when I was a child.

For some reason, my new doctor wasn’t able to find my EHE vaccination records, for example. This is even though SHC system doctors, I’ve learned from inquiring recently, do have access to Care Everywhere, which is EPIC’s medical records exchange. Care Everywhere is supposed to be a way for doctors such as my primary care doctor to view patient records generated by other providers.

In October after my visit, I went to the EHE site and requested that their records be sent to SHC. As I recall, I had requested before that EHE share those records with my previous primary care doctor’s office, as I mentioned also a SHC system.

Today I was wondering if my new SHC doctor had received the EHE records, so I called the main SHC medical records office because I assumed they manage a central records repository for a shared records service. The gentleman at the medical records office asked me how EHE sent the records, and I said I didn’t know. Were they sent by fax? I wasn’t sure. The gentleman said that if the records were faxed, that I should contact my doctor’s office directly. 

I don’t know anyone besides healthcare organizations that uses a fax system anymore. It’s a bit ironic that SHC still does, given that Vint Cerf while at Stanford University was a key internet pioneer back in the 1970s.  

Still navigating the thicket of interactive voice response

So I called my doctor’s office directly. The SHC phone system uses an interactive voice response (IVR) system which answers each call and reads callers at least one menu of options to route them to recorded instructions or a live person. The system’s designed to minimize the amount of time staff spends answering routine phone calls. If the caller has a frequently asked question, the IVR should be able to route them to a recording that answers their question.  

If you’re in the US and an adult, you’re probably familiar with the IVR routine, which can be quite time consuming for the caller to navigate, particularly if there’s no provision for a caller to dial 0 and just get to a person directly. IVR first gained adoption in the US in the 1980s. Now a number of enterprises have dispensed with IVR and are using chatbots instead, which have their own issues.

In the case of SHC’s primary care offices, the IVR system greets a caller by saying “Thank you for calling Primary Care Stanford. If this is a medical emergency, please hang up and dial 911. Please listen carefully as our menu options have recently changed. We want to protect your health and that of those around you. If you’re calling in regards to monkeypox inquiries such as testing and vaccinations, press 6. If you’re calling in regards to COVID-19 testing and vaccinations, press 2.  If you’re calling Primary Care, press 3.”

Callers must navigate through at least one and maybe two or three menu branches of options this way to go through the call routing process, and the time spent navigating is a burden placed on the shoulders of each caller. Often the menu items don’t describe what you’re looking for, and you’re faced with picking an option that seems most likely to get you to a live person so you can ask them directly for help.

Once I successfully completed the menu tree navigation process, I did connect with a staffer who noted down my query and said she’d forward it to my primary doctor’s team. At this point, I’ll wait to hear back from the team to see if SHC actually received the records.

Bottom line: The personal EHR integration tax and its healthcare industry context

Should each patient be required to become a permanent backup for the medical records integration and access process when necessary, as I have? No. I’ve spent hours prompting Stanford and EHE to get Stanford’s records up to date so my doctor’s office won’t keep asking me if I need this or that shot. My shots are up to date. Stanford needs the proof. 

The previous paper-based system was actually better from the patient’s standpoint, because each patient had a shot card they owned and kept with them. Those doing the vaccinations would log each vaccination a patient received on that patient’s card. Parents would store, protect and take responsibility for their children’s shot cards along with their own. During the COVID-19 epidemic, the local county health system used a shot card system. That was the default. 

Electronic health records (EHRs) have been around in some form or fashion since 1977. By 2024, the healthcare industry is forecast to spend nearly $20 billion annually on EHR systems alone. The bigger EHR implementations are multi-year projects. Florida-based AdventHealth, for example, embarked on a $660 million Epic EHR implementation in 2020, according to Freedonia Group. By the end of 2022, AdventHealth had spent $355 million on the implementation. EHR system bloat and waste is quite comparable to enterprise resource planning (ERP) system bloat and waste. And yet, EHR and ERP systems predominate, particularly among medium to large organizations.

What’s an alternative to a vendor cash cow-oriented medical records system that makes everyone else but the vendor chase after bits of scattered information? Allow each patient to own and control their own medical information via a patient knowledge graph–a modern equivalent to the shot card, but for all records. Each patient would grant access to that information via that patient’s secure Solid pod–a decentralized storage system that’s evolving from open web standards. 

Providers would read and write in an authorized, secure way to the patient’s graph via apps designed to use Solid (an open standard in development) that’s access controlled by the patient. Result? Zero-copy integration and data sovereignty for personal medical information. 

Why does it seem like we’re further away from this sort of human-centric information management than ever? Because enterprise information architecture is only changing gradually, at the edges. We’ll need to do much more awareness raising of the nature of the problem and the utility of the best, principled approach that respects data sovereignty — like the shot card used to, and like the original web was intended to.