• The elusive electronic medical record

    Just over thirty years ago, my father came home with an Apple II+ computer. We hooked it up to a black and white TV and a dot-matrix printer, and kept it upstairs in his study. Next, he bought a few books and taught himself Basic, which seemed the language of choice back in the day.

    Over the next few months, my father wrote himself a billing program for his surgical practice. He had to get the forms that printed out approved by Medicare and insurance companies, but he did, and before I knew it, he and my mother would spend nights and weekends sitting at that computer running his practice.

    Hearing this story, people have different reactions. Some applaud the can-do spirit that it took to build and design such a system thirty years ago. Some think my father must have been some sort of computer genius. Some wonder whatever happened to the cutting edge system he designed.

    You’ll have to trust me that I love my father dearly when I say that he is not technologically inclined. When I visit, one of my first jobs is to reset any clocks that are running off daylight savings times, hook up any new electronics they’ve bought, and update any of the computers. Today, my father has difficulty mastering the double-click of a mouse.

    His program, while wildly successful in his private practice of one, was used for a few years until other companies caught on and started producing similar programs. He bought one off the shelf, tried it out, hated it, and eventually abandoned it altogether. It never worked as well as his did, at least not for him.

    His program was never used by anyone but him. Of course, it never could be. He built it for himself – and it made sense only to him and my mother. For instance, in order to bill for a hemorrhoid repair, you had to know that the keyword was spelled “hemmorrroid”. You had to know to hit the enter key extra times in certain places with no prompting. You had to know how to batch the printing and feed the forms just so, in a way that made no sense to anyone else in the world.

    But it worked – for him – and so it fit into his clinical practice and no one else’s. Later, when he used someone else’s EMR, it did not. His system also couldn’t communicate with any other system in the world. So when hospitals and insurance companies started demanding it do certain things, it couldn’t. And so he stopped using it.

    This is one of the few anecdotes I use when I give talks. I do so because I believe that is perfectly illustrates many of the problems with EMRs in the US. First, every clinician in the world practices differently, as does every practice. It is nearly impossible to change behavior, and doing so just to fit a computer system seems unacceptable to many. Many off-the-shelf systems also don’t talk to each other – by design. If one company sells you a billing program, they want you to buy their laboratory program and e-prescribing program, too. It’s in their best interests that their billing program talk to those systems and not a competitors’, or you might buy theirs. Other organizations will also eventually start making demands on your system; sometimes those demands are incompatible. Plus, these things are expensive, hard to use, and difficult to support.

    So why bother?

    From the Washington Post:

    About 20 miles away in suburban Maryland, internist Jonathan Plotsky hunts for the same kind of information in charts, some of them six inches thick, others taking up three volumes. He is well aware of the benefits of electronic records, but like most U.S. doctors, Plotsky, 56, is hesitant to switch. At up to $50,000 per clinician, the systems cost too much for him and the part-time doctor with whom he practices, he says. He doesn’t know what to buy, how to install it or how he would transition to paperless.

    “I’m waiting to see what will work for people,” he says. “The cost is prohibitive. It won’t be any more revenue, and it will change the way I do things.”

    Let’s be clear – I love technology. I’m the quintessential early adopter. Moreover, I make my living doing research on EMR’s and clinical decision support systems that we design, build, and study. I have grants and papers in this area, and if – you’ll let me brag for a second – I’m probably one of the country’s leading experts in pediatric informatics. I could talk all day about the benefits of EMRs and clinical decision support, how much good could be done, and how many errors could be avoided. And I’m telling you that Dr. Plotsky is right on the money.

    About 20 percent of U.S. hospitals and and 30 percent of office-based primary-care doctors — about 46,000 practitioners — had adopted a basic electronic record in 2010, according to government statistics. But most doctors would need to upgrade those systems to qualify for federal incentives. Recent surveys show that more than 45,000 doctors and hospitals have sought information or registration assistance from the federally funded help centers set up around the country to give free hands-on support; an additional 21,000 have begun signing up for the payments.

    Advocates say the benefits of computerized systems are numerous. When a doctor or nurse is about to decide on a prescription or lab test or whether to hospitalize a patient, “there is nothing as powerful as giving them information that is relevant to them just at that point,” said David Blumenthal, the government’s national coordinator for health information technology. In addition to gathering each patient’s medical history in a single database, the systems use reminders and alerts that register allergies and unsafe interactions when a new drug is prescribed. They also allow doctors to check for previous labs and X-rays to prevent duplicative tests.

    Blumenthal, who recently announced his return to his Harvard University teaching position, said he benefited from such an alert when he ordered a CT scan of a patient’s kidney. An electronic reminder told him a previous CT scan had imaged the patient’s kidney. He canceled the order.

    “If every doctor had that kind of experience once a month, think of all the money and incovenience to the patients that could be saved,” he said.

    Let’s take a second and gasp in horror at the first sentence there. Only one in five hospitals and three in ten primary-care docs have a basic electronic medical record in the US. Almost every pizza place I call has a functioning electronic record system, but not our health care system. This is in spite of David Blumenthal’s correct assertion that there are reams of evidence showing a clinical benefit to them. So why is that?

    I’d encourage you to read the rest of Lena Sun’s piece, which is quite thorough, but you won’t be surprised by the answer. Such systems are hard to use and difficult to maintain. They disrupt clinical practice. They don’t increase efficiency and often don’t pay for themselves. They disrupt the doctor-patient interaction. And they are very, very expensive.

    I’ve spent the last seven years working as part of a team to design and study an open-source, reasonably cheap, clinical decision support system and EMR for kids. And I tell you – this can be glacial work. We spend a lot of time making sure doctors will use it. We make constant adjustments and adaptations in order to make the thing efficient, workflow-friendly, and effective. It’s hard and slow and expensive to do that work.

    But it needs to be done. I fear that the current incentives – simple monetary carrots and sticks – that the government is trying in order to increase the use of information technology in the practice of medicine won’t work. Just as we have a patchwork insurance system in the US, we have a patchwork IT system as well. There are relatively few standards, tons of companies, and lots of failures. It costs too much, it doesn’t work as well as you’d think, and there are way too many avoidable errors.

    So once in a while, there is the anecdotal success story – like my father. For a period of time, for one practice, one system works fantastically. But if the practice changes, or the company that makes the system folds, or if the standards change, then that success story goes away. It’s a terribly inefficient way to build infrastructure.

    • Great post! I was wondering if you might be able to help me out. I’m currently a masters student in the area of Health and Pharmaceutical Economics, and attempting some research on the Cost-Effectiveness of EMR systems. However, after some exhaustive searching, I’m having some considerable difficulties finding literature on the topic. There seem to be many papers on the Cost-Benefit side of things, but little in Cost-Effectiveness. Any suggestions on where I could look?


      • @Anthony – The following should help. I don’t claim these are the best places to start. Use them to get further into the lit. Consider contacting some of the authors. Also consider focusing on drugs. I think there are a lot of papers in that area.

        Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. National Academy Press: 2001.

        Bigelow JH, Fonkych K, Fung C, Wang J. Analysis of Healthcare Interventions That Change Patient Trajectories. RAND Corporation: 2005.

        Girosi F, Meili R, Scoville R. Extrapolating Evidence of Health Information Technology Savings and Costs. Rand Corporation: 2005.

        Kohn,LT,Corrigan,JM,Donaldson,MS,eds. To Err Is Human: Building a Safer Health System. Washington: National Academies Press. 1999; .

        Byrne C, Vincent A, Johnston D, Pan E, Chandrika S, Middleton Bi. Level of Effort and Data Sources to Assess the Value of the Veterans Health Administration’s Investments in Health Information Technology. Veterans Health Administration: 2008.

        Spetz J, Phibbs C, Burgess J. The Effect of Information Technology on Nurses and Patients in the Veterans Health Administration. Veterans Health Administration: 2009.

        Drazen E, Gilbourd B, Metzger J, Welebob EM. Saving Lives, Saving Money In Practice: Strategies for Computerized Physician Order Entry in Massachusetts Hospitals. Computer Sciences Corporation (CSC): 2009.

    • I’m surprised you didn’t mention the billions of dollars being pumped into states to foster the culture change you find is lacking. Not only are doctors being given a financial incentive to adopt and meaningfully use EHRs, but there are organizations in place to help docs select the right software and train them on their use (regional/local extension centers).

    • Another anecdote: I went to China last year and when I put my ATM card it, it gave me Chinese money. My wife new about it immediately because she gets a text whenever a certain amount is withdrawn from our account. I don’t get why it can be that easy with money and that hard with medical records. My transaction was lots simpler and the interaction that needs to be recorded in medical care is complex….still, anything to be learned from banking?

    • Great post. I was with you all the way to the last sentence–maybe it’s inefficient, but it’s still the most efficient way possible.

    • My hope is that EMRs will also talk with each other. My emergency case this afternoon was an elderly lady from out of state. I had virtually no reliable history on her. I got every test I had time for before she needed to go to the OR. I had no idea if I knew everything I needed to know. Even worse in some ways, are the patients who show up for urgent surgery who have extensive workups at one of our competitor hospitals. It is almost impossible to get info from them on a timely basis, and they are only 5 miles away.


    • Do you have any more info on the open-source clinical decision support system? I’m intrigued.

    • Why is medical care still dominated by powerful artisans? My guess is excessive licencing.
      If it were not for excessive licencing doctors who were resistant to computer tech would ether be moved into management or retired.

    • @Austin – Thanks a lot, I appreciate the help.

    • I second John’s request. If it’s open-source, when are you going to start crowd-sourcing some of the work?

    • OK! I hear you. Believe me, I’m not trying to hide it.

      Our system is called CHICA, or Child Health Improvement through Computer Automation. You can search pubmed for it to see all the papers we’ve written.

      It’s built on OpenMRS (http://openmrs.org/).

    • ‘ When a doctor or nurse is about to decide on a prescription or lab test or whether to hospitalize a patient, “there is nothing as powerful as giving them information that is relevant to them just at that point,” ‘

      This is typical hooey from someone who is not involved in patient care. Being given the “relevant information” 20 times a day whenever I order a CBC or a Tylenol is distracting enough as to impair patient care.

    • EMRs requires the most highly trained member of the “health care team” to personally create the medical record (or dictate to a “scribe” real time remember the stenographer) What other system has the CEO type records for review by enter level clerks?

      The security requirements of HIPPI keep the computers that store one part of the medical record from linking with computers that house other parts of the record, thus requiring the data be reentered by hand.

      Boiler plate text of normal parts of the exam are pasted into the record to meet the billing requirements for complete examination and documentation of normal body systems.

      The redundant copies of examinations and other information inflates the size of the medical record and thus increases the “billable hours” allowed. This also perpetrates errors in the record.

      The completed record is easy for law clerks and insurance company secretary to scan for error of commission and ommission for law suits and payment denial.

      Most medical information required by a doctor to understand and continue treatment for a patient can be written in one or two lines: for example:

      Immunocompetent G4P3 Non Smoker All ADL+ fam 64yo WF. H. Zoster dv1 of V OD X 48h
      NDA .. ISIDS & Famvar X 7 RTC PRN

      This would require at least 6 pages in EMR.

      And many other problems not to mention cost.

    • Mr. Carroll made a fundamental error in writing that “almost every pizza place I call has a functioning electronic record system”. The pizza place has a functioning electronic ordering and inventory-control system (as, I’m sure, does every health provider – because they charge for each input instead of for bundled services). But no pizza place keeps a record of what their customers want. (Some retailers do profile their customers, with loyalty cards and whatnot, but I don’t have to use a loyalty card when I shop there. I am free to remain anonymous at any retailer, if I prefer.)

      The consequential difference is that the pizza places’ inventory-controls allow them more flexibility in dealing with customers’ idiosyncratic demands. Obamacare’s EMRs demand less flexibility in meeting patients’ unique demands.

      Mr. Taylor: Banks cannot exist without speaking to each other. They have to borrow and lend money to each other daily. So the natural incentive is for electronic data interchange. With health-providers, it’s not the same.

    • Mr. Graham is certainly the smartest guy in this room. Health care is burdened by what I call the trifecta for fubar – regulation, litigation and 3rd party compensation (not too many industries can perform well with two of these characteristics, let alone three). I think the EMR is probably the smallest problem to think about, but definitely cooler to talk about than the three above. I think we should spend more time on the other three first. Pizza joints worked just fine before a point of sale system and still do today. Same rule applies to health care.