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.