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Electronic Medical Records – The $100 Billion Boondoggle

January 29, 2011
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What are we getting for our national $100 billion investment in electronic medical records (EMRs), or $200 billion, or $300 billion – who knows what the final cost will be? In the primary care ambulatory world, not very much.

It’s not that EMRs are useless, they just don’t help very much. A recent study compared the average hemoglobin A1C levels, which measure average blood sugar levels in diabetics, between clinics that had EMRs and those that didn’t. The EMR clinics’ average hemoglobin A1C levels were 0.26% lower than the paper record clinics. About 5% more patients in the EMR clinics reached blood pressure goals, but there was no difference in cholesterol control. The long-term health improvements of these differences are negligible.

Another study compared the performance of clinics with and without EMRs on quality of care measures for patients taking anti-inflammatory medicines (NSAIDs). There was a 3% difference in the number of patients receiving guideline-recommended care.

Other studies find small positive effects, and others have even found the quality of care is worse with EMRs. Even the most ardent EMR supporters should be disappointed in these results.

Why don’t EMRs have a bigger impact on care quality? There are at least four assumptions of the EMR pushers that should be challenged.

1.  EMRs reduce medical errors – They clearly reduce errors with root causes such as illegible handwriting, but those errors are replaced with other errors: system crashes, data entry errors, and software that is built more for capturing billing data than improving clinical care.

2.  More information equals better care – Oftentimes more information just means there is more distracting noise for the doctor to process that ultimately doesn’t and shouldn’t influence her medical decisions. A perfect example is the GE commercial where the patient is on the theater stage and the audience of doctors spouts off results of old tests. Information such as the results of a gallbladder sonogram 15 years ago really doesn’t matter today. If the gallbladder was removed because the sonogram showed gallstones, then it’s gone. There is nothing to gain in knowing how big the liver measured or how much stool was in the intestine.
3.  Family physicians don’t provide recommended care because they don’t know what to do – Family physicians don’t need reminders of what constitutes high quality care. They need time to deal with all the complexities of patient care, which can’t be accomplished in a 15-minute visit for many patients.
4.  EMRs reduce healthcare costs – Many of the chronic care and preventive interventions EMR reminder systems remind doctors to provide increase costs to the healthcare system. Examples include mammograms, some vaccines, cholesterol testing and treatment, and many drugs used for chronic disease treatment. Many analysts have noted the dearth of rigorously collected data measuring the full costs of EMR implementation, or its cost-effectiveness. Estimates by EMR advocates that EMRs will reduce overall healthcare costs can generously be described as an exercise in wishful thinking.

Next week I’ll show how EMRs have harmed primary care.

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13 Responses to Electronic Medical Records – The $100 Billion Boondoggle

  1. John Epling on January 29, 2011 at 4:45 pm

    Richard,
    I buy (and there’s evidence to suggest) all your points except the “physicians don’t need reminders” one…In the way care is currently structured, reminders have been shown to improve care. But your point about needing more time doesn’t necessarily solve the problem of physicians not doing the routine stuff we’re supposed to (and, of course hasn’t been researched – I don’t know of any system that gives primary care “enough time”). There’s more that just time that impinges on a physician remembering things, and for (evidence-based) protocol-driven things like screenings, immunizations and chronic care the EHR is ideally suited – along with a system of standing orders and nursing staff empowered to order such things – to get that important, routine stuff done.
    If the whole system is working well – including the EHR – then primary care docs can concentrate on the important stuff – relationship building, motivating change, care of multi-morbidity and diagnostic dilemmas.
    We’re really early into the whole EHR implementation thing…we are just now getting over the “EHR is electronic paper” mindset (and some haven’t) – now we need to think differently and let go of our current model (I said it!) and figure out how EHRs can free us from the mind-numbing stuff, enable us to access rich data about the populations we serve, and help us be doctors again.
    That’s what I think…of course, I could be wrong…;-)

    • Richard Young MD on January 30, 2011 at 7:43 pm

      John,

      Thanks for the great thoughts.

      I’m human and therefore imperfect, and I need reminders in many areas of my life to get done what I need to get done. However, I see no substantive difference between an electronic pop-up reminder and a flow sheet or tickler list in a paper chart.

      Evidence of care process measures in primary care that are less than the theoretical ideal has been published before and after the growth of EMRs. Therefore, there are larger forces at work than just reminders, which include patient preferences, patients with severe chronic diseases (hypertensives in poor control despite taking 5 medications, e.g.), financial barriers such as co-pays, medication side effects, and many others.

      I think one of the biggest “others” is time. I’ll expand on that idea next week.

      Stay warm,
      Richard

    • southern pcp on January 31, 2011 at 11:03 am

      “There’s more that just time that impinges on a physician remembering things, and for (evidence-based) protocol-driven things like screenings, immunizations and chronic care the EHR is ideally suited – along with a system of standing orders and nursing staff empowered to order such things – to get that important, routine stuff done.”

      That can all be done more efficiently and cheaper with a paper flow chart and standing orders. I know. I was just told by the largest insurer in my area that I would no longer have any standard-of-care reviews because my charts are always without deficiencies.

  2. Aaron S on January 30, 2011 at 1:03 pm

    As an avid an active EMR user, I agree with the majority of this article.
    1) Our EMR has resolved handwriting issues, but it lacks the smarts to prevent someone from clicking on the wrong drug, or wrong formulation… I often find entries of patients taking aspirin “suppositories” or zithromax “IV” simply because a medical assistant clicked the wrong row on a cluttered screen. It takes the keen eye of the physician to notice these subtle errors before a new prescription copies the error forward (and it’s not too hard for the doctor to overlook this, either).

    2) Information overload is not the biggest problem, in my opinion. The old paper charts were just as densely packed with this data. The EMR does make it easier to locate, filter, sort through data (especially digital data such as progress notes and lab results). It doesn’t handle scanned-in records nearly as gracefully – but still no worse than a paper chart.

    3) ** This is the big one ** We family docs do, for the most part know what to recommend, and when to recommend it. For the most part, we program our own EMRs to remind us (so the software isn’t telling us anything new). The key is that, regardless of whether the EMR reminds me, without a dedicated preventive visit, I don’t get properly reimbursed for the additional time and work involved in reviewing a chart, making recommendations about issues NOT unrelated to the patient’s chief-complaint(s) for that visit, counseling on those recommendations, documenting the discussion, and implementing the recommendations. So, in reality, the only practical opportunity to be preventive is during a preventive-care visit. And since these are less likely to be sought out by patients (“Why should I see the doctor if I’m not sick?”) it is easy for these measures to slip through the cracks. I don’t profit from referring for colonoscopies, mammograms, dietary counseling, diabetic education, or a whole slew of other important services. But it costs me a great deal of time and effort to arrange these. So, although the evidence behind annual check-ups is lacking, I will attest that they are the only reimbursible way for doctors to provide proactive preventive and chronic care management (EMR or not).

    …which means:
    4) May not be as true. I don’t think I can recall a time, ever, that I ordered a test simply because my EMR told me to. So, as long as the EMR is programmed with appropriate, guideline-supported, evidence-based rules, it should not lead to OVERUSE – but perhaps help improve underperformance. Of course, health care costs will rise if we start providing appropriate services to more people – but isn’t there a down-the-road savings?
    I think the myth is that doctors who use EMRs are all sharing a collective database, and (with a few small regional exceptions) this is far from the truth. So, within a hospital system, EMR may reduce redundant testing. But in a community of independent practices, we still operate without the benefit of a universal patient chart. There are some developing models for data-sharing, like the Tarrant County Sandlot, or iRefer in Dallas. Individual EMRs are experimenting with tools to simply data-sharing. But this is a concept still not ready for widespread use.

    I wouldn’t willingly give up my EMR — and I think that while it might not make me a better doctor, and certainly doesn’t make me any wealthier (quite the opposite, in fact) it still has advantages to me and my patients.


    I’ve been enjoying your blog since I recently discovered it. Keep up the great work!
    -Aaron

    • Richard Young MD on January 30, 2011 at 7:51 pm

      Aaron,

      Thanks for taking the time to write such a thoughtful reply. I agree with everything you said. Let me highlight also your BIG POINT about the fact that we’re not paid for the work we do, and you provided a great list of examples.

      One of my frustrations is that I’ll even go to primary care research meetings and some well-meaning PhD researcher will suggest some intervention to improve a clinical care process, it is obvious she has no earthly idea about the practicalities of running a small business: a physician’s practice. When challenged, a typical response is “the nurse can do it.” My nurses work their fannies off too. And if they’re not paid for their time either to provide extra services than a one-problem visit, then the practice still loses money.

      Richard

  3. Christopher Gregory on January 31, 2011 at 3:22 pm

    In 30+ years of work advising physicians, there have been many times when I’ve walked into the bullpen and found a physician wracked with information overload (either engulfed by paper or madly pecking away at a computer), or during evening telephone discussions with my physicians going slightly bonkers charting/reviewing buried in an information jungle. It is the worst in primary care because the universe is often passing before their eyes. It’s arguably much more difficult to assess/reconcile information for the entire body human than a part.

    My question is this. If we are progressing in an information age, what are the true benefits of EMR? Was EMR not conceived to make vital information accessible? How much is too much? If one watches the television commercial of a stricken parent in the ER, and a child standing by helplessly telling the ER doc “I don’t know” in response to critical health questions – isn’t that supposed to be a benefit of rapidly accessible information? It happened to me once and I couldn’t tell the doc what meds my Mom was taking, or when this or when that happened.

    Isn’t it conceivable that there is some gradient of information that serves a critical function, without overloading a system with useless, outdated information?

    I have discussed with IBM the concept of an EMR “portal” which makes a community exchange theoretically possible. Would not such a system serve to alert physicians to possible problems as a frontline benefit, like drug interactions. Would it not serve a purpose if pahrmacists could access such information to screen detect harmful interactions? I’ve spoken with docs who tell me that not knowing can set up some very bad outcomes.

    Seems to me that the extremes of perspective have all created valid arguments for avoidance of a rapid-fire accessibility system(s). Am I missing something from my non-physician perspective?

    • Richard Young MD on January 31, 2011 at 11:38 pm

      The problem with some of the drug interaction programs is they can’t distinguish between a highly likely severe interaction and a theoretical minimal interaction. Some of the earlier EMR systems had drug interaction pop-ups that became so obnoxious the doctors turned off the feature.

      The “I don’t know his medications” commercial is another example of a scare tactic used by a company selling technology. A better solution would be for the ER staff in that commercial to call the patient’s family physician. Low tech but highly effective. Or course, many of these tech-driven companies and facilities wouldn’t know what a family physician looks like.

      • southern pcp on February 2, 2011 at 7:29 am

        Trying one e-prescribing system, Prozac and Proctofoam came up as an interaction.

  4. Valerie Garrett on January 31, 2011 at 5:52 pm

    I got the iphone a few months ago and was impressed with all the apps Apple had to offer. I got a PHR for myself and it was free but the only thing the company offered was a card. I would rather go for a PHR that comes in flash drive and get automatic reminders, and I think that whether it’s an app or Medefile, or any other PHR company that it is beneficial to both patients and EHR’s. I hope to see a surplus in this field.

  5. David Vaughan on February 1, 2011 at 7:37 pm

    Hi Richard,
    I enjoyed your comments. I would like to add a note. Not only did our EMR (NextGen) come with a high financial cost, but it also came with an unexpectedly high cost in documentation time. Even after 2 years of tweaking and learning the system, I can easily spend 2 hours a night just getting everything in, because there is not enough time during each visit to document well. I would never have anticipated this problem. Even the dedicated templates are cumbersome; there is just no efficient way to do a diabetic foot exam. Apparently not all EMRs are user-friendly. This one certainly has added extra time to my day.
    Hope all is well with you.

    • Richard Young MD on February 1, 2011 at 10:49 pm

      David,

      I’m doing great. It was great to hear from you. Thanks for taking the time to comment.

    • southern pcp on February 2, 2011 at 7:27 am

      Turning physicians into data entry clerks is a major systems problem with EMRs that is not being addressed.

  6. Emr on March 10, 2011 at 3:27 pm

    I think its not about doctors to waste time on Emr but to make some good choices with technology.

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