Let's Talk Electronic Medical Records (Cont.)

By James Fallows

Our new issue has an interview with Dr. David Blumenthal, who was in charge of the Obama administration's effort to promote the use of electronic medical records (EMRs). We've had two previous rounds of responses from doctors, technologists, patients, and others, one and two.

Now another round. 

1) It's generational. Previously I quoted Dr. Creed Wait, formerly of Texas and now of Nebraska. He enumerated the practical problems the EMR requirement created for him. A reply:

I read [those] gripes and wanted to weigh in as well.

I am a physician and have had the privilege of training and practicing in different places across the country.  I specialize in sports medicine.  My experience with EMR is greatly different from my fellow physician.  

Some of his complaints are valid, but it seems as though many of his issues are related to his own inadequacies utilizing or adapting to technology.  My observation has been that practitioners above the age of 40 in general have problems adapting their practice habits to new technology.  People under 40 (myself included) are already familiar with computers and can adapt more readily.  Another point to consider is that older physicians (as I assume my colleague is) will eventually retire, and current medical students and residents who will take their places already find the "paper and pen" method quaint, if not antiquated.

2) Is money the problem, or isn't it? Another rebuttal to Dr. Wait's report:

I wonder why he doesn't notice the self-contradiction in his complaint about the medical records mandate.

 On the one hand, he complains that small practices like his don't have the big budgets that the VA and others use to make electronic medical records work well.  

Then he complains about the $19B that the government has paid out to physicians for adopting electronic medical records, saying that if the systems worked well (like the cotton gin) no financial "carrots" would be necessary.  But if lack of money to implement the systems is the problem, why isn't government funding to those using the systems precisely the right policy?

3) It's all about the software companies. From a doctor on the Gulf Coast of Florida:

I would parrot the statements of most of the physicians that you have quoted:

- EMR degrades the quality of information transfer in medical notes.

- EMR increases time of documentation.

- EMR costs more than our prior system.

I would also point out that transcriptionists are part of the disappearing middle class.

Who wins?  EMR software companies…who I would point out market to CFOs, not physicians.

4) The driverless vehicle, a century before Google? From a non-physician:

Some comments:

- In 1985 I was teaching a group of state-level bureaucrats about our brand-new IBM System/36.  One of the men sitting at the rear was a man with 30 years or so in the agency (USDA-ASCS), very assertive. Midway through the lesson (entering name and address data) he beckoned me over and said: "I don't type."  

All of the complaints of the first doctor could be echoed in an assessment of our initial automation efforts.  We basically automated what we were doing on paper, without rethinking what we did to use the hardware better.  Took us years before we (the Washington bureaucrats and systems designers) learned better so our applications actually helped the county offices.

- I recommend this book to the doctor: Lakwete, Angela. Inventing the Cotton Gin: Machine and Myth in Antebellum America. The truth about the cotton gin is that it took a long time (i.e. 20 years or so) to work improve Whitney's gin and change the processing of the lint cotton downstream from the ginning to the point where it represented a great advance.

 -Finally, I'm old enough to remember the transition from horses to tractor on our farm.  Though the tractor then was a reliable machine, changing over was not a simple process--dad underestimated the time and cost.

So my point is the transition always takes longer than predicted, and usually is complex than the advocates of change  concede.  And there's always a trade-off.  My mother could remember returning from Binghamton, NY after selling their farm produce, and letting the team find their way home--the driverless-car 100 years before Google. 

5) "I'll choose a universal (electronic) record every time." From a reader in the Midwest.

I have some experience with EMRs—I’m a technology and healthcare writer and have written about them for many years for provider groups and insurers, and at one point, for an independent EMR lab that allowed small practices to experiment with various solutions before buying. I’m also a patient, of course, and my family here in [a major university city] sees clinicians within the University of [xx] Health System, which uses a very sophisticated EMR.

Your coverage of this issue has been fascinating. The criticisms of physicians from smaller independent practices do have an air of intransigence (we might call it whining), but many of the concerns are valid. The benefits of an EMR for a small, independent clinical practice are likely outweighed by the costs and complexity, certainly in the near term. But for larger practices and health systems, they’re indispensible. I can’t tell you how reassuring it is as a parent to know that any doctor or specialist we see has access to my daughter’s entire clinical history. If we have to run to the ER at 2am on a Saturday, god forbid, it is immensely comforting to know that the resident examining our child has exactly the same information as her primary care physician, and has a complete picture of her medical history since the day she was born. There is no scenario I can imagine in which the alternative leads to safer or more effective care.

But the physician who writes that “technological fixes only work in the context of appropriate institutional structures” is correct. The value we see in our local system as patients and parents is not really observed during a regular checkup or sick visit to the doctor’s office. It’s in having clinical information shared across every provider we come into contact with through the course of our lives. The minute we see a doctor outside the university system (if we go to an independent urgent care clinic, for example), those benefits begin to erode, and the larger story is a much harder sell.

But the market and regulatory regime do seem to be addressing this. The move toward accountable care organizations (ACOs) is very much an institutional framework under which EMRs make sense and begin to add tremendous value. ACOs are geared toward Medicare beneficiaries, but the consolidation happening in the larger industry is following the same path.

In many parts of the country, smaller practices can have their EMRs partially or entirely subsidized by the larger hospital systems with which they work. This makes sense on many levels. Hospital systems benefit by having a more consistent, universal medical record of the patients they see, while smaller practices and physician groups gain much lower barriers to adoption, as well as ongoing support and training superior to what they could sustain on their own. The downside is the loss of independence of the small practice. I can certainly see how, as small business owners, physicians might resist this change. But as a patient, I see the benefits to my family far outweighing the risks of that loss of independence.

Consolidation introduces its own challenges, and it’s not yet clear whether the financial incentive structures (especially in consolidation outside of ACOs) will counterbalance the higher prices that can result from fewer competitors in the marketplace. But in terms of quality and safety of the care provided, I’ll choose the larger provider group that’s embraced a universal medical record for my family every time.  

6) A solution for staring at the computer. A reader in northern California writes:

Re: information systems in medicine, I am a Kaiser patient, and am intrigued by one small comment made by several people, that doctors must turn their backs on the patient to enter data into the computer.    

No, at Kaiser, Northern California, they do not.  The computer is on a roll-around stand, and the doctor or nurse is facing me while using it.  Simple solution.   Perhaps there are other simple solutions for some of the complaints. 

7) Similarly positive experience in Seattle:

My primary care physician works out of a small non-profit clinic here. An EMR system has been in use there since soon after I my first visit about 5 years ago and my experience has been entirely positive. Examination rooms are arranged so the doctor doesn’t have to turn away from the patient while viewing the screen. Patient history is available at all three locations, to the doctor, nurse, assistant, and front desk. Other information, for example background for interpreting test results, is available promptly. There is a patient portal where doctor and patient can exchange messages such as test results. What’s not to like? 

I have no knowledge of the system in use nor of the staff’s opinion. My doctor, nurses, and assistants have keyboarded info during a visit and it doesn’t seem to me to be too distracting. The experience described by previous correspondents on this issue is amazingly poor and I can imagine their dislike of those systems. I can’t imagine this small non-profit clinic spending a great deal on an EMR several years ago unless they expected immediate benefit. From my point of view they got it.  

8) Finally for now, reliance on medical records as category error:

As an IT practitioner I have been following the slow-motion and entirely predictable train wreck of EMRs for some time now, starting with Microsoft HealthVault and the ill-fated Google Health in 2007

A timeline, with some observations: 

- March 2008: ars technica has a decent overview of the situation. The takeaway: "many of the reasons for poor US health outcomes have much deeper structural roots related to a lack of preventative care versus emergency care, issues that are tied in to the lack of a universal healthcare system and the nature of insurance companies, that are outside the scope of medical records databases".

- March 2010: The announcement of $20 billion in the stimulus bill for electronic health records (EHR) has started a gold rush. There's excellent coverage of the IT issues by Andy Oram on the O'Reilly Radar weblog. It elides the political question unfortunately - with single-payer many of the complexities of the IT implementations simply disappear. The problem of interoperability of competing systems vanishes, for one.

An IEEE Spectrum article covers some of the security implications. In particular my paranoia is confirmed by Dr. Deborah Peel, who writes

"Today our [the patient's] lab test results are disclosed to insurance companies before we even know the results. Prescriptions are data-mined by pharmacies, pharmaceutical technology vendors, hospitals and are sold to insurers, drug companies, employers and others willing to pay for the information."

EHR will only expedite this process. I'd like to see a blunt rule in the HIT regulations that gives ownership of the medical record to the patient and his heirs and assigns. Currently the ownership is vested somewhere in the aether.

- July 2010: the HIT has released its "meaningful use" criteria for the adoption of EHR by doctors, etc. This offers a few thousand dollars (from the stimulus package) for implementation of an EHR. As Andy Oram observes,

"The catch is that they can't just install the electronic system, but have to demonstrate that they're using it in ways that will improve patient care, reduce costs, allow different providers to securely share data, and provide data to government researchers in order to find better ways to care for patients. That's what "meaningful use" means."

A few thousand isn't going to do it. The costs of EHR fall upon the doctor, the benefits accrue to society and the patient. The costs are much higher than a couple of thousand, especially considering the current wholly dysfunctional state of EHR. Many EHRs have no API at all, others have incompatible ones, and so depressingly on. Single-payer with a single EHR solves all these problems at once, but because it's politically impossible, we're left with hideous technical problems.

Trying to solve US healthcare problems with EMR/EHRs is a category mistake, like trying to take the integral of a head of cabbage.. as your midwest doctor observed, " technological fixes only work in the context of appropriate institutional structures. "

Thanks for these; more in the queue. 

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