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How Electronic Medical Records Have Hurt Primary Care

February 5, 2011
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Two more recent studies I didn’t mention last week documented how little influence electronic medical records (EMRs) had on outpatient care.

One study measured 20 markers of quality between practices with and without EMRs over 255,402 national ambulatory patient visits. 19 of the 20 quality indicators were no different between the EMR and paper clinics. Among the EMR visits, comparing quality indicators between practices that had clinical support systems (pop-up reminders basically) and those that didn’t, 19 of the 20 quality indicators were no different.

The other study reviewed 53 previous reviews of the effectiveness of “eHealth.” It concluded “There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and “techno-enthusiasts” as if this was a given.” I couldn’t have said it better myself.

The safety net healthcare system I work for provides an example of a phenomenon occurring all over the country. It has committed about $150 million dollars to move the entire network to a fully-integrated EMR system, both inpatient and outpatient. I don’t fault the system for doing this. I understand how federal incentives and disincentives, and national conventional wisdom, have encouraged the system to commit to this undertaking.

The problem with this endeavor is that for the next several years, all significant capital and new operating money will be sucked into the EMR project. The reality of opportunity cost means this money can’t be spent on other uses.

If memory serves me, the network built large primary care centers in the past for about $2 million each. Operating expenses must be committed after a new primary care center is built, but you get a sense of the relative cost of an EMR system versus expanding primary care capacity in an integrated healthcare network. This financial decision comes at a time of flat tax revenue and an increasing number of patients who lost their private health insurance and now seek help from the county system.

While this national investment in EMRs continues across the country, the Council of Graduate Medical Education recently concluded, “There is a dramatic shortage of primary care physicians for adult care and a maldistribution among primary care physicians across the nation. Decreased medical student interest in primary care is caused by multiple factors in­cluding heavy workload and insufficient reimbursement.” It recommended American payers must “. . . increase payments immedi­ately to primary care physicians and practices.” Other national organizations have made similar statements about increasing primary care pay, even the American Medical Association at times, yet no payer has committed to a dramatic increase in primary care pay. Why hasn’t this happened?

In any complex system, there is only so much mental, emotional, and financial capacity for change. Pushed by technology companies and well-meaning health system and patient advocates, EMRs have become the latest diversion of time, energy, and resources of American healthcare toward technology and away from real primary care reform. My local healthcare system is a perfect example of how money spent for one purpose, EMRs, can’t be used for another purpose, expanding and supporting the primary care infrastructure.

Maybe in the future EMRs will become cheaper like DVD players and plasma TVs, and a new doctor entering practice won’t be faced with a huge up front capital expense to buy an EMR for her clinic. Unlike consumer electronics, I just don’t see this happening for EMRs. As the tech companies developing EMRs are learning, the complexity of healthcare is many times more difficult than delivering a movie into someone’s house.

Starting in 2004, the leading organizations of family medicine took aim at the future and shot family medicine in the foot. The EMR misfire started with the Future of Family Medicine project, which assumed EMRs would transform primary care — including improving patient care, patient satisfaction, and family physician income — without first testing the assumption. This was followed by the continued blind allegiance to EMRs in the disappointing TransforMed program.

How could a branch of medicine that claims to be about personal relationships and high touch care let itself be snookered into promoting another step toward hyper-technologized American Medicine, as opposed to real support for practicing family physicians and their patients through payment reform? It boggles my mind.

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6 Responses to How Electronic Medical Records Have Hurt Primary Care

  1. Gerry Wieder on February 6, 2011 at 1:05 pm

    At best, I see evidence here that EMR implementation doesn’t make any significant improvement in the delivery of care at the point of care, and scant evidence that having and EMR actually makes patient care worse (the premise put forward in title of this article).

    In parts of the industrialize world with wider EMR activity than the U.S. (India, some countries in Europe), there are demonstrated improvements in patient outcomes, and level of medical innovation (again India) that at least equals the U.S.

    • Richard Young MD on February 6, 2011 at 10:22 pm

      Gerry,

      Thanks for your thoughts. There are a few studies that actually found care measures got worse after EMR implementation, but I think the totality of the evidence is that it’s pretty neutral. It’s hard to deconstruct the cause/effect of EMRs vs. payment issues vs. generalist physician supply just by observing other countries’ performance. Probably the best evidence is the controlled studies performed in the U.S. recently. Also, be careful to separate process measures such as how often hemoglobin A1Cs are checked vs. outcomes patients care about such as hospitalizations, ER visits, MIs, strokes, and death.

    • southern pcp on February 9, 2011 at 9:32 am

      I think part of explanation is that in some other countries, EMRs are actually designed to improve patient care.

      Here, because of the strangle-hold of ICD/CPT, EMRs are, as others have said, basically just glorified billing machines, with a poorly-designed patient care module on the side.

  2. southern pcp on February 9, 2011 at 9:30 am

    “How could a branch of medicine that claims to be about personal relationships and high touch care let itself be snookered into promoting another step toward hyper-technologized American Medicine, as opposed to real support for practicing family physicians and their patients through payment reform? It boggles my mind.”

    Every practicing family doc I know feels the same way. A previous president wrote that the current AAFP leadership is more interested in photo-ops than working for their members. I know longer think of the AAFP as incompetent. I am convinced that they are actively hostile to working physicians. They seem to have completely insulated themselves from differing points of view. Any thoughts as to what we can do? Thanks.

    • Richard Young MD on February 9, 2011 at 10:36 pm

      southern,

      I think the leadership of the AAFP is slowing turning the ship in the right direction. Let’s have a glass-is-half-full recognition that we finally have a PAC after years of misguided idealism.

      I know national politics is messy and complicated, and I don’t pretend to begin to understand the nuances. I believe Dr. Goertz is doing a great job behind the scenes at making sure the right bullet points are spoken both in public and in private, though he probably says EMR too much (full disclosure, I know him). In the final analysis, the leadership of a large organization can’t do much more than the membership supports. Another important reform is for America’s family physicians to rise above their passive nice-guy natures and realize that if they advocate for better professional lives for themselves, it also means our patients’ lives will be improved, both through better healthcare and less stress on the non-healthcare majority of our economy.

      • southern pcp on February 10, 2011 at 7:56 am

        Thanks for the reply.

        I wish I could take the half-full attitude. But it seems to me (after 20 years in practice), as the prognosis for family medicine becomes more dire, the gap between what needs to be done and what the AAFP is doing is becoming much wider.

        A PAC is great, but if they spend their time and money lobbying for PCMH demo projects and EMR funding, aren’t they making things worse? Why does the AAFP continue to affiliate with the AMA, which has been intentionally destroying our speciality with the RUC? Surely, a well-publicized rejection of this corrupt organization could not make things any worse than they are!

        “Another important reform is for America’s family physicians to rise above their passive nice-guy natures”

        And that’s exactly what we need from our leaders.

        Really, the only hope I can see is for the AAFP to openly declare primary care in complete crisis. 100% of their time and money needs to go into a down and dirty fight for payment reform. All EMR and PCMH activities should be completely defunded. It may not work, but trying to “get along” sure hasn’t worked, and it would a least give me the sense that someone is looking out for my interests. I follow the AAFP very closely, and I do not feel that way now.

        That’s my rant and I’m sticking to it.

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