The Eyes of Big Medicine: Electronic Medical Records

This is the third part in a series of articles on the rollout of Obamacare and how the law will change our health care system. Each week, we will publish two articles -- one on the changes in medicine and medical care and one on changes in the insurance industry. We hope this series of articles will help you make better decisions when it comes to your health care and how you buy insurance.

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The first two articles discussed the growth of government-controlled Big Medicine and how it will affect medical care. This next piece will cover the role of electronic medical records (EMRs) in Big Medicine.

The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 essentially mandates that physicians and hospitals adopt electronic records by 2014, or face penalties in the form of reduced Medicare/Medicaid payments.

At first glance, adopting electronic medical records would seem a no-brainer for doctors and hospitals. After all, electronic records are the norm for many successful businesses, assisting with sales, inventory, and billing. In theory, electronic medical records should reduce costs for doctors and help them practice more efficiently.

Yet as Dr. Adam Sharp notes, EMRs are a “dirty word” to many doctors because EMRs are cumbersome, hinder doctors’ ability to practice, and are too expensive.

In the New York Times, Dr. Pauline Chen described how EMRs are impairing doctors’ ability to interact with patients. Many young doctors in training are so busy filling out obligatory electronic forms, they are now spending only 8 minutes per patient each day. As a result, they cut corners:

When finally in a room with patients, they try to [rush through interviews] by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.

As Dr. Chen noted, the bad habits they learn in training will carry over to when they become independent practitioners.

Another recent study showed that young doctors spent only 12% of their time in direct patient care compared with a whopping 40% of their time in front of a computer. Veteran ER physician-blogger “WhiteCoat” recently tracked his workflow and similarly found that 50% of his time was spent on the computer, not with patients.

One pernicious effect of doctors spending so much time on the computer is that they tend to “treat the chart” rather than treating the actual patient.

Dr. Richard Gunderman described an extreme example of this phenomenon:

An intern recently presented a newly admitted patient on morning rounds, reporting that the patient was “status post BKA (below the knee amputation).” “How do you know?” the attending physician inquired. “It has been noted on each of the patient’s prior three discharge notes,” replied the intern, looking up from his computer screen. “Okay,” responded the attending physician. “Let’s go see the patient.”

When the team arrived in the patient’s room, they made a surprising discovery. The patient had two feet and ten toes. Where did the history of BKA come from? It turned out that four hospitalizations ago, the voice recognition dictation system had misunderstood DKA (diabetic ketoacidosis) as BKA, and none of the physicians who reviewed the chart had detected the error. It had now become a permanent part of the electronic medical record — as if written in stone.

As Dr. Gunderman warned, “The flesh-and-blood patient is getting buried under gigabytes of data.”

Furthermore, these electronic medical record systems can be expensive, forcing doctors in practice to make some difficult business choices. One of my local colleagues here in Colorado described his conundrum:

While many small practices would love to implement new technologies, such as electronic medical records (EMR), in order to better deliver care, we have special challenges that are not addressed in health care reform regulations. Most small practices operate with low profit margins making introduction of expensive systems difficult.

Even with government incentives, costs can run well into six figures, especially with multiple providers. Large hospital-based practices are at a competitive advantage to implement such government mandates while small practices are forced to choose between hiring/maintaining medical staff, adding EMRs or selling out to Big Medicine to avoid such challenges.

Nor do EMRs appear to save much money. In January 2013, the New York Times reported that "the conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care.”

EMRs are not inherently bad. A well-designed EMR can add tremendous value to many medical practices. In a free market, doctors and hospitals would gladly purchase EMR systems that made sense for their particular circumstances. Based on their specific requirements, some practices might purchase an EMR and others might not. Over time, the free market would bring down EMR costs and improve their quality.  But the choice of whether and when to purchase an EMR should be left up to each individual hospital and medical practice. It’s not the government's role to pressure medical practices into adopting EMRs any more than it’s the government’s job to tell everyone that they should purchase a smartphone.

So why is the government pushing EMRs so aggressively? One clue comes from Dr. Farzad Mostashari, national coordinator for Health Information Technology. In a 2012 interview, he readily acknowledged that doctors could provide excellent patient care using traditional paper charts. But he explained the advantage of electronic records as follows: “You need information to be able to do population health management.” In other words, EMRs are necessary for tracking the medical care being given to large populations of patients — and the treatment decisions of their doctors.

EMRs thus provide an excellent tool for the government to control doctors. As mentioned in the first article of the series, the expenses of buying EMRs are a major factor in driving doctors out of independent private practice and into more easily controlled large provider groups. And once doctors have been herded into these large entities, EMRs allow the government to monitor which doctors are adhering to approved practice guidelines and which doctors are “outliers.”

Many privacy advocates have also raised concerns about the security of patient data in EMRs. EMRs necessarily include sensitive personal medical and financial information about patients, making them a tempting target for hackers. In a novel twist, some hackers even broke into the EMR system for a group of doctors in Illinois, encrypted all their patient data, and demanded a ransom for the password. (The doctors refused to pay and instead notified the authorities.)

Other privacy advocates are concerned that federal agencies like the IRS might misuse patient medical records for political purposes.

In theory, this is a risk. But I doubt we’ll see heavy-handed political misuses of personal medical records. We won’t see hospital administrators telling patients, “You voted for the wrong candidate last year, so no chemotherapy for you!” Instead, the danger is more subtle. Walter Russell Mead describes the appeal of electronic medical records for proponents of government-controlled Big Medicine as follows:

For some, these kinds of information systems offer the hope of a centrally guided, centrally controlled health care system. Bureaucrats in Washington will crunch the numbers and regulate the national health care system based on the numbers. They think and hope that Big Data will empower Big Government, and that armed with the information about ‘best practices’ that they get from the data, they will be able to micro-manage what health care practitioners do.

In other words, the greatest danger to patients is not that their EMR data might be misused. Rather, the biggest danger is that their data will be used as intended — i.e., to control Americans’ health care by controlling the caregivers. In other words, electronic medical records will be the “eyes” of Big Medicine.

So what can Americans do about this? This will be the topic of the final article in the series.

Coming next week: What patients can do about Big Medicine.