Previously on this topic: my Atlantic Q&A with Dr. David Blumenthal, who supervised the Obama administration effort to move medical records into electronic form; and installments one, two, and three. Here is another round of reader responses.
1) A new way to maximize billings. From Ronald Russell of Kenmore, Washington:
As a member of Group Heath Cooperative in Puget Sound for over 20 years, I've seen first hand many positive aspects of computerizing patient records. Whomever you see, your records are instantly accessible- that's comforting when you land in the ER in the middle of the night. Web access means you have access to some of those records yourself, and can communicate with your providers easily.
Unfortunately, I've also seen a negative aspect in how EMR's are being used that got only the slightest passing mention in this discussion, one that gets the incentives exactly backwards. This is the reason I'm now a former GHC member.
Digital records are also being aggressively used to maximize patient billings. At GHC, it used to be the case that a standard office visit was a flat charge- most recently $80. Now, when your physician asks a question, responds to one of yours, and makes a note in your record, this becomes another billing code. The result is that a 15 minute office visit can easily run to several hundred dollars, perhaps just because you mention a concern or the physician asks another question.
Every patient note entered in the digital record rings the cash register again in billing- and not in a way that anyone seems able to explain, or that physicians are aware of. The cynic in me wonders how long until they are compensated on commission, or get bonuses for entering more billing codes per visit.
The dollar amounts charged are often absurdly high, there is no accessible "price list" for consumers. My auto mechanic is legally required to explain his charges in advance, my health care provider never has to.
Of course, for consumers with full coverage or copay-only plans, this would pass unnoticed, as just an accounting detial. But for those of us with high deductibles that mean we essentially pay out of pocket for everything, this is a powerful disincentive to discuss concerns with your doctor or interact beyond the minimum business at hand. I don't believe this is good for patient care.
Fortunately, due to the ACA, I've been able to move to another insurance plan that mandates a flat charge for standard office visits, even before you meet the deductible. So perhaps that one small part of the market is working. Unfortunately, this brought up another problem with these records- ours are now locked up inside the Group Health system, and no longer accessible to me- at least, apparently, without paying for them.
These issues are not so much inherent problems with EMR's as they are symptoms of a broken health care system, in particular where the provider and the insurer are one and the same. I put them out there to add to the discussion.
2) A way to get the doctor to look at you. In response to a previous complaint about doctors stare at their computers rather than their patients:
[A previous reader says:] "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."
I'm in IT, and have worked at several hospitals where these stands are used, and the usual nomenclature is COW (computer on wheels, of course). I'm often reminded to be careful there are no women around when discussing the COWs in the room...
3) Once again the VA is doing it right:
I'm a 68 yr. old Vietnam vet (USMC) who is rated 90% 'Service Connected' disabled: hearing aids (I was in an artillery battery in Nam for 19 months); Type II Diabetes and Ischemic Heart Disease (Agent Orange exposure) and assorted other things.
I can't praise the VA enough. Through HealtheVet I can re-order meds and have them mailed to me, same with hearing aid batteries. I can set up or cancel appointments or ask my Primary Care doc, or any of the physicians who treat me, questions and get an answer within 24 hours. I can go to ANY VA facility in the world (yes, there are VA clinics and hospitals outside the US) and they will have total access to my medical records.
From the hell holes that VA hospitals were in the '70's, as depicted in the movie Born On The Fourth of July, they now are as good as it gets in the US. I give Bill Clinton props for the revamping he and his VA Secretary undertook that got the VA to where it is today. It may be struggling a little with the overwhelming influx from the Bush/Cheney/Rumsfeld fiascos but I have no complaints here in NYC. Semper Fi
4) Promise from the patients' point of view:
The use of EMR is obviously in early days, and flaws are easy to identify. My experience, however, shows the great promise of EMR to improve medical care and help patients make medical decisions.
I have a mild case of MS, and go to [a major medical center] every year for a check-up. These include MRIs of my head every two years or so. I travel 200 miles to visit the clinic, so I want to get everything done on the same day. On MRI years, I’ll have the scan in the late morning at the imaging center that is allied with the clinic. When I see the nurse practitioner or physician’s assistant a few hours later, pictures of my brain are available in my electronic chart, and my medical professional looks at the scan with me, and explains what he or she sees. The reports of my last two scans are available to me right now on the MyChart website that [the center] makes available to its patients. And yes, my case is so boringly stable that there is no current need for me to see “the big man”.
That’s cool, but the real power was revealed to me in 2011, when the radiologist who reviewed my scan discovered that I have a small benign brain tumor, a meningioma. I was referred to a neurosurgeon, also allied with Strong, where it was recommended that I should have my head screwed painfully into a frame so that a surgeon could aim what is essentially a killer death-ray at my brain.
Except… when the medical professional and I looked together at the series of scans in my EMR dating back to 2002, there that pesky meningioma was, seemingly the same size as in the 2011 scan. This empowered me to turn down the surgery. I’d had that tumor for a decade or more with no ill effects. Prove to me that it’s growing, and I might consent to the surgery. A repeat scan a year later confirmed that the tumor is not growing.
There’s one key element here, of course: all of the professionals involved are allied with the same large medical center, so communication between them is smooth and nearly instantaneous. My GP 200 miles away is not part of their system. Still, I’m very happy that I had access to a decent EMR system in this case, which helped me to make an informed decision.
5) As long as the systems stay in touch:
I have several chronic illnesses, and because of the specialized nature of them, I have a lot of doctors. I live in the San Francisco Bay area, and have specialists at Stanford, in San Francisco, and then my local team near home. Here’s the thing - all of these facilities have have state of the art EMR systems, but the systems don’t talk to each other.
This means I spend a lot of my time bringing copies of records between various specialists, and communicating what one doctor said to another. As in telling my primary care doctor “My rheumatologist is concerned that the medicine you want me to take will have an impact on my spine issue”. Sometimes I get letters from one doctor that I have to carry to another. I keep my own records of my latest test results, culled from the various sources (included the online tools provided by some medical facilities), and bring them with me to appointments, so I can answer questions about when I last had a test, and what the results are.
I also have a list of every medicine and treatments I have tried, and the outcomes, as new doctor often has a standard approach to the first thing they want to try. And they haven’t had time to go through all the records that were sent to them. Since the systems are designed around billing, they don’t have easy ways to extract care info, such “Show me the medicines to which this patient has had an adverse reaction”.
Until there is a well integrated way for your doctors and their systems to communicate, coordination of care is going to be an issue. My career was in computer tech, and I know how hard it is to create interoperability standards.
To me, yet another argument for single payer system, is that we could standardize on some basic data collection and exchange.
6) From a Yank in Canada:
I moved to British Columbia eight years ago from California.
The first thing I had to get used to when I went to the doctor here was just... walking... out. No stopping at the receptionist to deal with payment and/or insurance. Just... walk... out.
My clinic in California had started doing electronic records before I left, but I recall it as being kind of clunky. Here, however it doesn't seem as clunky; it seems more integrated into the appointment. Perhaps it is because I see young doctors (my clinic is a teaching clinic), but I think it's because the appointments are structured differently.
Here, the appointment starts with me sitting, fully clothed, in a chair, to the side of a desk. The doctor sits at the desk with both me and the screen visible. He or she asks me if anything has changed, and talk about why I came in. Frequently, the doc will look something up on the web that is out of his/her area of expertise, and they are not shy about doing so. (Usually not Wikipedia, something more like PubMed.) If he/she needs to examine me, *then* I get given a gown.
By contrast, my recollection of appointments in the US is that they started with height/weight/blood pressure measurements by a nurse. (This was true even when I was in my 20s and now seems like overkill. Why did they need to take these measurements every time, when my measurements didn't budge for years at a time?) Then the nurse would give me a gown, and I'd get undressed and sit on the exam table. That meant that I would *start* the consultation sitting uncomfortably on the exam table. (There often weren't even two chairs in the room; maybe there was a chair and a lower stool.) In that configuration, it is not easy to position the computer so that the doc can see both the screen and the patient.
Another thing that is different: I almost never fill out a form before my appointment at my regular clinic. If I am going to a new practice (like an after-hours clinic), yes. If I am getting some new and different procedure, yes. But they don't ask me to tell them who I am and where I live and what my insurance is and who my next of kin blah blah over and over again. Occasionally they ask me verbally if anything has changed, and that's it.
7) Allowing doctors to do more than just fill in the forms. From a librarian:
One comment based on my experience, I appreciate the doctor who said the system would not let him record what he wanted to say. I think these systems should allow writing free-form notes, sketches, scanned items, etc.
I am a retired librarian and early in my career I worked on several of the early computer systems for recording the arrival of issues of magazines in libraries. I'm sure this is much less complex than medical records, but it is more complex than one might think. These early computer systems couldn't accommodate the creativity/inaccuracy of journal publishers and printers when there was an issue number 12 1/2, or, more often, the printer did not change the volume number in the new year until he discovered the mistake midway, so you have volume 14 for a year and a half but number 1-6 in one year were not the same as 1-6 in the next.
In medicine, the doctor's free-form notes can express his knowledge of how complex things really are, in his best estimation at the time, or the questions he has (another issue, do you want this in a record that will be shared with the insurance company, and thus perhaps used out of context in litigation -- but if the electronic record is the only one you have, where else do you put the information?)
I'm all for having evidence-based guidance in medicine, but I want the doctor to be able to take all of this information and then see if I fit the profile the computer predicted. How is this going to happen if the information isn't even recorded?