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Meaningless use: Electronic health records
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It was the digital equivalent of the Great Land Rush of 1889 when President Barack Obama mandated the use of electronic health records in 2009. Electronic health records were to be used in all medical offices and health care facilities in the country.
With nearly 1 million physicians and thousands of hospitals and other health care facilities that would need to comply, a gigantic, multibillion-dollar market for computer technology was created overnight. The software companies responded by slapping together programs and racing forward with what they had. There was no time to perfect the programs no matter how rickety they were. After all, the perfect was the enemy of the good. What counted was market share. As long as the programs met the government’s criteria, any problems could be solved later. And problems there were.
Incentives, efficiencies
The United Kingdom tried to implement an electronic health record (EHR) system called Connecting for Health. The system was abandoned after burning through $16 billion. The U.S. government, in its quest for a national health care technology infrastructure, allocated $30 billion in incentive payments to help make it happen. The program was called Health Information Technology for Economic and Clinical Health (HITECH), and with it was born “meaningful use,” a program that developed standards for incentive payment eligibility. Payments averaged about $44,000 per physician and millions of dollars per hospital.
Richard O. Dolinar
Years ago, physician offices switched to computerized billing when that method became more efficient than billing manually. Computerized billing didn’t have to be mandated, and offices didn’t need to be bribed to adopt a better system. But now, despite incentive payments, physicians have been reluctant to use EHRs because the technology has not matured sufficiently. The platforms decrease rather than increase efficiency and can be dangerous for patients.
EHRs are a good idea. From the clinician’s perspective, they could eliminate the need to search for lost paper charts, make for easy retrieval of data from well-organized charts, eliminate the need to read someone else’s handwriting and allow multiple users to view the chart simultaneously from different sites. They also could provide advantages for billing departments, third-party payers and government regulators.
Are the current EHR’s ready to do this? Heck no!
Just ask the doctors who use them. In January, the American Medical Association and 37 specialty societies sent a letter to HHS warning that currently available EHRs are not only cumbersome and inefficient, but also pose risks to the patients whose providers use them. Or read the testimony of Jeffrey Shuren, MD, director of the FDA’s Center for Devices and Radiological Health (CDRH). The CDRH is responsible for ensuring the safety, effectiveness and quality of medical devices, including software. Shuren stated that in a 2-year period 44 patient injuries and six deaths that were thought to be attributed to EHRs were reported to his office. Because these reports are voluntary, they might represent only the tip of the iceberg. It looks like the CDRH has its work cut out for it.
Patient safety
Many of the problems involving EHRs stem from the physician–computer interface. In the rush to develop EHRs, this dimension has not been adequately researched or addressed. Doctors interact differently with patients when there is a computer involved.
A 2013 study of Johns Hopkins medical interns found that they spent only 12% of their time talking to patients and 40% of their time working on computers. Another study found that ED physicians spent 43% of their time recording data and only 28% of their time with patients.
When doctors are in an exam room staring at a computer screen, they risk missing nuances of communication that patients telegraph only via their body language. Eye contact has gone the way of Dr. Welby and, in some cases, so has actual patient contact. In one case that occurred in the hospital where I practice, a physician was notified that an ICU patient had developed shortness of breath. Without actually going to the patient’s bedside and physically examining her, the provider viewed her via a remote camera and used the EHR to diagnose a pulmonary embolus. To his credit, he did follow the pulmonary embolus algorithm exactly and had the nurse administer an anticoagulant. Unfortunately, the patient did not have a pulmonary embolus, but instead was having a massive gastrointestinal bleed.
Receiving FDA approval to bring a drug to market takes many years of research and more than $2 billion. EHRs do more than just change the office workflow pattern. They fundamentally transform the actual practice of medicine. They should be evaluated and tested at least as thoroughly as the medications they are used to order.
Compromised time, security
When using EHRs, the health care provider’s attention can be compromised by the need to perform so many computer procedures. Meaningful use requirements are among these. One example told to me by colleagues: meaningful use requires that 5% of patients send a message through the patient portal, so to qualify, physicians had their patients send in requests for baseball scores and other nonsensical things. This wasn’t meaningful use, but meaningless use of the office staff’s precious time.
Meaningful use also requires physicians to show that they are doing due diligence to protect the security of the EHR. This obligation is ironic in light of the 2013 hacking of Department of Defense health records and the massive data breach by the Chinese into the Office of Personnel Management reported in June that involved the security clearance files of more than 24 million government employees. If the government can’t protect its own electronic records, how can I be expected to protect mine? Prior to being forced into EHRs, my paper charts were more secure in my office than government electronic records were in Washington, D.C.
Coding for billing is another computer task diverting attention from the patient. Years ago, there were only three levels of office visits — short, regular and long. It could not have been simpler. A colleague explained it to me in less than 5 minutes. Now Medicare requires us to use codes with myriad combinations and nuances. I spent a whole day in a coding course going through a thick manual to comprehend it.
As if these challenges are not enough, in October, ICD-10 will add another layer of complexity to be reckoned with on the computer. We’ll have more than 100 diagnoses for diabetes.
Snake oil
Physicians trying to provide truly meaningful care for their patients are finding EHRs to be real time killers for themselves and their staff. Because the technology has not matured sufficiently for the doctor’s needs, it often diverts attention from the patient. When focus is diverted, medical care can be adversely affected. A head down in the computer is not the same as looking at the patient in front of you.
Robert Wachter’s recent book on EHRs, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (McGraw-Hill Education; 2015) is both informative and entertaining. Wachter interviewed Matthew Burton, MD, a human factors expert at Mayo Clinic who spends his time working to “bridge the worlds of clinical medicine and information technology.” When Wachter asked Burton what he thought about the massive federal push to get EHRs into health care provider offices and hospitals, Burton replied, “They are mandating the use of snake oil.”
Snake oil or not, if you have been reluctant to make the mad rush into EHRs, you are not alone, but be aware the government has announced that the physicians not using EHRs will be penalized in the near future.
- References:
- American Medical Association. January 21, 2015 sign-on letter to ONC on proposed modifications to the EHR certification process. Jan. 21, 2015. Available at www.ama-assn.org/ama/pub/advocacy/topics/digital-health/medicare-medicaid-incentive-programs.page. Accessed Aug. 19, 2015.
- Block L, et al. J Gen Intern Med. 2013;doi:10.1007/s11606-013-2376-6.
- Citizens Council for Health Freedom website. FDA Testifies to six deaths and 44 injuries related to health IT. November 2012. Available at: www.cchfreedom.org/cchf.php/597#.VdsPTPlVikq. Accessed Aug. 24, 2015.
- Hill RG Jr, et al. Am J Emerg Med. 2013;doi:10.1016/j.ajem.2013.06.028..
- For more information:
- Richard O. Dolinar, MD, is an Endocrine Today Editorial Board member. He can be reached at rdolinar@heartland.org. He reports no relevant financial disclosures.