Rocky road to electronic medical records by Marjorie Arons-Barron

The entry below is being cross posted from Marjorie Arons-Barron’s own blog.


stethoscopeHave you ever wondered if the doctor who saw you in his office would recognize you if you met at the grocery?  He or she might not, and it’s not just because you’re in street clothes. It might be that, with new health care regulations for computerized data gathering, he spent most of your annual checkup facing the computer screen, not looking at or interacting with – you.

Obamacare has done many good things: getting 20 million more people on health insurance; eliminating preexisting conditions as a reason to deny coverage; allowing young people to stay longer on their parents’ insurance. It also mandates conversion to electronic medical records (EMR), a great way to enable doctors and hospitals  to exchange patient information, reduce duplicate tests, and improve patient care. At least, that’s the idea.

Things started well enough when hospitals had their own in-house computer gurus, but their ability to share records with other systems was limited. It still is today, and that’s not the only issue. For many providers,  the process has become one of epic proportions, especially with Epic software, the company which controls a majority of the multi-billion-dollar conversion business.   “On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy,” according to an emergency department chairman in San Francisco.

Clearly the system was not designed with the end-user in mind.  As the author of Digital Doctor put it, Boeing engineers would never design a cockpit computer without input from the pilots.

Epic promised a comprehensive data collection system to maximize and speed up reimbursements.  Docs say its software may be useful for a general hospital or clinic, but its protocol is not suited to facilities providing specialized care, such as for patients with cancer, burns, physical therapy or diabetes.  Providers across the board are experiencing the pains of conversion.  And patients should be prepared for scheduled appointments to be cancelled, prolonged waits, lengthy visits and even lost health records.

After billions of dollars spent converting to EMR, hospitals are still stymied in the exchange of patient records.  Lack of interoperability has raised the ire of Congress. And other aspects of the software are decidedly not intuitive or user-friendly. If data aren’t properly entered, there will be coding problems that thwart reimbursement. And the decision trees do not necessarily conform with the ways doctors elicit information from and assess patients. Both doctors and patients are discouraged from asking open-ended questions and patients, from volunteering information, while doctors fill out rigid check lists. At other times, the system shuts itself off mid appointment,  and doctors have to log in again.

Because the idea is to have the most comprehensive information on each patient visit, a doctor in a follow-up session can’t skip the far-reaching information gathered in an original visit, asking only the relevant questions and skipping others. In effect, the software architecture is  controlling their thought processes. Some time-pressed doctors simply input old test data using the current date.

A doctor who is stymied and can’t “close an encounter” (that is, finish a report on a patient visit) is supposed to call an in-house “super user” or a help desk. Getting help can take two or three days.

Because Medicare reimbursements are structured to allow only so much time per patient visit, doctors can’t focus on the patients and input their notes immediately afterward because they are forced to move directly on to the next patient. The doctor can no longer dictate patient notes remotely but must do it sitting before the computer in order to access the 10-digit code of the patient visit.   All this means that the doctor can see fewer patients. I’m told that Maine Medical Center, Lahey and others have actually lost money in the early stages of using this software.

Medicare  cuts reimbursements to providers not complying with “meaningful” use of electronic medical records (EMR). The real meaning is that patients have to compete with the computer for the doctor’s attention. Neither doctors, nor nurses nor patients are happy about this.  Apparently the only entities satisfied by the new software are the vendors themselves (including Cerner, Allscripts and Epic), whose lobbying enabled their participation in the shaping of federal IT regulations and standards for health care.
They were also lavish in their campaign contributions. Ironically, despite the government’s push for nationwide uniformity, the Pentagon last summer awarded a $4.3 billion contract to Cerner.

As one doctor wrote in a 2012 issue of the Journal of the American Medical Association, the federal government is spending in excess of $20 billion to incentivize converting to electronic medical records.  We should all wonder how that money will be spent and what will be the human costs incurred along the road to electronic nirvana.

I’ve seen a few of the “old guard” doctors still jotting notes while facing their patients, not letting the software come between them and those seeking their help.  But they seem to be the exception these days.  Frustrated, many are being driven into retirement, just when there’s a shortage of doctors.

There is no going back, nor should we. But software vendors must be compelled to get end-users involved and be as actively involved in resolving problems as they were cashing in on the opportunities presented by Obamacare’s push for EMR. Only then will patients realize the quality care promised in the Affordable Care Act.

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