Don’t get me wrong, EMRs (Electronic Medical Records) are inevitable. Over the long-run they are almost certainly good for physicians, patients and the healthcare industry.
However, their origin and the ulterior motives currently driving their adoption is sowing the seeds of their failure. First, what is ACTUALLY happening out there? The most recent CDC data would seem to be encouraging for EMR adoption (http://1.usa.gov/vu8wiy), with EMR use (finally) passing 50%.
Too bad there is more to the story.
If you look at adoption rates for so called “fully functional EMRs” (http://bit.ly/uUQ3FV), the adoption rate remains in the low teens (full data for 2011 is not yet available). So why is there an almost 4-fold discrepancy between “any EMR” and “fully functional EMR”? If EMRs are so great, why does the government have to essentially “bribe” physicians to adopt them through incentives such as the meaningful use incentive program (http://go.cms.gov/97BFXJ)? Why is this so important to them that they didn’t even wait for the healthcare affordability act to implement this “incentive”? (They put it in the stimulus package after Obama had only been in office a few months.)
The 50% adoption rates seen in the first link reflect the presence of ANY type of an EMR-like technology. While it is a great headline for sure, the second link shows that this is an overly broad declaration. When we look at “fully functional systems,” meaning they are being used for a full work-flow solution, we get numbers in the low teens instead. (When you subtract out unique situations such as Kaiser, the VA, and a few large independent doctor networks, I suspect the actual number is much lower.)
One reason that incentives and threats of decreased payment are necessary for EMR adoption is that the industry and physicians have known for years that EMRs do not improve productivity and that it is highly questionable that EMRs lead to better patient outcomes. So why is all this taxpayer debt being accrued by throwing borrowed money at the healthcare industry to drive EMR adoption, if the end users are so disenchanted? As Jonathan Bush, the Founder-CEO of AthenaHealth (a major EMR supplier) famously said, “It’s healthcare information technology’s version of cash-for-clunkers” (http://bit.ly/9ZgUa7), and,
Because it is actually all about control.
The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies….by simply removing a button or an option in the EMR. If you can’t select a particular treatment option, for all intents and purposes the option doesn’t exist or the red tape to choose it is so painful that there is little incentive to “fight the system.”
For patients, this means that they will only be able to consume the healthcare that they “qualify” for or be forced to find another way to obtain the care that they want and need. It is the second outcome, see previous post (Benjamin Franklin, Lightning & Ex-Communication) that is the most intriguing, because as “shoppers,” patients will want to be informed and have choices as they take on more responsibility for the cost and quality of their own care. This approach works very well with Health Savings Accounts, which were conveniently deemphasized in the healthcare reform effort. Like the lightning going to ground, this is the inevitable future for healthcare in this country (assuming the other alternative, an acceleration to a single payor system does not occur first).
For physicians…well, it isn’t hard to figure out where this is all heading. EMRs are quickly becoming the instrument by which we are controlled and managed. As an example, many organizations are already starting to restrict diagnostic testing and therapies via EMR.
What’s next? Patient referrals? It will be the final step in subjugating physicians.
So why is genuine EMR adoption struggling so much? After all, one may argue that the accessibility of instant data that technology now enables is the greatest single advance in patient care so far this century. With so much money being thrown at the problem, one might expect a much greater adoption. Why hasn’t it played out in a much more positive way?
This comes back to the origin and ulterior motives of EMRs. First, EMRs have been largely a top down effort. Rather than working with physicians to design the technologies and drive adoption, the experience (and almost universally the perception) is that the technology has been thrust upon physicians by administrators. Compounding this is the unintended consequences of the meaningful use government incentives (or cash-for-clunkers program to use Jonathan Bush’s, more colorful language). Having left the guidelines vague and largely written by a small group of industry insiders, most products have become a Tower of Babel with atrocious user interfaces and user experiences that….well, I don’t blame my fellow physicians for not wanting to use them. In addition to being expensive, they are complex, inefficient, and do not make physicians or their staff more productive.
Widespread adoption of an EMR (or multiple compatible EMRs) that is intuitive and easy to use, that empowers the end user and patients, and that actually helps to make the healthcare system more efficient would be a good thing for doctors, patients, and the industry. However, unless we recognize what the ultimate goals are and better involve the people most critical to their effective use (physicians), I believe Jonathan’s prediction will be true and cash-for-clunkers applied to the healthcare sector will turn out about as successful as that other government program…TARP.
Adam Sharp, MD
Founder par8o & SERMO
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You have chosen a gray color for the test on a gray background……………difficult to read
“…test…” = TEXT
Thanks Herbert
EHR is riddled with unanswered questions about cost, safety, data security and privacy, liability, and even possible benefits. EHR is a Trojan Horse that the US government and insurance industry left at healthcare’s door to infiltrate the exam room and get the data. Both will use the data against patients and physicians to deny care by denying meds, tests, procedures, surgeries and physician care delivered in earnest prior to payment denial. EHR will lead to pay for performance. More accurately stated: nonpay for objectives not met. This will lead to further care rationing and loss of patient lives; all for insurance asset protection and government power.
Physician always have and still have the power, but choose not to use it. We must ALL refuse to participate in government programs and insurance networks. Both are selling us down the river to take the fall for insurance profiteering and government power grab uptimately causing preventable patient illness and death. Wake up colleagues and wean yourselves off the abusive relationship of government and the insurance industry. Work for patients directly with no outside interference.
Data equal power: patients and their physicians should own it
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Data-equal-power-Patients-and-their-physicians-sho/ArticleStandard/Article/detail/753994
EHRs, government & insurance: when did we lose sight of the patient?
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Viewpoint-EHRs-insurance-and-government-When-did-w/ArticleStandard/Article/detail/699149
Number four from Forbes top predictions of healthcare trends in 2012:
4. Health information technology will stall. There’s a huge need for better computer systems to improve medicine, and the government is pushing hospitals to adopt them. But I tend to agree with analyst and fund manager Les Funtleyder at Miller, Tabak, who argues that hospitals are going to be slow to adopt new computer systems in 2012. What’s really needed is a disruptive innovation, a computer system so good that it solves many of medicine’s problems. We’re probably not there yet.
Well doctors may not like them. But, you will need Information Tech to revolutionize health care. Maybe it’s time doctors worked on creating their own systems. But doctors cannot get by with the old way any longer. Information technology will create better outcomes, you can bet on it. If its not done right, eventually it will be.
Perhaps it’s not a problem of Healthcare IT but more a problem of lack of incentives. As a wise doctor friend of mine said, “almost all docs own smartphones. We are not technology phobic, we’re losing money phobic.” I’d argue there is too much tech innovation when what is necessary is business model innovation.
Agitprop from a Ddulite (opposite of Luddite, that is, a radical technophile).
Most medical errors have nothing to do with documentation, either paper or electronic. See “Is Healthcare IT a Solution to the Wrong Problem?” at http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html
Further, the term “revolutionize” is a hysterical overstatement of the capabilty of health IT. See “IBM’s Watson, Jeopardy, and Revolutionizing Medicine” at http://hcrenewal.blogspot.com/2011/01/ibms-watson-jeopardy-and-revolutioning.html
Disagree. Most healthcare errors have nothing to do with record keeping, either electronic or paper. See “Is Healthcare IT a Solution to the Wrong Problem?” at http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html .
Also see “Health IT Ddulites and Disregard for the Rights of Others” on irrational exuberance about health IT, at http://hcrenewal.blogspot.com/2012/02/health-it-ddulites-and-disregard-for.html .
You did a good job sharing the red flags….but I thought TARP was paid back…one of the few Keynesian economic plans that worked…..an exception….but maybe not a good comparison? Although, overall the article is very interesting.
As a patient the doctor’s private notes area of the EMR’s can produce some pretty agitated reactions. The Open Notes project showed that when doctors profile a patient with their own interjections…um…patients weren’t too happy to find out they were labeled a “jerk”! Ha! Just a type of patient profiling that will probably eventually be regulated! Sigh! And it was probably true:). Oddly, patient bullying seems completely acceptable…..it’s done online for the world to see. If a doctor enters into a patient’s EMR they cannot have a certain classification of a drug…no other doctor in that hospital system can override it and prescribe (this gets complicated when it Is pain relief). It can be a type of life sentence that even another doctor cannot override. This happened to someone I know….a specialist…made an appeal…the notes remain.
One wonders in a culture that is calling doctors to task….are these electronic records helpful to that relationship most patients desire….or does it give patients the freedom to move on with ease…doctor shopping will become the double edged sword.
Good insight – and reasonable criticism of EHR UX. I would also agree with Eric that what’s missing from the equation is business model innovation. Most EHR’s have simply duplicated (many poorly) the paper process of record-keeping – which is billing-centric not patient or provider-centric. That’s a far cry from their potential and it’s incumbent on all of us as innovators to do a better job. Don’t know if you’ve seen any of them – but I think some of the newer cloud-based services (Practice Fusion, DrChrono, Care Cloud to name 3) have a much improved (if not perfect) UX – specifically for the small practice – including just a single doc.
Some additional commentary from the IT team at D4PC…
http://finance.townhall.com/columnists/mikekoriwchak/2012/01/05/doctors_unethusiastic_about_obamacare_geeks
I believe Dan and Eric have it right- if i can perhaps put it a slightly different way- assuming EMRs are a ‘disruptive innovation’, then, by Clayton Christiansens’ logic, what needs to follow, or be part and parcel of that, is a disruptive business model. That has not occurred. Folks, whether they be IT or well intentioned docs, have ‘backed into’ EMRs with our current model of billing, fee for service, and , what i believe, are outdated, mechanistic descriptors of illness that we call ‘disease’(we’re great at telling people ‘what’ they have, but not ‘why’). the EMRs I’ve seen are totally built around ICD9 (10) codes and how best ‘to get the charge out cleanly’ with all the right boxes checked! They are not patient centric, health maintenance or wellness inspired, far from user friendly, and generally ‘glitchy’. Our model is currently broken and EMRs, as they currently exist, are just a high tech part of that broken system–of course no one likes them!
The high failure rate of EMR system implementation (30-50% in most studies) is not so much a reflection of the technology as a lack of knowledge of basic change management on the part of physicians. We don’t learn anything about business in medical school and we certainly don’t learn how to integrate complex technologies such as EMR into a small business. But it is a people management issue not a tool management one.
I disagree that EMR systems are by definition inefficient and that they don’t improve productivity. We have not found this to be the case in our own practice after 3 1/2 years of EMR use. But what most practices don’t realize is that it is just part of an overall sea-change in the way you practice medicine. Even the best EMR system cannot fix crappy workflow processes – if anything, it will make them more obvious. Our EMR implementation was planned for 3 years before we went live and the software wasn’t chosen until half way through this process. Most doctors run out and buy the first EMR they fall in love with and then make their administrator implement it in three months – this is like buying a new tool and then trying to figure out how to use it.
On the other hand, I do agree that the financial incentives from the government, with complicity on the part of insurance companies, are a clever way of controlling physicians through the guise of promoting ‘better’ healthcare delivery. Any time that the government and private carriers agree on something, you have to pause and think. Rather than having to cull through stacks of paper charts, auditors can now make you upload your entire file set for their bots to search through.
But EMR systems are here to stay. Electronic practice management systems replaced paper scheduler and pegboard ledger books and paper medical records will soon be a thing of the past. Physicians can be resistant and be dragged kicking and screaming into the 21st Century. Or they can get educated and informed through sites such as this one, check references on the systems out there, and realize that this will be the most expensive and difficult thing they will have to do in their career – besides raising kids.
Re: ‘I disagree that EMR systems are by definition inefficient and that they don’t improve productivity. We have not found this to be the case in our own practice after 3 1/2 years of EMR use.’
That is an anecdote where n=1, but others disagree. Further, have you conducted rigorous studies, or is this just your “feel” for what has transpired in your practice?
See http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html for some scientific studies on the issue.
My practice has been using an EMR for over 7 years. It’s not perfect, but it does make my life easier most of the time. However, I would, under no circumstances, ever put in for government money to pay for this system–even if I were adopting it now and it met meaningful use criteria. I see this as the bowl of pottage we’re being asked to sell our professional birghright for–along with the privacy of our patients. Once we take the money, the government will be in the exam room with us. Patients will have no privacy and could have their information used by the government, insurance companies, and other entities in ways they could never predict. For physicians, instant practice audits, recoupment of overpayments and fines will be the government’s use of your EMR. I’m sure they’ll link their mining of your EMR data to your bank account. This will be the efficieny they hope to gain from EMR’s.
Data equal power: Patients and their physicians should own them
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Data-equal-power-Patients-and-their-physicians-sho/ArticleStandard/Article/detail/753994
There are pros and cons to computer use overall. In general, I have found computers to be marvelous at numerical or statistical work. A stock portfolio maintained on a computer, for example, provides incredible power that was not possible with a ledger. Quicken for home or business finance, or online banking – these both represent other areas where computers produce greater efficiency.
Computers are near equivalents for other tasks. For example, maintaining a desk calendar is better in some ways on paper. I have both a computer and paper calendar, generally finding myself using the paper one because of ease of accomplishing specific purposes (e.g. quickly seeing whether I correctly scheduled myself once per week at a given location).
For text based tasks, computers are often less efficient than paper. Medical records exist for the purpose of recording text-based information. Most physicians can write faster than they can type. Most physicians will put more data into a written record than they will in a typed record. Having spent part of the past two decades reviewing medical records for various companies, I can assure you that I always cringe when faced with a computer record to review. The records are generally superficial, duplicative, and fail to provide the type of data available in most written records. They use checkboxes and codes instead of narrative and diagnoses. They encourage copy-and-paste information, or fill-in-the-blank entry styles that are not informative to the reader. While one day, they may prove useful, we’re not there yet.
For data mining, computers are wonderful. So if I had the question: “What percent of my patients have major depression?” or “What is the average dose I provide of Zoloft to patients with major depression?” or “What percentage of SSRI’s prescribed is represented by Celexa?” Ahhh, that’s where computers are perfect. The trouble is – I never have those questions. The people who do have those questions are the same ones who are pushing for EMR’s, and those people are neither physician nor patient.
I wrote my own EMR 20 years ago. I am not bragging, but it is great. I makes notes faster than I can dictate them. It maximizes my collections and even my billing. It knows when I don’t get paid even my cost on labs and warns me before I order a test that will cost me more than I will get paid. It warns me of drug allergies. It does scheduling of patients and tracks no shows so we can deal with them before they no show again. It does my payroll. The list goes on and on. What it does not do is let the insurance companies or government monitor me. It saves money and makes money that is way above the $44,000 over 5 years that comrad Obama is offering. If anybody wants to turn it into a commercial product, let me know. I am not selling it, I am giving it away for free to the right group. I would be glad to help some group develope it into a commercial package, but I don’t want to provide tech support.
I agree that the 3rd party payors and goverment want us to adopt a system that will be as bad or worse for us than managed care. I strongly urge my colleagues….don’t do it.
In a jujitsu move, physicians might find they can use EMRs as a great tool for fighting payers and other top-down enforcers attempting to “manage care” away from physicians. What do I mean by this? Medical science still can trump (thankfully) managed care – the perfect case in point is personalized cancer therapy. Here is a field in which oncologists are driving guidelines and blazing ahead with new advances every six months, as genomics-driven molecular diagnostics and targeted therapies emerge.
How can EMRs be used? As a generator of “real-world,” bottom-up data and “trials,” which are becoming increasingly accepted scientifically. This is the perfect vehicle for physicians and patients to band together and generate evidence regarding what works and what doesn’t. This is “ammunition” for “care pathways” and reimbursement arguments.
Physician use of EMRs might take a few years to get right, but I’d argue that physician leaders need to climb this learning curve quickly, because the payers and other industry players have already begun to mine these data.
Eleanor Herrimen, MD, MBA
Physician order entry has taken the doc away from the bedside and parked him/her in front of a computer. In no world, can this be better for the patient in the long run. I need to be in the room, with my fingers on the pulse, not sitting with my fingers on the keys.
Maybe there is a problem with the CSS here? I can’t read anything here without highlighting it with the mouse, because it’s all white. I’m using Opera if it helps.
The most useful affordable tool for doing all that an EMR is supposed to achieve is Google docs or a product similar to it. As Eleanor Herriman has explained, there is so much that can be done with shared data. I wish I could meet with Adam and Dan someday and bring some of these ideas to fruition. It does not even need a large investment, just a lot of time and dedication to understanding what physicians want and seek in their daily practice of their art. The government is dabbling in an area in which it has no expertise and the only guidance it has is from crappy software vendors.
I have been saying this for many years in Maryland Medicine(see page 12 of the pdf), even as I wrote my own EMR which I still use. Does it pass muster for “meaningful use”? No, not by their standards, but it is meaningful for me, as the physician actually interacting with the patient.
Missing link: http://www.medchi.org/sites/default/files/Summer%202010%20Maryland%20Medicine.pdf
I have mixed feelings about EMRs. As an early adopter of EMRs and having been a beta tester of many as they were first introduced, I do feel they can increase patient flow and physician efficiency. However, the cost to the doctor-patient relationship is huge. I felt that as a primary care pediatrician, an urgent care pediatrician and when working shifts in the ER. There is simply no easy way to work on a computer screen and take a history without the young patient getting antsy and the parents feeling you are distracted. If you attempt to conduct the visit the old fashioned way – taking notes on paper and typing in the information later on, the “system” accuses you of being inefficient so you lose on that end as well.
As a patient, I’ve felt the ding as my patients have and still do. I see very talented doctors struggling with keeping pace with their maddening schedules, staring more at the computer screen than at me, while hunting for data, entering data and then typing in their notes. I don’t feel even the saviest of history takers comes across as warm with even the best EMRs in one of the best medical systems in the country, the Boston area, were I live and practice and where my physicians are.
I’m a huge supporter and believer of technology but don’t feel we have found the right equation yet. Before we push for complete adoption of EMRs for all physicians we have to respect why there isn’t better adoption of the products we have and truly listen to the experiences of those using today’s products on both sides of the stethoscope.
Adam,
It’s worse than you think.
EHRs are in reality experimental medical devices, approved by nobody, and used by physicians at their own risk without patient consent. See http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html , http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html and http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html .
For more on problems with EHRs and other clinical IT, see “Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties” at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/ , as well as the many EHR-related posts at the Healthcare Renewal Blog at http://hcrenewal.blogspot.com .