HEALTHCARE GOES DIGITAL
In my last blog, I promised to delight you with my observations about the Electronic Medical Record (EMR). In accordance with the current custom of using anachronisms rather than words in the medical literature, I will henceforth use the term EMR in my discussion of the topic. Since early on in its development the computer has contributed much to medicine. Without it the various scanners routinely used to make instant diagnoses could not have been developed. It has become an essential tool in medical research. Without computers what many believe was the most important medical discovery of the century, namely the unraveling of the complexities of the human genome could not have happened. One can hardly imagine any area of medicine that has not been influenced by the so called digital age.
Considering all this, it is little wonder that the computer would eventually be touted as the answer to all the problems said to exist in the delivery of healthcare in the United States. The promise was that it would: 1) save money, 2) reduce errors, and 3) improve outcomes. The stick that The Department of Health and Human Services used to encourage adoption of EMRs was to penalize those non-compliant by reducing their reimbursement rates.
1) SAVE MONEY (?)
It is a bit difficult to imagine there could be significant savings when one considers the cost of the initiation and ongoing support for these systems. One study estimates the initial cost of a five physician group to set up a system to be $233,000, not taking into account an average of 600 hours needed for training in its use. Following the initial investment it is estimated maintenance costs would average $17,000 per year. Since the costs for a solo practitioner would obviously be higher, it is not surprising that many such individualists are either retiring, joining a group, or taking a salaried position.
1) SAVE MONEY (continued) / Too many zeros…
But physicians’ costs are chickenfeed compared to the costs of hospital computer systems. Perhaps the most outlandish was the $4 billion spent by Kaiser Permanente. They report however that this will result in a cost of only $444.00 per each of their insured. This came after an admitted $300,000 dollars was spent on a previous plan which was abandoned. The interviewee, CIO Philip Fasano, insists that the $4 billion expended for the current plan is well spent as he believes it will save 15 to 17 percent of costs by eliminating duplicate testing. It will be interesting to see if such savings will result in a reduction of premiums. In addition to the price paid by hospitals and physicians to set up and maintain EMRs, there is the $30 billion spent by the feds on these projects. In my research on this subject I did come upon more numbers, but by then I was so busy counting zeros that I became too dizzy to record them.
2) REDUCE MEDICAL ERRORS ?
As for the reduction in medical errors, the most obvious benefit accrues from the virtual elimination of handwritten orders, reports, prescriptions etc. From personal experience I can attest these are often illegible, and consequently subject to interpretation. Some may insist that poor handwriting is a prerequisite for graduation from medical school. If that is true, then I have been imminently qualified as penmanship was not my strong suite in first grade and it has gone downhill from there. In spite of the problems associated with writing, verbal orders and reports carry an even greater risk of miscommunication. It has been demonstrated time and again that the more steps through which information passes, the greater the likelihood of error.
2) REDUCE MEDICAL ERRORS / The disconnect between theory and application
When information is communicated digitally, it follows there should be fewer errors. If such information can be delivered automatically the risk should be even less. For example, hospital laboratories are largely automated these days, and it follows that if a machine delivers its report seamlessly i.e. without touching human hands it should be less likely to be misread, misplaced, or ascribed to the wrong patient. Unfortunately, Erin McCann of Healthcare IT reports that in a nationwide study 74% of nurses reported feeling burdened by the need to do data entry, which took time away from patient care. The impression left is that much data must be entered manually; consequently most systems are anything but seamless, and therefore still subject to error.
It is easy to imagine the scenario in which a patient’s electronic medical record could be lifesaving. For example, when an unconscious patient is brought to an emergency room his medical record may be critical in making a diagnosis in situations where time may be literally a matter of life and death. As a matter of fact there are many situations when the instantaneous availability of a patient’s record may save time, unnecessary tests, and even lives. It should no longer be necessary to spend time in hospital record rooms or doctor’s offices copying records, x-rays, scans and such. Not only written reports, but actual copies of films, EKGs and such could be called up in order to see if changes have occurred. Come to think of it, there would be no need for record rooms or the floor to ceiling racks stuffed with file folders we see in our doctor’s offices. Yes, in a perfect digital world Joe Patient would carry his entire medical record with him wherever he went and it would be accessible whenever needed, but anyone who owns a computer knows that we are some distance from perfection when it comes to this computer stuff (more about that later).
3) BETTER OUTCOMES ?
The third premise that EMR would create “better outcomes” is still up for grabs. It is noteworthy that, according to a report in FiercehealthIT, 17% of physicians surveyed thought EMRs actually worsened patient care. One might be led to think this group would consist mostly of old digitally challenged physicians like myself, but the disturbing fact is that the number of negative comments has increased since 2012.
According to a Patrick Caldwell piece in Mother Jones5, 75.5% of hospitals were using EMR programs by 2014, but I am not aware of any indications that quality of medical care has improved. Indeed, I don’t know if it would be possible to do such an assessment of an issue that complex. He goes on to issue a scathing report on the business practices of competing providers of EMR software. He contends that the various programs do not share information with each other in order to protect company secrets. This would prevent the seamless passage of information unless all his healthcare providers subscribe to the same system thus defeating a major purpose of the program. Thus Joe’s record would only be available to a consulting doctor or hospital ER if they subscribed to the same version as did Joe’s regular physician. Peter Pronovost MD, director for patient safety and quality at Johns Hopkins, was likewise critical with his statement that: “Medicine invests heavily in medical technology, yet the promised improvement in patient safety and productivity has not been realized.”
EMRs and Me
My own brief experience with an EMR tends to validate the premise that interoperability is a problem. When a facility where I was working adopted a program, I was able to sufficiently overcome my age related aversiveness to change and make a half-hearted attempt at compliance. I tried to hone my deficient typing skills (we had no typing classes in medical school), and dutifully began typing check marks in the boxes provided, which often resulted in a great deal of useless information. There were some advantages, such as the ability to send prescriptions on line rather than writing them on paper or calling the pharmacy. In addition to the convenience for both myself and my patients, it solved my penmanship problem, reduced errors, and prevented forged or altered prescriptions.
Maybe this EMR thing will work after all
With that in mind, I was heartened by the news that our local hospital was going digital. We were dependent upon the hospital’s psychiatric department as a place to send our patients who needed intensive treatment, and for the psychiatric department’s extensive outpatient diagnostic capabilities. I had visions of entering my patients’ identifying numbers in the computer and instantly being privy to every bit of medical information about him. No longer would nurses spend time on the phone calling about lab work, or waiting for the record room to respond to requests for discharge summaries, or reports from consults. The fax machine would no longer go through a ream of paper every couple of days. I would no longer be accused of nurse abuse because of questions like: “Where in the hell did you put that lab work?” As some of my younger, more verbal patients would say: “Dream on baby!” For as computer geeks would say their system was incompatible with ours (in plain speak, their system would not talk to ours) and we were forced to continue to rely on that older, but more reliable invention called the telephone.
Is our healthcare system broken?
The statistics available seem to confirm the premise that the U.S. healthcare system is broken. In an interview by PBS, Mark Pearson the head of the health policy division of the Organization for Economic Co-operation and Development (OECD) provided some discouraging statistics. Politicians have long trumpeted the fact that we spend over 17% of the gross national product (GNP) on healthcare, which is second only to defense spending.
Healthcare by the numbers
Pearson reported that we spent $8,233 dollars per person in 2010, which was two and a half times more than the average per person cost in 33 other developed countries. The average cost for a hospital stay in the U.S. is $18,000 which is three times that of the other countries, in spite of the fact that hospital stays were shorter in the U.S. The Commonwealth fund reports that 25% of that cost is for administration. Drug prices in other countries are sometimes less than half the price we pay, in spite of the fact that the majority of new medications are developed in the U.S., often with financial support from the National Institute of Health. Of course the drug companies also get some help from their friends in congress who have without apology passed a law forbidding Medicare from negotiating prices. Oh yes, just another example of the perverse golden rule of the corridors of power, namely: “those with the gold make the rules.”
What are we getting for all this money?
After digesting all this information, you may be asking, what am I getting for all this money? The answer: not much. There is no doubt that we lead the world in medical research, and people come from all over the world to study in our institutions. We have been the absolute leader in the development of medical technology. Then, why is my life expectancy over one year less than it is in 33 other countries? We might blame it on lifestyle, obesity and such, or could it be that our shortened hospital stays could have a deleterious effect?
Words matter, but true listening requires vision
Patients have complained to me that they are often told their doctor cannot see them in between appointments and they are told to go to the emergency room sometimes with even minor complaints. But the most frequently heard grievance was “my doctor doesn’t listen to me.” Not surprisingly, this was more commonly heard as the digital age invaded the consultation room and some physicians pecked away at their computers while the patient talked. Of course, there is much more to effective communication than the use of words, and no matter how attentive the listener, without visual cues much of the message is lost.
In my humble opinion, it is incredibly naïve to think that computerization could have a major effect in closing the gap between us and the OECD nations. After all we are undoubtedly ahead of them in implementing EMRs and management systems; consequently, any advantage gained would be countered as they would inevitably follow suit with similar technology. You may be asking what is the answer, if EMRs are not. I have long held the position that there is a shortage of medical doctors in this country, and OECD study tends to bear this out. They report the U.S. has 2.4 physicians per 1,000 people while the average for the countries scrutinized was 3.1 per 1,000. Thus we have fewer physicians, fewer hospitals, and shorter hospital stays at 2 ½ times the cost.
What we do have are more CT and MRI scanners along with lots of other expensive gadgets, and they are utilized much more frequently than in other countries. One disturbing bit of research by the Dartmouth Institute for Health Policy concludes there are very large differences in the rates of utilization of such diagnostic machines in different areas of the country.
Even more upsetting is their conclusions that the number of elective surgeries, cardiac interventions, and even open heart surgeries are all performed at vastly different rates in different areas of the country. Should we conclude from this that some areas of the country are over treated or that others are undertreated? Information obtained from the OECD study would suggest the former is likely true. Hospitals are required to have a utilization committee composed of physicians who look for outliers among their peers; however, in my experience they are not very effective in rooting out excesses. Indeed, if they were one would not expect to see such disparities in diagnostic procedures and treatments.
Enter Managed Care
In recent years insurance companies’ managed care programs have gotten into the act. They exercise control by simply not paying for services they feel are excessive. I believe it is safe to say that they are universally hated by physicians. I share that feeling with more intensity than most of my colleagues because I blame them for the too early discharge of one of my patients which led to his death. It is interesting that the courts have ruled in such cases that the managed care company suffers no liability with the rationale that they are not denying treatment, only refusing to pay for it.
No doubt, many of the problems I have enumerated with The EMRs will be fixed eventually, and the concept can be of marvelous benefit, but it is also clear to me that computers will not fix everything that is wrong with our medical system.
So, what is the answer?
At this point, if you are still awake, you may be thinking: “OK wise guy, if you are so smart, what would you do about it?” And I would reply, “Thanks for asking for of course I have all the answers.” After all, I have been a participant and observer as medicine evolved into the current mess, besides I now have learned how to use Google.
The Age of Assembly Line Medicine
It may seem counterintuitive, but I am convinced that a significant part of the problem is due to a shortage of physicians. No, it is not merely a matter of competition although that is not necessarily a bad thing, rather it has to do with the pressure to be productive. Dealing with lives merits deliberation, and impulsive decision making is apt to lead to errors. The production processes of assembly line manufacturing Henry Ford developed may be advantageous for manufacturing cars, but completely inappropriate for treating human beings, especially those who are sick, in pain and in distress.
The lost art of LISTENING
One of my professors from medical school once said: “if you listen carefully to your patients they will make the diagnosis for you 80% of the time.” As I mentioned previously many of my patients complained that their doctor was not attentive, and always seemed in a hurry. Since there is a shortage of physicians, there will be a need to see more patients; consequently less time is made available to talk, and the doctor seems remote and uncaring. The patient may leave with unanswered questions and harboring a great deal of anger. When called upon to consult with hospitalized patients as a psychiatrist, I often found the problem to be the result of a doctor patient relationship gone bad. To the physician, the patient seemed unruly and uncooperative when they just didn’t feel they were being heard.
Another downside of failed communication between a physician and patient is litigation. As a matter of fact, insurers report this scenario is a major cause of malpractice suits, and that the best protection from malpractice suits is a good doctor patient relationship. Of course the cost of these suits, which are less prevalent in other countries is also said to be a major cost factor. Some states have initiated procedures to help reduce the number of suits and to limit the amounts which could be paid; meanwhile refusing to search for reasons for why there are so many suits filed.
A few years ago, after retiring from private practice, I began working part time at a public facility that had a very long waiting list of people needing to be seen. I was asked if I would be able see a patient every 10 minutes. I replied haughtily that I was not a prescription technician, yet afterward wondered how many of the people on that waiting list might be suicidal. These are the kinds of dilemmas facing doctors, especially those in primary care settings (i.e., if you spend adequate time with each patient, how many won’t be seen at all). In my small town, there are very few primary care physicians who are currently accepting new patients leaving many people to seek care at our ER which of course is much more expensive. The solution, which is currently underway, is to license those with lessor training to diagnose and treat. I am sure there is also the thought that these nurse practitioners, physician’s assistants and such will demand lower fees, although that may not have work out as expected. I also question the wisdom of solving the doctor shortage in this manner, especially during a time when the increasing complexities in medicine demand more knowledge than ever before.
Fee-based vs. appointment-based physicians
There is also, in my opinion, a maldistribution of physicians, with the shortage most acute among primary care doctors. Family doctors have always been the grunts in the healthcare domain, with the specialists commanding the most respect especially the surgical specialties. Those who do procedures are reimbursed based on a fee schedule while primary care docs are essentially paid based on time spent with the patient. This can lead to serious inequities in incomes. The days of the solo general practitioner are past, for most find they cannot generate enough income to pay their overhead. It requires a considerable staff to do billing, get authorizations from insurance companies, fill out forms, deal with managed care, medicare, medicaid, pharmacies etc. He is forced to accept insurance company fee schedules if he wants to be “on their panel”. Add his malpractice insurance to the mix and soon he will be looking for a salaried job or a group to join. Young doctors may be saddled with hundreds of thousands of dollars of student loan debt which can be a powerful motivator in choosing a career choice as he may look toward the more lucrative specialties.
In 1965, I had been doing general practice for a very few years and when medicare came in to being that year I was convinced that this was the beginning of the end, and Joe McCarthy was right when he said we were well on our way to being taken over by the communists. The precedent of connecting healthcare to employment had already become entrenched by corporations who used that fringe benefit to attract workers during the labor shortages of world war II, but in the 60s Blue Cross and Blue Shield were the only significant players and all that was necessary was to send a bill and receive payment. Of course it made no sense for health insurance to be tied to employment, but the labor unions were not about to give up that goody, and it remains in ObamaCare, which is one of the reasons why although better than nothing it is not by much.
Now, 50 years later, I have eaten so much crow that I regurgitate black feathers as I have become an unabashed promoter of a single payer system, that is medicare for everyone. Such an idea is certainly not new as it was first proposed by Teddy Roosevelt in 1912. I have dealt with a system that has become increasingly complex each year, and have done battle with giant corporations whose major function appears to be to find ways to deny treatment to those whom I feel are in need. I have this perhaps naïve view that with the insurance companies out of business and their lobbyists gone maybe our do nothing congress might do something beneficial for their constituents.
One frequently hears that socialized medicine would bankrupt the country due to the inevitable inefficiencies that would result. The reality is that medicare may be the only efficiently run federal program in existence with an administrative overhead of less than 3%. The affordable care act only allows health insurance companies 20% in administrative costs, whoopee. Of course this does not take into account the millions of dollars spent by hospitals and doctors which would be greatly simplified if they only had one entity with whom to deal. Even without taking this into account, we would reduce total health care costs by at least 15% if not more.
More savings could also accrue were congress to repeal that ridiculous law prohibiting medicare from negotiating drug prices. In addition to the effect on total costs, I find it repugnant that populations all over the world pay less than I do for my medications. This seems unlikely to change since Pharma seems to be especially adroit with their lobbying efforts. I would be very interested to hear from Congress their rationale for this law. It must be a dandy.
There is also the economic effect on businesses to be considered. Many industries report that providing health care for their employees is a rapidly rising expense that makes it difficult for them to compete internationally. One would think they would be busy lobbying for a single payer system. The digital movement in healthcare has spawned new departments in most institutions. In the mental health center where I had recently worked one person managed to keep all the computer stuff running, until the introduction of an EMR. It soon became necessary to hire 2 more people, and an IT department was born.
Longevity has its advantages, and in my case it has allowed me to witness and in a small way be part of the profession of medicine during a period of momentous discoveries. The 60 years of my involvement saw the virtual elimination of many illnesses which had been responsible for millions of deaths and untold suffering. When I began practicing medicine, if someone told me that it would one day be possible to transplant a human heart I would have laughed in their face. To confirm the suspicion of a brain tumor would require two or three days of tests some of which were dangerous, now an in depth picture of the brain is available in a matter of minutes. Even in my own field of psychiatry the study of the mechanisms underlying brain functions has revolutionized the field, and the complexities described often leave me wondering what the hell they are talking about. This paper is in no way meant to denigrate these accomplishments; rather it is an attempt to expose some of the factors which have resulted in an inefficient and costly system of providing them to the masses.
At the outset, I listed three goals that were hoped to be accomplished by the digitization of our medical records. The first was to decrease cost. From what I was able to glean from my research and personal experience I have concluded that the attainment of such a goal is unlikely. As for the other two, I am convinced that an all-encompassing computerized system has the potential to improve treatment outcomes and reduce errors. Unfortunately, the systems in play are too fragmented for that potential to be realized. It would appear that fixes are readily available. It remains to be seen if they will be applied.
As with most old guys I like to end my conversations with reminiscences of the good old days even though the current ones may be better. In spite of a lifetime in which I have witnessed the most exciting time ever in medicine, a time of more discoveries and progress made in the alleviation of suffering than had occurred in thousands of years, I sometimes feel nostalgic for the way things used to be even though without the miracles of modern medicine I would probably not be here today. I recall a time when the doctor patient relationship seemed much more personal than it does today, when doctors saw themselves as healers rather than fixers or technicians. I remember a time when one could even talk to one’s doctor on the phone. Now if I have a question for my doctor I must answer to the receptionist regarding my reason for calling, and if she considers it worthy of note, she will post a message to the doctor’s nurse or direct the call to the nurse’s voice mail, and if the nurse considers the question worth consideration she may consult with the doctor, but if not will devise her own answer. If she is not too busy, I may be fortunate enough to receive a call back with either the doctor’s or her answer to my question. In any event the doctor will be insulated from the stupid patient with his stupid questions. You might think that since I am a physician I would be more readily granted access, but you would be wrong for the fellowship of physicians is no longer a strong tradition.
How it used to work
I remember a time when most people had a personal physician, and usually their relationship was indeed personal. If admitted to the hospital your personal physician would see you daily even if he had referred you to a specialist, now you are apt to be followed by a hospitalist whom you are meeting for the first time. Were you to have surgery, your doctor would assist if possible. A visit to the emergency room would prompt a call to your doctor. If you were unable to come to his office, he would come to you. In short your doctor was in charge and responsible for your treatment. He would likely know your strengths, your weaknesses and usually knew most of the members of your family. In short the doctor patient relationship was very personal.
There have always been those dedicated to healing their fellow man even in prehistoric times and in the most primitive of cultures. Much of the science has been off track; however, there has been much learned about the art of medicine. It would be a great loss if that knowledge were abandoned in favor of purely digital solutions.
1. Health Affairs: Study puts a price on EMR implementation in small practices
2. Info World: tech’s bottom line May 2, 2013.
3. Healthcare IT News: Nurses blame interoperability woes for medical errors. March 15, 2015
4. FierceHealthIT: The cost benefit calculation of electronic health records systems.
5. Mother Jones: Epic Fail, November/December 2015.
6. PBS Newshour: Health Costs, How the U.S. compares with other countries October22,2012.
7. The Dartmouth Atlas of Healthcare: Reflections on Geographic Variations in Healthcare, May 12, 2010.