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.

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