Why electronic medical records won’t improve patient care or cut costs

Have electronic medical records made a difference in patient care?

According to a study looking at digital medical record adoption of 3,000 hospitals, electronic records have made little difference in cost or quality of care.

That’s discouraging, considering that the government is investing billions of dollars into the technology.

Very few physicians use electronic record systems effectively. For instance, many are simply scanning paper records into a computer, which provides minimal benefit. It’s difficult to track quality improvement data doing that. The problem is further compounded by the archaic interfaces that the current generation of EMRs have, which is akin to a user interface circa Windows 95.

It’s no wonder that most doctors find electronic medical systems actually slows them down. The next generation of systems needs to focus on facilitating the doctor-patient encounter, rather than being an impediment. Taking a few lessons from Google, and improving the user interface would be a good start.

Only then can EMRs realize the potential relied upon by the government and health reformers.

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  • gerridoc

    One of the reasons that I left the clinical practice of medicine after 25 years was because I became very disenchanted with the hospital management who were pushing EMRs as a panacea for all that is wrong with health care. Physicians are considered to be intelligent, but any constructive criticism that we offered to the higher ups was ignored or dismissed.
    I am still in favor of EMRs, but it is important to recognize their limitations.

  • http://askanmd.blogspot.com/ Doctor D

    The trouble with EMR systems is that they are made with healthcare administrators, not physicians and nurses in mind. They are useful for bureaucrats and bean counters but a terrible fail for the people that are usually using them in a clinical situation.

    It reminds me of the old days when computers were designed for IT professionals not end-users. I blog and use a Mac and the modern internet. Using most EMR systems feels like going back to the stone age.

    Kevin, I hope EMR companies are reading your blog. They need to stop complaining that doctors are ludites. Most of us are very sophisticated, and if they can provide a stable system that doesn’t feel like computing in 1992 we be happy to use it.

  • family practitioner

    I have had an EMR since 2004.
    It is nice.
    It is neat.
    Has it improved patient care? No.
    Have I received 1 penny from insurance companies or the government to offset the cost? No.

    The cool aid has been mixed. Obama drinks it, so does Newt Gingrich. So do health policy wonks in the AMA, AAFP, etc.

  • Kishore

    I think that part of the problem is that people are expecting immediate results from EMRs. A huge part of their potential benefit lies in the ability to mine extremely large amounts of health data in computers and use our ever-improving computing power to analyze this data.

    Imagine a future where you have a patient come in with a given genetic profile, past medical history, and symptoms and you can look up in the “world EMR” a past incidence of a patient with a similar genetic profile, medical history, and similar presenting symptoms. You can analyze this case and use it to help you treat the current patient.

  • R Watkins

    A valuable EMR based on current technology and devoted ONLY to better patient care is very easy to imagine. Unfortunately, EMRs now in use are primarily designed for:
    data collection by insurance companies and government agencies; higher levels of coding; improved charge capture; liabiliity protection; and so on. Patient care is last on the list, and therefore the product is unusable by practicing physicians.

    The role of our primary care organizations in acting as unpaid shills for the EMR industry is worse than deplorable. They have miserably failed their members by not accurately presenting the strengths and weaknesses of EMRs.

    We should listen to the wisdom of the marketplace: if these were good products, they would sell themselves without incentives and such. It is becoming clear that the EMR emperor is wearing no clothes. The current sales pitch can be translated : “Yes, we know they’re lousy products, but the government is going to require them, so you better buy one now.”

  • jsmith

    Posts 1-3 are correct. Post 4 is pie in the sky, presupposing that the general physicians would look at that wonderful data will actually exist. They won’t, and one of the reasons is that the med students will look at what they have to do as PCPs, including jockeying hellish EHRs, and will say thanks but no thanks. Will the NPs working in retail clinics do the jockeying?
    We have had an EHR since 2006. It has been a net money-loser, not a tremendous amount, but some. It crashes from time to time, but is usually back up within 15 minutes or so. (We have an IT guy who is very good.) It has made data somewhat easier to get out of and somewhat harder to get into the medical record. It has not improved ultimate measures of quality, namely morbidity and mortality, one iota. It has not increased surrogate measures of quality such as pap and mammo and immunization rates, one iota.. It has decreased our productivity slightly. For us, it has not been a nightmare. It just hasn’t done any good. It has earned a tidy profit for the vendors.

  • http://delawaredisability.com Steve Butler

    I am an attorney that practices in the area of Social Security Disability. I review medical records on a daily basis. I agree that electronic medical records are not currently being used effectively, but I blame the problem on poor design. The record systems are not designed to facilitate normal practice.

    The benefit of any computerized record keeping is legibility. This is an important reason why EMRs are needed (and why they should be used to do more than scan in paper records). But good software design dictates that systems should be designed around how the end user works. The EMRs should not make a medical professional’s life more difficult.

    The number one change that needs to be made in EMRs, is that the software designers must realize that a complete medical examination is not performed on every visit. There is no reason that a routine follow-up visit should be 4-8 pages (which is the norm). The complaint (subjective) field should be updated on each visit. The history field should prompt the medical professional to update any changes in history, and those changes should be clearly noted with the date of change and emphasis. Review of systems and physical examination should only be included if the exams are completed. Anything not done should not be included. The diagnosis section should be handled the same as history, and plan of care should always have to be updated with new information.

    The problem that I see daily, is there are indications that an entire review of systems and physical examination were performed when they were not. The danger I foresee, is that these indications will be used for malpractice claims against physicians. I think that physicians should understand what is in their medical records when they switch to EMRs, and should not indicate that all areas were reviewed during a visit if they were not.

    I published more thoughts on this issue on my blog: http://delawaredisability.com/2009/12/electronic-medical-records/. Thank you for your perspective, and I hope that changes are made to make EMRs easier to use and more accurate.

  • Cospo

    As a patient (and retired health professional) I’d like to put in my two cents. EMR came into existence after my retirement so I can’t really speak to personal experience USING it; however, I can say plenty about how I feel as a patient. I have a couple physicians who use it IN THE EXAM room during my visits and a couple who don’t use it, at least not in front of me. I find that the EMR docs are sitting across the room, a good distance from me with their heads stuck in the computer. After the initial greeting they seat themselves at the little desk as far removed from my side of the room as possible and then with hardly a glance in my direction begin to pull up info, grunt a few times, then ask me a couple questions and may or may not give Rx and then make a beeline for the door like there’s a fire. On the other hand, the docs who (seem) to rely on the old timey paper files sit closer, look me in the eye, talk with me and allow time for me to explain what’s going on and how it affects me (and my family), etc. They actually touch me, ie. listen to my chest, examine my limbs,etc. and then tell me what they observed AND reassure me. I feel as if they have really listened to my complaint/problem and want to help me. I don’t seem to be an interruption in their computing time. I think that one observation made above is right – the EMR helps the insurance companies and government agencies to collect data, which is great. But user friendly improvements to the system should enable providers to give patients proper care while showing some compassionate caring at the same time instead of having to use up time trying to figure out the computer program glitches. I’m wondering how cold and impersonal helathcare is going to become.

  • Kishore

    jsmith, I appreciate your comment and would like to respond. I think the problem with your viewpoint is that you’re taking a very short-term perspective on the impact on EMRs. No one expects them to immediately improve quality of care, and I agree with you that there are issues with the implementation of them. But I guarantee that medical students raised on EMRs will have a much easier time using them than older physicians upon whom they’ve been forced. For these students, EMRs will not hinder productivity but will simply be a way of life, the same way they’ve been using computers their entire life. Medical students nowadays do everything on their computers (notetaking, reading, etc.), and using EMRs will be a natural progression of that. I think that if you ask most current medical students, they’d say they’d rather do things on a computer than writing it down on paper.

    And I think you’re underestimating the types of new results that can be gained by analyzing large amounts of standardized data. Take a look at this article for an example of what I’m trying to talk about:
    http://www.wired.com/wiredscience/2009/09/domestic-abuse-prediction/

    I find it hard to believe that some still think we should be using paper and pen when technology has taken over virtually every field. I agree that EMRs need to be better adapted to the workfow of healthcare operations, but there is so much potential for them to improve healthcare. Everything that physicians do is a matter of “tagging” patients with datapoints, and EMRs have the potential to basically turn the world’s healthcare facilities into large, data-aggregating clinical trials.

  • jsmith

    Kishore, If med students want to type, let them type. No one’s stopping them. We didn’t use pen and paper. We used excellent transcriptionists. Steve Butler’s post is great. The main use of EHRs is legibility!!! Wow. I say again, transcriptionists.
    You would do well to not expose yourself to scorn by trying to use Wired as a source on a medical blog. A real reference is Himmelstein et al in the Am Journal Medicine that Kevin referred to .
    Sorry, but I’m not buyin’ what you’re sellin’. I use an EHR 5 days per week. Potential is great, but I really care more about reality in the form of 25-30 patients per day.
    And if the government wants us to participate in clinical trials, it should do so with our permission, defray the direct and indirect costs of our EHRs and pay us clinical investigator fees. Hell, if the money was right I might even sign up for that.

  • jsmith

    Cospo, Excellent comments. A lot of people feel exactly as you do. I try hard not to use the computer in the exam room. I use a sheet of note paper on a clipboard. The doctor-patient interaction is much better for my patients and for me if I do my computer work later at my office desk.

  • Kishore

    jsmith, I apologize if I came off like I’m trying to antagonize you. Wired is actually a pretty good magazine, and I figured an article in Wired could simplify these topics for the average reader unfamiliar with the topics, but here’s a link for a published article by the group if anyone wants to take a look:
    http://www.ncbi.nlm.nih.gov/pubmed/19789406

    The point I’m basically trying to make is: I agree that EMRs shouldn’t be forced upon small groups of doctors who have no incentives to use them (i.e. when they lower their productivity without immediately improving outcomes), and, frankly, doctors shouldn’t be made to swallow all the costs here. But, there is a very real benefit to data aggregation from medical records and new insights that can be gathered from these types of data analysis. Just think about any clinical research that is conducted by logging lots of data on patients and outcomes and then statistically analyzing this data – EMRs will allow us to do this on a very large scale in hospitals all around the world! Furthermore, we’ll be able to look at data on patients who represent real-world examples with lots of comorbidities, etc. – the types of patients typically excluded from clinical trials.

    Basically, I agree with everything you all are saying about the ways EMRs are being implemented currently. Doctors shouldn’t have to bear the burdens of all losses in productivity, profits, etc. At one hospital, I was aghast to learn that when EMRs were introduced, no one input information from the files of past patients, and the doctors were the ones expected to fill in all of this past medical information from their thick folders on patients. But, this doesn’t mean EMRs can’t improve patient care in the long term.

  • http://www.docsurg.blogspot.com Aggravated DocSurg

    oops, got my HTML tags wrong…

    I think the 11th rule of “The House of God” needs to be updated for the EMR era:

    SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO AN EMR THAT ONLY TRIPLES MY WORK AND I WILL KISS HIS THE SOFTWARE ENGINEER’S FEET.

  • alex

    “But I guarantee that medical students raised on EMRs will have a much easier time using them than older physicians upon whom they’ve been forced. For these students, EMRs will not hinder productivity but will simply be a way of life, the same way they’ve been using computers their entire life.”

    I graduated from medical school last year. I paid my way through college programming; I can program in five different languages all the way from VB down to assembly. It is safe to say I am probably the extreme of your example.

    Every EMR I’ve worked with has done a wonderful job of hindering my productivity. Every package – and I’ve used at least 4 different major EMR package – requires massive amounts of extraneous information to constantly be put in, typically to satisfy some stupid billing requirement. A paper note can be written in about a minute and a half. At a very MINIMUM, if you enter it while you’re sitting there talking to the patient (rather impolite), it’s about three times longer to put the same visit into an EMR. Actually, just thinking about it annoys the piss out of me. When I get into practice I intend to find the least electronic EMR that satisfies the stupid requirements the government will impose for being “digitized”.

  • R Watkins

    Alex:

    Thank you for contributing.

    Kishore has fallen back on that old cliche of the luddite docs: his point of view is that the problem is not the lousy products, but the brain dead docs who are too stupid to learn how to use them. Interesting point to bring up on an electronic discussion board.

    I wrote my first computer programs in the sixth grade in 1964. I still use paper charts, as I have not found any EMR (and I’ve looked!) that is as efficient and as accurate. When I show residents my one page, legible data base, that contains all chronic and acute problems, all family, social, and past medical history, all consults and hospitalizations, all routine preventative care on one page (no scrolling, no pointing and clicking), they’re stunned.

    To claim that medical students who have never been exposed to good paper charts prefer EMRS (duh!) is totally phony data.

  • Anonymous

    It may be just me, but there seems to be lots of confusion in the responses here about the differences between data entry, user behavior with respect to data entry processes, and computation.

    EHR data entry is, in the main, abysmal. It should certainly be fixed. That an EHR with most or all data entry issues solved would be quite valuable seems self-evident.

  • http://www.healthcare311.com gjudd

    It may be just me, but there seems to be considerable confusion here about differences between data entry, user behavior with respect to data entry constraints, and computation.

    EHR data entry is, in the main, abysmal, and should (and can) certainly be improved. Dismissing the potential of EHR due to the present realities of data entry and data entry behaviors is short-sighted at best.

  • http://fertilityfile.com IVF-MD

    It is morally wrong to force doctors to adopt EMR. In my practice, the natural drive to improve efficiency has made us do certain things electronically and certain things on paper so that maximal efficiency and best quality of care is achieved. For some intrusive bureaucrat who knows nothing of the daily practice of good medicine to arbitrarily dictate what we must do makes care more costly and inefficient. Of course, we have to question what their motivation is. Do they get pressure from the IT companies that stand to make big money? Is it for the benefit of the compliance attorneys who will need to be hired to make sure the EMR is HIPAA compliant? Special interests donate a lot to the politicians but the little everyday man and woman whose medical care is being compromised sadly does not get heard. Please educate the public as to one instance in history where bureaucratic interference has done less harm than good.

  • jsmith

    Kishore, Thanks for BMJ reference. And I was almost ready to cut you some slack until I read Alex’s excellent post. The problem in a nutshell: Fact: Physician labor is scarce and expensive. Fact: EHRs force physicians to engage in activities at which they have a comparative disadvantage, like typing and scrolling and printing. (Please Google Ricardian Comparative Advantage if you are unfamiliar with this counter-intuitive but absolutely crucial insight of 19th century economics.) Conclusion: EHRs reduce physician productivity.
    If we didn’t have to enter data or waste our time trying to find it on the EHR it could change the equation, as others have noted. If and when those systems become available, docs would be well-advised to look at them. But even the best of what we have now is junk.

  • R Watkins

    We’ve learned how dangerous it is to text while driving (most recent data: texting increases chance of an accident 24x, driving drunk 4x). Could doing data entry while doctoring be equally dangerous?

  • stisdale

    Et al,
    I have enjoyed the dialog that has come up with this subject. These points only solidify to me that a NEW approach must be implimented for EMR to work. Simple fact is, computers are here to stay and with GREEN being the new color- paper will not be around forever.
    A friend and I started EMDMC. Our company is trying a different approach with EMR. We are focused on the patient/doctors vs institutions/govt.
    It is web-based, and all you need is a simple computer, scanner, and intenet access. There is no million dollar licensing, or fees. Best thing is the patient actually gets to see their EMR (for a fee). More intergration to come as we get clients. http://www.emdmc.com —Enough plug.

    I believe that paper will be here for maybe 10 years. It is tangible, and makes people feel good. But the simple fact, if a program can be taylored to each individual company, it becomes part of the company. It creates simplicity and makes the worker happier.
    Our company is taking that approach. We WANT to sit down with the doctors and help them create a program that they feel comfortable with, and most of all- simple and easy to use.
    The hardest problem with EMR is that it is aimed at the largest institutions, not common folks. How can you develop a new approach to something without getting interaction from the masses? Simply throwing money on a fire isn’t the solution. The solution is working with the logs to create a long and steady fire that last much longer than a simple flareup.
    MISCONCEPTION–To doctors, EMR=MILLIONS of dollars and that just isn’t so.

  • jsmith

    stisdale, I’m sure you’d like to sit down with docs, but as you can tell from the comments, a lot of docs are not so keen on sitting down with you ! But I wish you good luck. Innovation made this country great. If you come up something good at the right price, it will be adopted post haste. You’ll get so rich so fast it’ll make your head spin.
    P.S. We do in fact realize that EHRs don’t cost millions. Tens of thousands is quite enough for something of absolutely no use.

  • cptmac

    As a patient, what I like about EMR’s is, it helps my doctors help me get better. I have a lot of weird drug allergies. There is no way that any doctor is going to remember them.
    One – reglan gives me medically induced Parkinsons.
    So, when I needed a colonoscopy, my GI doc automatically prescribed reglan. Because of EMR, an alert went to the pharmacy and to my GI doc.

    My GI doc called and e-mailed me. My pharmacist let me know he would not give me the reglan. All because a computer noted I should not take this drug. Some of my friends think my docs should remember every little thing about me, but I find this ridiculous. Even I, on occassion forget what I’m allergic to. Thank goodness a computer can remember.

  • stisdale

    Jsmith,
    I am not motivated by money alone- I am more motivated knowing this may save my life one day.
    I got into this because of my mother- she passed away earlier this year.She had gall stones. Was an ER nurse for 20 years, and after what I saw for the 50 days that she was alive– I know there is a better way.
    It may help me sleep better knowing that I have money, but I will sleep MUCH better knowing that I might have saved a life.
    The funny thing is a love a good fight!
    I could write a book on here about how watseful most things are in certain industries/government. We all could.
    But to find an affordable and permanent solution to a problem that has cursed an industry would be a wonderful thrill.

  • Kishore

    gjudd, I think you’re right. We’ve been debating different things. I think I’ve been coming off like I’m in favor of poorly designed EMRs, which I’m not. I mostly just took exception to the title of this post, “Why electronic medical records won’t improve patient care or cut costs,” when I think they have the potential to do these things, though I agree they’re not being implemented correctly.

    It seems like the user interface needs some work, but I still think the potential is there with data aggregation and statistical study of this data, etc.

  • bob

    Boy it feels great to know I’m not the only doc. who got stiffed with an EMR. It slows me down big time and detracts from the quality of my interaction with patients. I have wanted an EMR for 15 years and I like computers but the reality is not like the dream. It is more like a nightmare. I think you hit the nail on the head with the part about the user interface. If I could just roll my curser over the hypertext or module icon that I want and have it expand the way it does on a modern web browser I might actually come to enjoy my work again.