Why physicians don’t adopt electronic medical records

Most of his article is very good. The parts about fearing that you’ll lose patients is silly, like Panda said I really don’t know anyone crying for more patients and as the boomers get older this is just going to become more the case. The parts about liability and extra time are dead on, though. The idea of being legally responsible for reviewing every aspect of a patient’s care when it involves 20 doctors and you have a 15 minute visit is a goddamn nightmare.

The (real) reasons doctors don’t jump onto EMRs:

1. They are expensive as hell. They cost a lot to buy and just as much to support, especially if you have other data-generating devices which must be fully integrated with the EMR. $100K or more for initial purchase plus downstream costs plus new hardware. Oh, and you have to pay to train and update the staff, including periodic training of new hires. As for downstream costs, there are expensive and partially hidden costs attached to the billing mechanisms that force many users of these systems to pay per-filing user fees to electronic clearinghouses or large “one-time” (if you really believe that) fees per provider to file for payment. That isn’t a savings; it’s one more hand in your till.

2. They make you inefficient during implementation, which can last many months. This costs in revenue, which has no way to be recovered, especially after 1.

3. Suppliers have a poor track record for long-term viability. Unfortunately there have already been some expensive failed products which have left practice buyers with expensive, proprietary dead-end systems that have to be replaced.

4. Besides speeding up coding and doing some little prompts to boost coding levels, and reducing some office shelfspace, and maybe reducing by one FTE employee in labor cost/yr, there aren’t many other gains for the private practitioner. Electronic prescriptions still need to be typed in. Without widespread implementation and accessible master data storage of patient data (i.e., not on the server of some other doctor’s office) the benefits to the doctor remain small and intramural. Not a strong incentive for the costs.

5. HIPAA really isn’t much of a worry. As long as a vendor is compliant, most practices won’t worry too much about compliance. Criminal hacking into medical information databases is a matter for others besides practitioners to worry about.

6. No carrots, all sticks, and insurers and the federal government are the primary beneficiaries, while the practices are saddled with 100% of the costs.

Look at this:

http://en.wikipedia.org/wiki/National_Programme_for_IT

and decide if you want the same in the USA.

You could easily take your own medical record and store it on a memory stick that you could keep somewhere safe.

There have been multiple reports, both in the USA and the UK, of data leaks from healthcare organizations, private and government. Identifying data, sensitive medical data and sensitive financial data. The British postgraduate match equivalent to our match leaked data on physicians.

Anon. 12:29, get real.

I meant what I wrote. HIPAA is a federally-mandated, unfunded, shoved-down-the-throat-pointy-end-first government scheme. It is the classic all sticks and no carrots approach that people who shall remain nameless but would like to be President have gifted us. As I see it, my job is compliance in good faith and not one thing more. I see nothing morally compelling about HIPAA nor do I ever intend to give it any sort of moral consideration beyond minimal compliance. HIPAA is a big fat dollop of pork to the compliance industry and the IT businesses that sprung from its passage. It is a miserable obligation and a “fix” for a problem that didn’t exist, nothing more.

You may want to believe there should be some ethical notion that should trouble doctors about access to records, but there really isn’t. Whether a criminal hacker breaks into my secured database or a criminal burglar breaks into my locked fileroom, it’s all the same to me, and not morally troubling to me in the least. I won’t lose a wink of sleep over this.

Sorry to burst your bubble.

Physicians have had a tradition of maintaining patient privacy that goes back to Hippocrates.

People always say things about doctors and the Hippocratic Oath, most of which is not in the Oath. A promise to maintain confidences actually IS in the Hippocratic Oath.

Between traditional medical ethics and State law all over the country, physicians did not need HIPPA. We already were bound to maintain privacy.

What HIPPA really is about, is explicit LOSS of privacy to BUSINESS and GOVERNMENT.

So we physicians are worrying over whether or not to put sign-in sheets in our office, or whether we can talk to another physician for advice, while pharmaceutical firms can datamine your prescription records all they want and there’s nothing you can do about it.

It seems to be fashionable to complain about doctors. Here we have Scott MacStravic wondering why on earth physicians seem to have difficulties transitioning to electronic medical records. Wise and heavy words are being used, concerns are expressed motives are speculated. Academic reasons are considered. Oh, my. We physicians are not different to anybody else. We are just a little more independent and demanding. We are just like everybody else: we want things to be done quickly and easily. If you present us something that is easy, we’ll do it. Why are we not running to adopt EMRs? They are clumsy, klutzy, slow and expensive systems. None of these software people has had the smarts to start with the consumer. Nobody has studied what physicians do in everyday practice, how exactly they do it, studied it down to the smallest detail, studied the exact work and documentation process. That is what they should do, and then, please take that process and take all, but all the routine work out of it, leave only the “presidential decider” part in, throw in a little help in the deciding department too, give it some AI, make it adaptable, so that we can have it “our way” like Burger King, then make it smart, build in favorites, make the system able to learn our specific style, our specific preferences diagnoses, billing codes etc, make it able to link to literally everything, put it on a graphical surface, maybe one that you can also click on with your finger or your regular pen or with one of those fancy computer pens, that system would sell like the proverbial hot cakes.

Look at what we have in reality? We have overpriced sytems that look more like Windows 3.1 – Programmers, have you ever heard of MAC or have you seen Vista? Have you ever been to Yahoo.com? Have you thought about “ease of navigation”? I doubt it.
The system my health care system has presented me is a prime example of a clunker. The core was programmed 20 years ago, and you see it and feel it. History and tradition are a good thing, but not in software. It is so old fashioned, you see the Windows 3.1 still peeking through the creaks. It is crystal clear that it is a patchwork of not very well integrated components. It is embarrassing. Amount of work that has gone into investigating consumer needs and making it easier to use: Minimal. Price: Maximal.

And, talking about money. The clumsy Centricity that I am using has a completely separate billing component. The billing component knows nothing about what goes on in the EMR. This is the biggest stupidity I have ever seen. Billing should be done fully by the software based on the documentation. And should you fail to immediately understand this, you do not belong here in this discussion. We document what we do and we bill according towhat we do. Billing is 100% dependent on what we do, straightforward. So simple, a caveman could do it. And the famous software package Centricity of the famous American company GE should be able to do it too. It should be designed to do it in the first place. It should not even be separate from the documentation part, it should be a completely integrated part of documentation.

With all due respect, Scott is not a physician and has never used an EMR in daily life. I just finished implementing an EMR in my practice. As a hospital employed physician I did not have to buy the system, I just received the hardware and software and started using it.I am a computer enthusiast. And I was very, very disappointed by the EMR (Centricity from GE). It slows me down, it drains my productivity, it makes simple tasks complicated, every little thing takes clicks and click and clicks and more clicks and then some more clicks. It does not provide good access to data, it does not give me the same quick overview of a patient that I had in my paper chart. upon opening my paper chart I had the “summary”, a kind of history of the patient with some personalizing remarks and notes and reminders – all on the left side. one glance and I remembered the patient and knew what was going on. My EMR does not allow that, it only gives me the stupid ICD 9 codes, uncoded comments, notes and remarks are “forbidden”. When I protested about the lack in functionality I heard the sadistic comment “We try to keep the system standardized”. Hey, that works in big corporations, not in private practice. Another one is “We have to do this for patient safety” of “it is a HIPPA requirement”. Patient safety is such a fabulously chic buzzword at the moment. But it is a very bad excuse for a clumsy, klutzy system that makes you confirm and confirm and confirm again the most simple steps!
I drive a Volvo for security and it drives as well or better as any other car. Security happens behind the scene. My Volvo does not force me to stop every 100 feet to look around and it does not limit my speed to 25 mph in the name of safety, my car does not force me to stop before making a right turn and confirm that I really plan to make a right turn and so on.
Everybody out there, please understand. The sole idea of software is efficiency and ease of use.
The idea is the Three Click Visit. First click to confirm the history entered by the patient or the nurse, second confirming the template that the system chooses for you and third confirming the prescriptions that will be faxed to the pharmacy, the education leaflet printed for the patient and the automatic letter being faxed to the PCP.That would be a system everybody runs to adopt. Please do not try to find contorted far fetched theoretical reasons for “lack of adoption”.
IT IS THE EASE OF USE AND THE COST.
Repeat after me: EASE OF USE AND COST, EASE OF USE AND COST, EASE OF USE AND COST
And that, my dear concerned observers, is the reason that physicians are slow in adopting EMRs! EMRs on the market today are complicated, user unfriendly, inflexible and expensive. What a winning combination! We can’t wait to buy one of those systems. Did I mention that they drain productivity, but we get paid less instead of more? Physicians are just a tougher clientele. We are not employees in a big corporation where you can simply slap a computer on each desk and say: put up with it or leave. We actually (still) have the freedom to choose (still). We would love to have EMRs, but we are not going to put up with crappy ones. So, make some good ones, and keep the price down. Is that so hard to understand? If Yahoo was as difficult and clumsy to sue as my EMR, it would already have vanished from the net.
Can someone please design a systems with a surface like Vista or Mac OS, a system that is built after careful user studies and user analysis, after studying what physicians do all the time, systems that physicians can adapt and mold exactly to the way they want.
And then make those systems cheaper. Forget the abusive purchase prices and the high maintenance costs. Doctors are not rich anymore!

The real problem’s with EMR are control and privacy. The purpose is to give the commisars of the soviet real time control of medical care, rather than post hoc review. Both physician and patient will lose autonomy. The digitized data, like pharmacy records now, will be dessiminated widely throughout the healthcare network and data-mined extensively. With universal EMR, your health will factor into your borrowing, your employment, everything. Those who don’t think so were born yesterday.
….I also agree with this comment from anonymous. This is the biggest concern. EMR recrords in the hands of HMOs? You have seen nothing yet! Wait until you are declined a payment for a visit because your record says that your nurse measured the blood pressure on the left side on day and the right side the next day – sorry, can’t compare, we can’t pay, you are practicing substandard medicine! Youa re a Tier 2 doctor, sorry higher copay for your patients!
You have seen nothing yet. The HMOs should be kept completely away from the EMRs. Check your agreements and don’t sign away the access. They should only be able to get a very short summary of the chart and the diagnoses. Nothing more, or you will regret it!

“You may want to believe there should be some ethical notion that should trouble doctors about access to records, but there really isn’t.”

I took the Hippocratic oath. I think an oath is something serious and breaking mine would trouble me. I think medicine is moral enterprise which shoud only be practiced by those who take oaths and duties seriously. There are too many opportunoties for a conflict between the doctors self-interest and the patients interest for it to be otherwise. Your attittude troubles me greatly.

Your are right about HIPAA, but HIPAA is not the origen of or definitive of the physician’s ethical obligation, which is at least 2500 years old, is a central defining feature of allopathic medicine, and preceeds and supercedes the relevant law.

The actions of the workmen and employees in your office are completely your responsibility and you are responsible for ensuring that they do not breach confidentiality. You are responsible for the quality of the locks that you put on your doors and when you lock it. You are likewise still repsonsible for maintaining the security of your medical records if you choose an outside service. They are your agent in that matter and are being paid by you to carry out your responsibilities.

What is released to insurance companies is only released with the patients permission and is limited in scope–not the entire record and not all the records of your practice.

As for your being annoyed . . . well be annoyed, be very very annoyed. From your comments I am convinced that on this issue, my ethics and understanding of my obligation is superior to yours–not as good with the prissy-assed comments though.

Evan, where are you? Please be so kind to inform us of this great EMR system. I don’t want to suffer needlessly.