Stockholm syndrome and Epic’s takeover of medical records

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Now, the health care connection.  As a result of the billions of dollars allocated by Congress to health information systems as part of the stimulus program, those companies who had a head start in implementing electronic medical records quickly found themselves in demand.  Of all those companies, Epic is the most successful. Forbes notes, “By next year 40% of the U.S. population–127 million patients–will have their medical information stored in an Epic digital record.”  (Here in Massachusetts, the biggest convert was Partners Healthcare System:  “System development and implementation will occur over a 10-year period and represent a capital investment of approximately $600 – 700 million.”  Elsewhere, notes Forbes: “The biggest win: a $4 billion project to digitize medical records for health care giant Kaiser Permanente.”

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best.  For example, Partners said, “The new health care landscape will challenge us to engage in population health management, improve the coordination of health care, and accept financial risk for the care of our patients. This new system will enable us to meet those challenges.”

But it can hurt to go down this path.  In another article, Forbes notes:

Customers, such as New Hampshire’s Dartmouth-Hitchcock Medical Center are feeling the pinch. DHMC which implemented Epic last year at a cost of $80 million, expects a weak operating performance in 2012, partly because of expenses related to Epic.

Now, re-read the definition of the Stockholm syndrome and see if it isn’t apt.  But it doesn’t have to be this way, as I have noted in quoting an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:

It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn’t reside within single EHR systems, and there’s a clear path toward better, safer, cheaper, and nimbler tools for managing health care’s complex tasks.

Here’s the ultimate corporate risk for Epic.  Now that it controls this big a piece of the American market–paid for by federal appropriations–if something ever goes wrong (e.g., a coding or decision support error that results in harm to patients), you can expect a bunch of Congressional committees to come down on the firm like a ton of bricks.  It doesn’t matter which political party is in the majority.

People will ask:  “Isn’t an EMR as much of a medical device as the ones regulated by the FDA?  Isn’t the handling of prescription drugs by EMRs as much a part of drug dispensing as the drugs themselves?  Shouldn’t EMRs be regulated by the federal government for that reason, too?  How did this firm get such a big share of such a critical market with no government review?”

Paul Levy is the former President and CEO of Beth Israel Deaconess Medical Center in Boston and blogs at Not Running a Hospital. He is the author of Goal Play!: Leadership Lessons from the Soccer Field and How a Blog Held Off the Most Powerful Union in America.

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  • Charles Smith

    Congress needs to fund an open source platform and mandate that all EMRs use it. Interoperability should be mandatory. Then you would see the free market eliminate proprietary monoliths like Epic.

  • Laura Mitchell

    That’s one of the things that really bothers me about electronic medical records. I think it’s called HL7 compliance (with allows systems to interface or communicate) and right now it’s optional, not mandatory. I think this is very unsafe, especially in situations where seconds count.

    Where I used to work, we had Cerner, which I thought was pretty bad (Home Health was using McKesson). At least we still had OB Trace Vue (HP Medical, which became Agilent, which was bought by Philips) for L&D, but because of politics, we had to double chart in both systems. Last year (fortunately, I was no longer there. I loved Trace Vue and this would’ve broken my heart), they went totally to the dark side (Cerner worked the bugs out the fetal monitoring program).

    It bothers me that it’s all about money and this stuff is “proprietary” when we’re talking about people’s lives and well being.

  • Edward Chory

    We go live with Epic tomorrow. Good timing. Many annoying aspects. Top 3: lack of communication between systems, no2, focus on documentation for meaningful use and maximizing hospital reimbursement not safe, efficient patient care, now 3 after reading this arrogance of EPIC. God help use. If Epic is so bad why is it being chosen by so many hospitals and achieving such market dominance?

  • TpoIFID

    Heil Hitler to Epic!

  • TheresaWillett MDPhD

    Thanks for the most apt comparison, Paul! As an avid follower of tech both in and outside of medicine, I am intensely disappointed and even angered by the heavy handed and primitive EMR cartel. Patients deserve better. We all do. We need to more than just hope for accountability with so much at stake.

  • PcpMD

    Not trying to be a contrarian, but I’m not sure what all of the hubub is about. I work for a large integrated healthcare system that adopted a version of epic for all of its numerous outpatient clinics and hospitals. Our version of this EMR is currently the largest private EMR system on the plant (second only to the VA). This system serves several thousand physicians, several million patients, and countless ancillary/paramedical staff.

    In the last 6 years, we’ve only seen the EMR continue to grow in functionality and power. We’ve had several powerful customization to our version of Epic to be sure, and our own IT team has added a simple “toolbar” that runs sophisticated macros to automate some of the click-intensive steps in navigation.

    The end result has been an immensely powerful, game-changing, multi-million dollar saving system that’s more or less universally adored by our practitioners. Its allowed us to integrate our health care in ways that we hadn’t even imagined at its inception. I don’t know a single person who would want to go back to paper charts. We’re now 4 years into this, and it keeps getting better. I’m kind of surprised by the Epic-hate I’m seeing here, as its so contrary to my own experience.

  • Sandra

    Thanks for defining what I’m experiencing from my HMO’s customer service and the providers saying that I should be understanding of all the errors in my billing and EMR. Why can’t we have accurate financial and medical records?

  • Molly_Rn

    If you are talking about Judith Faulkner’s Epic, I am surprised at the problems and fears. At least in the past Epic was by far the very best EMR out there. Four of us (ED docs and nurses) started an ED specific software system in the late 80′s and by the time we were bought out in the late 90′s I had nothing but respect for Epic. Their system then was actually well thought through from the clinician’s perspective. I sure hope they haven’t changed because that would be a terrible loss.

  • Chris St. Clair

    The key issue here is the demand for interoperability and reportability. Whenever an information system is purchased, the ability to produce outbound data for use by other systems and for reporting should be a standard part of the system. It is unacceptable for medical companies to ask clinicians to maintain these records without providing them with way to get to data so they can analyze that care. Waiting months or years for IT to get around to producing reports is archaic!

  • Michael Olesen

    I would like to see health care reform include HL7 compliance as well as a requirement for some standardization of interfaces and functionality. I have used Epic and other systems and have similar experiences with all of them. None yet offers a perfect solution for my needs but I have learned to adapt.
    One of the major benefits we could have from HL7 compliance is also the ability to collect standardized data in order to more accurately measure healthcare outcomes, quality, and safety. The volume of data that could be collected would add a great deal of statistical power to determine what therapies are most effective and provide information on which facilties and providers have the best outcomes.
    One of my main complaints with these systems is the ease at which clinicians can cut and paste each others’ notes. I know of one instance where I believe this ability led to the removal of a healthy kidney instead of the diseased one. Further administrative controls should be built into these systems to help prevent tragic errors such as these. Some of the various quality measures could be built into the workflows to require verification of things such as a “time out” in the OR.


    Definition of ‘Game Changer’

    1. A person who is a visionary.

    2. A company that alters its business strategy and conceives an entirely new business plan. This type of company switches up and forms a new business strategy in order to compete directly or indirectly with competitors. A game changer changes the way that something is done, thought about or made.

    This is a global issue my friends…

  • Nick Sophinos

    It goes even farther than Epic “not interested in providing the capability for [their] system to be integrated into other medical record systems.” The are not capable of doing so. They are just too big, fat, and stupid. They too are held captive by the technology legacy of their own systems.

  • Barbara Koblinski

    Some of the ills of any EMR is clinician training, which is expensive and time consuming. Yes, charting can be burdensome, but major difference in electronic and manual are the ability to seamlessly make notes for future care and the ability to dodge the system i.e. avoid the discharge activities. (The computer now mandates rather than the Medical Records Administrator hunting down physicians.) EMRs, by statute, touch the outside world, be it government or the insurance world and that touch should not be minimized.

    There is a huge opportunity for misuse that can have a long-term insurance outcome for the patient. Consider a poorly trained user who uses Epic coding as a “sticky note” system when charting diagnoses, using it as a reminder to recheck items at the next patient visit in addition to charting actual diagnoses. These diagnoses pass, sooner rather than later to outside agencies, who use them equally to determine who qualifies for government programs/labels for the young or pre-existing conditions when considering optional insurance or for long-term-care insurance. The affordable healthcare act does not mandate great care, only basic care. Beware the patient who uses a healthcare provider who does not understand the multiple impacts of diagnosis coding (It is not just for immediate payment.) These are the providers who can, and do, harm patients, but not in a way that has immediate health impact.

  • Sharon

    I believe there is an open source platform at the VA. See the book, Best Care Anywhere by Phillip Longman.

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