Tech April 2014

Why Doctors Still Use Pen and Paper

The healthcare reformer David Blumenthal explains why the medical system can’t move into the digital age.
Alváro Dominquéz

The health-care system is one of the most technology-dependent parts of the American economy, and one of the most primitive. Every patient knows, and dreads, the first stage of any doctor visit: sitting down with a clipboard and filling out forms by hand.

David Blumenthal, a physician and former Harvard Medical School professor, was from 2009 to 2011 the national coordinator for health information technology, in charge of modernizing the nation’s medical-records systems. He now directs The Commonwealth Fund, a foundation that conducts health-policy research. Here, he talks about why progress has been so slow, and when and how that might change.

James Fallows: From the lay public’s point of view, medical records seem incredibly backward. Is the situation any better than it looks?

David Blumenthal: It’s on the way to getting better. But we still have a long way to go. The reason why the medical profession has been so slow to adopt technology at the point of contact with patients is that there is an asymmetry of benefits.

From the patient’s perspective, this is a no-brainer. The benefits are substantial. But from the provider’s perspective, there are substantial costs in setting up and using the systems. Until now, providers haven’t recovered those costs, either in payment or in increased satisfaction, or in any other way. Ultimately, there are of course benefits to the professional as well. It’s beyond question that you become a better physician, a better nurse, a better manager when you have the digital data at your fingertips. But the costs are considerable, and they have fallen on people who have no economic incentive to make the transition. The benefits of a more efficient practice largely accrue to people paying the bills. The way economists would describe this is that the medical marketplace is broken.

JF: This is a subset of the general brokenness of the medical marketplace, right?

DB: Yes. There are many problems that come from the brokenness of the health-care market. To put it another way, if the medical market functioned like the car industry or the computer industry or the service industry, with true competition based on quality and price, providers would have adopted electronic records long ago. I’m not advocating pure market competition in health care. But there are many ways in which the medical marketplace should work better, and this is one of them.

JF: What’s the best thought-experiment example of medical-marketplace incentives working the right way? The VA?

DB: When the benefits of using better technology are “internalized,” as the economists would say, there has been much more rapid, complete, and effective adoption of electronic medical records. So, the VA: the benefits are internalized, because the VA has to live within a budget. In private health-care organizations like Kaiser or the Geisinger plan in Pennsylvania, or the Group Health Cooperative in Puget Sound, electronic medical records were adopted decades ago, and are widely used and highly effective. You don’t need a thought experiment to find living, breathing examples of what happens when the incentives work right.

JF: What’s the connection between the electronic-records effort you directed and the larger Obamacare strategy?

DB: This may be a Beltway detail, but the law that I implemented was not in the Affordable Care Act. It was actually part of the earlier and much maligned stimulus bill. The hope was that promoting medical records would lay the groundwork for a more efficient health-care system, and thereby make universal coverage more affordable to the country—

JF: And—

DB: And you’re about to ask whether it did.

JF: Yes.

DB: It would have. And it will. But it needs time to realize its potential.

“If the medical market functioned like the car industry … providers would have adopted electronic records long ago.”

I think the parallel is the time it took from when computerization became prevalent in other industries to the time when worker productivity improved. We are only three years into the process of making digital information widely available in health care. And health care is an extraordinarily complex, knowledge-intensive industry. If you want a thought experiment, you could ask yourself how good modern medicine is when physicians and nurses know nothing at all about the patient. So information is absolutely the critical resource in health care, more important than steel in making cars. When you change the way information is used and collected in medicine, you change everything about the way work is done. It is an enormously disruptive process within the health-care system. It takes time to accommodate. In places like Kaiser and Geisinger, electronic medical records are already making a big impact. But that is mostly because those organizations started using them a long time ago.

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James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne. More

James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.

Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.

Fallows welcomes and frequently quotes from reader mail sent via the "Email" button below. Unless you specify otherwise, we consider any incoming mail available for possible quotation -- but not with the sender's real name unless you explicitly state that it may be used. If you are wondering why Fallows does not use a "Comments" field below his posts, please see previous explanations here and here.

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