EMR panacea under attack
I’ve argued here on Dr. Bobbs that EMRs are not ready for prime time for most practices and will not result in increases in efficiency or cost reductions for practices that are not ready for them, that is to say, most medical practices. It appears I’m not alone in this assessment. Brandi White at the American Academy of Family Physicians’ Noteworthy Blog:
Electronic medical records are being touted as an essential ingredient in health care reform. Most recently, the Obama administration proposed the national adoption of EMRs on the grounds that it would save $80 billion a year and improve the quality of health care.
But not everyone is drinking the Kool-Aid.
Drs. Jerome Groopman and Pamela Hartzband, faculty of Harvard Medical School (and, notably, both Obama supporters), recently called EMR adoption “an overly simplistic and unsubstantiated part of the solution” and had this to say in The Wall Street Journal:
“The basis for the president’s proposal is a theoretical study published in 2005 by the RAND Corporation, funded by companies including Hewlett-Packard and Xerox that stand to financially benefit from such an electronic system. And, as the RAND policy analysts readily admit in their report, there was no compelling evidence at the time to support their theoretical claims. Moreover, in the four years since the report, considerable data have been obtained that undermine their claims. The RAND study and the Obama proposal it spawned appear to be an elegant exercise in wishful thinking.”
While there are real benefits of EMRs – such as medication alerts, reminders and increased legibility – it turns out that, despite all the hype, there’s no evidence that EMRs actually save the system money and improve outcomes. (They also can’t share data with one another and are cost prohibitive in many cases, but that’s another blog entry.)
Groopman and Hartzband cited several studies demonstrating the problems with EMRs:
“A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer – 48 compared to seven in the paper-based cohort. … A 2008 study published in Circulation, a premier cardiology journal, assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that ‘current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems.’ Similarly, researchers from the Brigham and Women’s Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. These experts concluded, ‘As implemented, electronic health records were not associated with better quality ambulatory care.’ And just this past January, a group of Canadian researchers reviewed more than 3,700 published papers on the use of electronic medical records in primary care delivered in seven countries. They found no solid evidence of either benefits or drawbacks accruing to patients. This gap in knowledge, they concluded, ‘should be of concern to adopters, payers, and jurisdictions.'”
The bottom line: Once again, physicians are being told to invest their time and dollars in an unproven strategy on the hope that it will eventually pay off. An alternative approach, one advocated by the Network for Regional Healthcare Improvement, would be to create a system that rewards physicians and pays them fairly for achieving the desired outcomes regardless of the specific technology or tools they employ.
It is a constant source of amazement that self-proclaimed health policy “experts” seem to accept as a matter of faith that replacing hundreds of dollars worth of paper in every medical office with tens of thousands of dollars of EMR hardware and software will cause health care costs to plummet. Of course, our government appears to think that we can spend our way out of a recession and big business sees nothing amiss about being flown into Washington, D.C. in a private jet to beg for taxpayer money to prop up the corporation they’ve run into the ground. It all seems to be of a piece with the Alice in Wonderland logic of our time.
Moreover, while EMRs are good at quickly generating large, detailed notes, they are less adept at producing concise, actionable information as noted by Grider, et al in Medical Economics:
In April 2008, a study published in the New England Journal of Medicine reported similar problems, pointing out that “Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians’ thoughtful review and analysis. They may be ‘efficient’ for the purpose of documentation but not for creative clinical thinking.”
The study also reported an example of the consequences of these problems: “A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development . . . Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.”
It gets even better. From a medicolegal standpoint, those big, impressive EMR notes may be less of a shield than a lightning rod:
[C]ertain types of data-entry functionality…result in “cloned documentation,” in which the records of every visit read almost word-for-word the same except for minor variations confined almost exclusively to the chief complaint.
Physicians have long been counseled that a well-documented medical record provides the best defense in the event of a claim of medical liability. The June 2008 issue of the Journal of AHIMA quoted EHR legal expert Patricia Trites on the potential danger of electronic systems that permit copying of near-identical documentation into large numbers of patient records: “From a medical-legal standpoint, what would [lawyers] do when they [see] this chart?” she asks. “They are going to rip it apart.”
Of course, physicians can already do a lot of dubious documentation with check box sheets, or by having a template for their transcriptionist (e.g. “Physical exam: insert normal gynecologic exam into note.”). And much of the documentation from patient encounter to patient encounter is repetitive: Most heart exams reveal regular rate and rhythm, normal S1 and S2, no murmurs, gallops, or rubs, for example. But third party payors have a built-in incentive to try to avoid paying for claims and lawyers will often twist the facts to favor what they are trying to prove: An overly brief encounter note or a massive, templated encounter note can both be used to argue that the physician is trying to hide something.
I suspect the EMR backlash will continue and grow.