Almost 4 years ago, the government announced it would require doctors and hospitals who accept Medicare to implement electronic medical records (EMRs). At the time, I posted a blog about the pitfalls of this decision. I said that EMRs would not save money, and that the quality of medical care would suffer. I explained that in a recently published editorial in the WSJ, two Harvard Medical School professors had mirrored my opinion. These doctors stated, for the record, that they had voted for Mr. Obama for president. Theirs was not a partisan political attack on EMRs. These professors supported Mr. Obama’s policies in general. However, they were deeply disappointed that Mr. Obama had made the unsubstantiated claim that by implementing electronic records, the nation would “save $80-billion-dollars per year” in medical costs. It was further asserted that electronic medical records would “decrease medical errors, reduce duplication of testing and would improve the quality of care.” The professors noted that Harvard had implemented electronic medical records 8 years earlier, and that this move had neither decreased costs, nor improved medical care.
Let’s fast forward to September, 2012: The New York Times has just reported that electronic medical records have increased, not decreased, the cost of medical care. The increased costs are in the billions! This is not surprising. For any practicing physician, this result was completely predictable. Since Medicare and private insurance reimbursement is based upon the level of complexity of any given doctor visit, the designers and sellers of electronic billing programs have made “upcoding,” or billing more for the same visit, as simple as clicking a button. These records programs are written in template form, so that it is very easy for physicians to bill a higher level of complexity by picking a different template. If you need more paperwork under Medicare guidelines for the higher charge, you simply add the necessary information in boiler-plate form. As an example of this phenomenon, I am now getting 4-page dictations from ENT physicians, for a simple ear wax removal. Ear wax removal can now be billed at a higher code due to EMRs, because there are 4 pages of single-spaced, typed nonsense, justifying the cost of a more expensive wax removal. Yet the removal of said ear wax is no more complicated than it was 30 years ago. It is also worth no more than it was 30 years ago. EMRs have literally added billions to our healthcare costs, and have added no real value.
Now, it is bad enough to learn that this incredibly expensive conversion to electronic medical records will actually cost tax payers more money than standard records. However, there is a much more dangerous aspect to EMRs, which may well be affecting the quality of the medical care that you are now receiving. The EMR is actually inferior in quality to a traditional, dictated, paper record. Let me explain.
The Doctor Visit Narrative
When a patient comes to see me with a problem, such as chest pain, I dictate my findings into an inexpensive, $29 plastic cassette recorder. The tape is then transcribed by a medical transcriptionist, the old fashion way. This record becomes a snapshot in time. It includes all of the pertinent positive and negative findings during my exam. It is not a boilerplate or template generated by a computer program. It is an individualized record, reflective of what I actually heard from the patient and saw with my own eyes. This record paints a picture of an individual’s symptoms and exam findings.
When I look back at my record at a later date, this narrative reminds me of exactly what I was thinking at the time of the last visit, and tells other doctors who might review my records precisely what my thoughts were during the visit. Since a medical history often evolves and changes over time, this narrative is incredibly important in the process of diagnosing and treating complex medical problems. There is no substitute for this kind of individualized documentation, along with the documentation of the doctor’s thinking that was employed during problem solving.
As an example, let’s take another look at the hypothetical example of a patient with “chest pain.” In seeing such a patient, I would describe the nature of the chest pain, the duration of the pain, precipitating factors, and things that relieved the pain. I would record the absence of symptoms and physical exam findings that would implicate less common causes of chest pain – other than heart disease – such as a blood clot to the lung, gallbladder disease, a dissection of the thoracic aorta, or esophageal spasm. At the end of my dictation, there would be a formal “assessment.” This assessment would represent a synthesis of the data, and would describe my clinical impressions – the reasons that I believed that diagnosis X was the most likely cause of the chest pain. Finally, there would be a “plan” in my dictation, which would follow logically from the assessment. The plan would include any tests that I would have ordered, referrals to a specialist or the kind of follow-up I had scheduled. It would also include specific instructions I gave to the patient.
An Electronic-Alternative Universe
Sadly, in an electronic medical record, an alternative universe is often created that bears little resemblance to the facts or to a specific person. This universe is not based in observation, but is driven by billing concerns. It is often very difficult to glean what a doctor was thinking by reading an electronic record. Standard templates have replaced individual narratives, often times with very little in the way of an assessment or plan. When I read these electronic records, I often have no idea what the doctor was actually thinking. There are times when I will actually have to call a specialist and try to get more details. Ten years ago, I would get a letter from a specialist, telling me what he thought was going on with my patient, along with a copy of a high-quality progress note. This is a thing of the past. This shift has resulted in a dumbing-down of the medical record and an assault on the very process of medical reasoning.
Many doctors who use electronic medical records are responsible for typing their own records. This is yet another way to “lower costs,” by cutting the transcriptionist out of the picture. However, time constraints force the doctor to type as little as possible, because he is trying to see more and more patients every day. So the doctor now starts with a template, which contains many canned questions and answers for a given code, followed by a one-word assessment, which he manually types into the document. How do I know this? Because the questions and answers I get from these EMRs are identical for every patient with the same diagnosis, regardless of the differences in their cases. I am at the point that I can now tell which EMR program a urologist is using, because his notes are no different from those of his colleague!
What’s the Big Deal?
So who cares if there is no narrative record as to what the physician was observing and thinking? Does it really matter? Yes, it does! The practice of medicine involves many variables, which can change over time. A new question or new symptom can completely change the diagnostic possibilities and therefore, the treatment. People are individuals. They often present with funny manifestations of common problems, like heart disease presenting as elbow pain with exertion. When the doctor’s primary focus is to simply pick the closest template from a computer program, with the highest possible billing code, and he/she fails to describe the subtleties of his/her thinking, critical clinical information is lost forever. This directly impacts patient care. Three weeks later, the doctor cannot remember the differences between one case and the next. In addition, important information is not communicated to other doctors on the medical team.
The great economist and philosopher, Thomas Sowell, points out that many “great ideas” dreamed up by people with high IQs in positions of authority have often resulted in catastrophic failures for society. The reason is simple: When people with no working knowledge of a profession make policy changes, they cannot anticipate potential problems or unintended consequences, no matter how smart they may be. Politicians and central planners have no “consequential knowledge” of most professions. Consequential knowledge, as defined by Sowell, is knowledge gleaned from working in a specialized area, the presence or absence of which, can have great consequences. Without a working knowledge in the field of medicine, for example, politicians have no way of knowing what the unintended consequences of EMRs. More importantly, when they make wrong-headed decisions, there are no consequences for them. Though his “solutions” often create more problems than they solve, the politician simply moves on to his next great plan. Hence, we have a Medicare and Medicaid system that is going bankrupt, as we implement a new “cost-saving program” for EMRs, which costs us even more.
Your Doctor’s Records
As you know, I have declined – for many reasons – to convert to electronic medical records in my office. I continue to use a paper medical record, since I have no financial conflict of interest or pressure to act against my better judgment from third-party payers. As a result, my records remain narrative. Other doctors – such as specialists I might send you to see – will know precisely what I am thinking when they review your medical records. They will know what I’ve already done to evaluate your complaints before you see them and they will be able to operate more efficiently on your behalf.
With a paper record, the confidentiality of your medical records will be maintained. No one can hack into a computer system and look at your private and personal information on-line. As you’ve no doubt read, multiple episodes have already occurred in which the medical records of thousands of patients have been posted on the internet.
No two people in my practice are the same. People in my practice are not treated as an “ICD 9 Code.” They are not just another case of chest pain or BPH. When I am dealing with a complex problem that evolves over time, I know exactly what I have done in the past by simply looking at my chart. If there is something that I failed to think of initially, it is all documented, and I can order additional testing as appropriate. Your evaluation will not be confused with that of other people in my practice, because no two charts look the same. I don’t use IC9 codes or templates, because they do not represent any medical reality and they serve no useful purpose.
Experiencing Life thru Bytes
Information technology can do wonderful things. But new technology is neither intrinsically bad nor good. The litmus test regarding the value of new technology should be the presence of clear evidence that the technology provides a better outcome. As an example, I have a computerized medical textbook that is updated electronically on a weekly basis, by the world’s leading medical authorities in every area of medicine. This is an invaluable tool in my practice and it has clearly improved patient care. I use it daily. However, using technology for technology’s sake – like EMRs – is foolish, and can actually compromise care.
If you don’t believe that there is the downside of the indiscriminate use of technology, and that we are moving toward a disconnection between electronics and reality, just look at young people at the mall or in a movie theater. Look at them with their electrical appendages – “tweeting” and “texting” – as if the real world around them does not deserve their focus and attention. “LOL! OMG!” Is it really better to look at an emoticon on a screen from another person with a hand-held device than to look at the person smiling across from you? I’ve actually observed couples on a date in a restaurant, texting someone else, as if their date was not even sitting at their table. You see people driving with their noses buried in their iPhones, texting as if the reality of driving their 3,000 pound vehicle is less important than a friend’s text about what he has just eaten for lunch. If television made us dumb, our electronic alternative universe is making us even dumber.
Electronic medical records are a cheap imitation of what really happens between a doctor and a patient during a medical visit. EMRs are a failed, expensive experiment. EMRs are not saving the system money; they are costing the system more. EMRs are not improving the care of patients; they are compromising the quality of care.
“I fear the day when the technology overlaps with our humanity. The world will only have a generation of idiots.”