Next Things First

A Physician’s Reaction to the New York Times’ EMR Story (From Howard Luks) by charlottegee

The NY Times ran another piece* on the potential benefits of an EMR platform. I’m not sure who was *behind the story*… but I disagree with a number of the statements and premises of their article.

I have blogged about this topic often enough … here, here and here.

I am not against technology. As a doctor, I am against  *shouldering the burden* and *paying a fortune* for technology that will probably not enable my patients, will not materially affect my business, and as currently designed will not reform health care or the practice of medicine. EMRs, as currently available today, are in their infancy. They are, for the most part, very poorly engineered, very expensive, and do not allow me to share patient data with hospitals, RHIOs, etc.

(image from California Physician)

(image from California Physician)

Physician innovators should have taken the lead on EMRs … but we didn’t. We should have been involved at all levels of the platform’s build-out, but we weren’t.

Who benefits MOST from an EMR, and the sharing of knowledge, tests and procedural data … ? *Nope* … it’s not the patient … but the managed care industry!!! *If* technology such as an EMR platform decreases the number of duplicated procedures, the managed care industry’s profits rise. *If* they need fewer FTEs to handle electronic claims, their profits rise.

Do you think they will decrease their premiums if their costs go down???? Nope. Look at the airline industry. Gas/fuel are at four-year lows … yet we are still paying a fuel surcharge!

So, if the MCOs are going to benefit the most …WHY SHOULD THE DOCS, many of whom are already operating on a very fine margin, SHOULDER THE ECONOMIC BURDEN of purchasing, rolling out and maintaining an EMR system that most relevant research shows they probably will not like in the first place????

“This requires the usual leap of faith that knowledge will yield good things — better care, doing things smarter and, yes, saving money in the long run.”*

Leap of faith??? I’m not jumping out of a plane and relying on a parachute opening. Design a platform I like, align the interests/economic burden of those who prosper from the IT expenditure, make it economically feasible, make the systems inter-operable, the data actionable and computable and I will be the first one to sign up.

“We have to restructure our medical culture,” he said. “We have to promote a culture that believes in the evidence and is trained in analyzing the evidence. It’s the only long-run answer to the challenges we face in health care — evidence-based medicine.”*

This has nothing to do with evidence-based medicine (EBM). Whenever possible, I have been practicing EBM for years. The problem is that we do not have enough evidence. Without interoperability, currently available EMR platforms will not lead to a plethora of EBM data.

There has to be a better way … another reason why the Obama administration needs to fund the health care venture capital sector to allow for disruptive innovation in a space clearly in need of a new way of thinking.

In addition, this clearly points to the need for physician thought leaders to be actively involved in the innovation process.

Submitted by Howard J Luks, MD


2 Comments so far
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A related piece in the latest Forbes (Jan 12, 2009 issue) by Lee Gomes points out that the main benefit of EMRs is upcoding by providers, with templated documentation providing an easy way to document at a high level of care. I have seen numerous examples of data being entered that wasn’t actually obtained, through things like clicking on “Negative ROS” and getting 14 systems filled in with denials without having to actually ask the questions! Gomes points out is that there is little evidence that efficiency or practice improvement results from these systems. He cites “alert spam”, the enormous number of interaction alerts that end up with the clinician clearing all of them (without really examining them) just to get to the next step. Presumably interaction checking was to be one of the immediate safety features of CPOE, only the way it’s implemented conflicts with physician workflow. The human-machine interaction was not adequately taken into account. We need more study of the psychology of the practitioner/computer interface.

Our hospital has a major information system that frequently disrupts workflow for many categories of staff. Physician order entry and nursing documentation are both cumbersome; there are no “second level decision support tools” as envisioned by HIMSS to assist us to provide “evidence based medicine”; to enter one bit of data requires a minute-long sign-on process; there’s no direct wireless accession of vital signs, which could easily be accomplished with inexpensive and currently available smart BP cuffs, thermometers and oxygen saturation meters and would have been a clear workflow benefit to users, and utterly blah screen design impedes comprehension. And this is a “leading” system!

As for who should pay, I agree that it is in the payers’ interest to facilitate quality (even they say as much), and if EMRs do that then they should have a major piece of that cost. Providers in the MCO environment can’t off-load some of their costs for business systems onto purchasers, as any other business is able to do, so it’s unfair to make providers shoulder all of the burden. Alternatively, if maintaining professionalism of the workforce (which means quality and efficiency and other things, and is a very important trait of our health care system that is increasingly suffering) is a goal, then systems need to be developed by clinicians assisted by programmers and industrial psychologists, not the other way around.

I’m actually less concerned about interoperability, which ought to be easy, than with usability, which seems very hard.

Comment by Lawrence L. Faltz, MD, MACP

A $20 billion federal allocation to have on-line medical records is nothing short of appalling. I predict it will be a wasted $20 billion. Been in a hospital lately? The only persons who touch you are the aides who take your blood pressure. A nurse will touch you if there is a need to look at your name band to give medications or hang blood. Nurses, among ourselves, complain about the time the EMRs take to enter data at the bedside, screen by screen. RNs are so occupied with entering every bit of data related to items used they don’t have time to spend doing the most important nursing function, talking with and listening to the patient. My sister-in-law during a telephone conversation over the holidays related her visit to her doctor to discuss a recurring rash that is not only bothersome but of concern. He spent the time on the keyboard asking her questions related to the checklist he was required to fill out for the EMR. He complained about the mandate to fill out the checklist and by the time he had gone through the checklist, the time allowed for the office visit was over. My sister-in-law didn’t have the opportunity to discuss the recurring rash with him which was her primary goal. She now has to make another appointment to focus on her primary problem to discover whether it is related to diabetes or has another cause.
Checklists narrow a doctor’s thinking according to Jerome Groopman, MD, Harvard University, in his recent book, “How Doctors Think.” He says, on page 99, “electronic technology can help organize vast clinical information and make it more accessible, but it can also drive a wedge between doctor and patient when used in this way to increase “efficiency.” It also risks more cognitive errors, because the doctor’s mind is set on filling in the blanks on the template. He is less likely to engage in open-ended questioning and may be deterred from focusing on data that do not fit on the template.” Dr. Groopman’s neight told him, “I really like him as my doctor,but for the first time in all these years he sat at his desk with one eye on the clock and one eye on the computer screen, only occasionally turing his head to look at me.” This is the same report my sister-in-law reported to me over the phone.
Where did the decision to spend $20 billion on EMRs or medical records on line come from? I certainly don’t want my medical record on line. I want control of my health information and want the privacy, security and confidentiality of my personal information also under my control and management. More than once the information in my EMR and PHR has been wrong or misinterpreted.
Who has documented the value of EMRs to demonstrate improvement in health literacy and health outcomes?
This is a request to the incoming Obama Administration whom I completely trust to be ethical, fair and balanced in listening to citizens. Please, relook at the $20 billion to go to EMRs, investigate deeper as to their value. More advanced health information management products and services are coming, some largely smart-phone based. There is no need for large financial investments in EMRs and PHRS which are static checklists and lists of diagnoses, medications, immunizations and past treatments. They are reflective of the past, not the present or the patient’s future path. They are focused on illness, not wellness.
Stop the roller coaster of EMRs and PHRs as they exist today. Again, who was advising the transition team and President-elect Obama. The executives of wealthy EMR companies? Same goes for storing individual’s personal health information on-line, a free service offered by some large technology corporations. It is seductive to access health information, minus identifiers, aggregate it and sell it to governments, corporations, pharmaceutical companies. People should be educated to question why a free service is being offered to store personal health information.

Comment by Gerene Schmidt MA, RN

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