Fixing EHRs requires changing the way we pay for care

I was talking to a colleague recently about his practice, and remarked that he was still keeping a paper medical record. Without hesitation, he made it clear that he not only liked the paper record, but he positively dreaded switching to an electronic record. He said sadly that he thought it was inevitable that he would be forced to switch, but hoped that the day would be far into the future.

Intellectually, I think most doctors (excluding the occasional luddite or those so set in their ways that nothing in their practices will ever change) understand the potential benefits of electronic record keeping: more complete information accessible to the clinician (and patient!) at any time, from any where; facilitated sharing of information among physicians caring for the same patient; the ability to provide clinical decision support (reminders about indicated services, drug-drug interactions, embedded care pathways, access to supporting clinical evidence); the ability to aggregate information for quality improvement purposes, and more.

And yet, reluctance to adopt an electronic record is prevalent. In general, the reasons — stated and unstated — include the common perception that an EMR slows clinicians down, the constraining nature of structured data entry, the tedium of typing (which often makes doctors feel like they are scribes), the barrier that the computer creates between the patient and the doctor, the frustration that the computer work-flow doesn’t match how doctors think or work, and the general reluctance to change what seems to be working (at least at the individual physician level). If it ain’t broke …

While this colleague and I put most of these issues on the table, he surprised me by saying that he also thought EMRs were bad because they promote fraud. He cited a computer-generated report that he had received from a surgical subspecialist that included a complete physical examination, including an assessment of the patient’s mental status. At the time, I conceded that it was unlikely (ok, it was absolutely impossible) that the surgeon had actually done all the things “documented” and had, instead, checked a bunch of boxes (or one “big box” that said everything was normal), but I insisted that it was unfair to blame the tool for its misuse. It was, I said, like condemning hammers because somebody smashed a windshield with one. After all, hammers are still pretty useful when you are faced with a nail.

I felt pretty good about the conversation, but kept thinking about the limitations of current EMRs, including their potential for abuse. Nearly all of the things that doctors dislike about them are “features” designed to capture information needed for billing purposes. That is, they are all about documenting what we did to or for the patient, not about how the patient was doing. How many elements of the physical exam were performed? How many systems reviewed? How much clinical reasoning demonstrated? Did I “do” enough to justify a level 3 office visit?

I recalled the utterly different EMR that I saw when I visited a primary care practice that was funded through a fully capitated contract with the union to which all of the patients in the practice belonged. The electronic record was basically a medication list and an annotated problem list, with narrative added to each problem as needed. That’s it.

Like so many other things that doctors hate about the current health care environment, the flaws of the current crop of commercially available EMRs are a consequence of how we pay for care. Since we are paid for “doing stuff,” we are constantly being challenged to prove that the stuff we are doing is justified, and that we actually did it. We are getting killed by the focus on process.

We ought to be focusing on outcomes. If we were compensated for caring for a population of people, and judged on their health outcomes (appropriately adjusted for the prevalence and severity of their illnesses), then we could be freed from the stifling limitations of so many contemporary EMRs, while still enjoying the benefits they can provide for us and our patients.

Ira Nash is a cardiologist who blogs at Auscultation.

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  • buzzkillerjsmith

    Fixing EHRs. Has anyone considered sledgehammers?

    Who said it here? southerdoc, was it you? Something like 1 year of holding off on EHRs is one fewer year of your professional life ruined.

    • Deceased MD

      It’s wonderful how low tech can solve high tech problems.

    • Dr. Drake Ramoray
    • southerndoc1

      Yes, I’ll take credit for that line and am more convinced than ever of the validity of that position. Thanks for the acknowledgement.

      To stretch the OP’s analogy past the breaking point, we have a system where physicians are paid to break windshields (count bullets) and are not paid to drive nails (listen to patients and diagnose). So, of course, we’ve very quickly developed hammers that are great for breaking windshields but are absolutely useless for driving nails.

      Will anyone deny that we’ve seen NONE of the benefits that were predicted to come from the use of EMRs?

      There were many of us who predicted that designing EMRS to work in a sick system would only make things worse; we were mocked and ridiculed. Now we Luddites are taking a sick pleasure in seeing everything bad that we predicted become reality. Actually, we prefer to think of ourselves as Cassandras: doomed to tell the truth but not have anyone believe us!

  • Thomas D Guastavino

    I have said it before and I will say it again. Physicians were first bribed, eventually they will be threatened, to prematurely implement ill prepared EMR systems so that the governement could have a tapable database to usher in accountable care prior to the full implementation of the ACA.

    • Deceased MD

      Agreed. It’s disgusting. Talk about being exploited under the guise of pt privacy HIPAA.

  • Steven Reznick

    I enjoy the idea of notes that are readable, information is exchangeable and available. You can tailor your notes to reflect what you actually do with an EMR if you want to.. Despite this the whole ARRA meaningful use program is a disaster adding workloads of administrative work for doctors and additional overhead costs to well meaning practices. I think the payment model has little to do with the efficiency or accuracy of the system used. The Feds could have hooked us all into the VA system which is user friendly and accurate if they wanted us all to use electronic records. what they really wanted was to create jobs and income in the manufacture of, maintenance of , service of electronic medical record systems. It is all about capitalism , greed and profit but once again for big business not the fee for service physician trying to avoid penalties for not complying while trying to keep their practices current and relevant.

    • southerndoc1

      Isn’t the VA system workable only because they’re not dealing with multiple insurers and don’t have to count bullets?

      • Steven Reznick

        If you are referring to the practice management or billing software probably yes. The actual electronic record seems readable and easy to use.

  • whoknows

    I am outraged by the data mining under the guise of privacy. I hung up the phone from a hospital calling to “put me in their database system”.

    Every personal piece of data was being asked. I simply said that I had been there before and I was not a database. Disgusting!

    • SarahJ89

      My doctor is now owned body and soul by the local “nonprofit” suburban hospital that masquerades as a “regional medical center” –despite having no affiliation with any medical school or teaching hospital.

      The cost of EMRs is what caused my doc to be bought out, after fighting for his independence for years. Since then I am harassed endlessly by the hospital with phone calls, letters and now e-mails in their patient portal (I can’t read them because it’s so user unfriendly I am unable to access it). It’s all about marketing. Every time my insurance announces it’s going to cover such and such a test, viola! the marketers at the hospital mines my doctor’s patient data and suddenly the HOSPITAL decides I need that test. The hospital. With which I have no relationship.

      All this does is undermine my confidence in my doctor. Gee, he mustn’t be very competent if his employer has to do his job for him, right?

      The real take away for me has been the knowledge my doctor cannot protect me from the system that employs him and from which he was not able to protect himself. We are now both just cash cows.

      • whoknows

        Oh Sarah, that is pretty sad. I am not clear how you are made aware that “you need” the new test approved by insurance. Is it the doc that is brainwashed to deliver the news because marketers flood him? or is it the actual hospital via email telling you.
        I feel the same. I was suppose to get a procedure at a hospital and all they cared about was obtaining my data and wanted me to pay them thousands of dollars in a deductible even though they did not of course tell me the price upfront-no transparency once again.
        Is your doc acknowledging any of this with you?

        • SarahJ89

          The hospital contacts me directly with form letters with a cheesy rubber stamp of my doc’s signature, phone calls that are nothing more than telemarketing and are completely out of context of my relationship with my PCP.

          I know my doctor cannot protect me from these money grubbers because she can’t protect herself. They wrote to her patients, selling them screening tests, when she was out on sick leave.

          Happily, my sweetie and I went to a specialist in another hospitals’ system yesterday. It was like night and day which gives me some hope not all practices are like this.

  • maggiebea

    as a non-physician in an odd corner of hospital-based patient care, I find it infuriating that the bulk of my time is spent scrolling through tables of click-boxes in which most of the time I will click “other” and then have a 20-character field in which to describe what “other” think I did. The freeform note field occurs at the bottom of the third page of the form that is theoretically tailored for my job function.

    But when I am finished, the next person in my job to see the patient has to click 5 separate pages (and wait for each to load) before they can read the ‘page’ generated by my assorted clicks and free-form typing. And then the freeform note is given the least prominent location on the page.

    Flipping pages in the paper record was MUCH quicker!

  • doc99

    It’ll take an EMP to fix Allscripts.

  • Michael Rack

    Both private insurance and Medicare bureaucrats want micro documentation- and the fines/penalties are a lot higher for Medicare documentation errors

  • SarahJ89

    I was testifying at a legislative hearing in my state years ago, around the time HMOs were coming in. The legislators were concerned about rising health care costs. Their solution? They made it clear they were handing over all power and decision making to the HMOs. “Maybe these people can solve the problem.” Really? By buying people off with gym memberships in exchange for poor or no care and lots of hassles?

    It was horrifying to see these legislators openly hand our health care system over to the insurance industry in our state. The problem is the hand of corporations in the sock puppet of government. Railing against the puppet accomplishes nothing but a bit venting.

  • Robert Bowman

    The biggest problem facing those who hope to measure care or accomplish pay by
    outcome is that individual patient factors with multiple dimensions of
    variation, shape care outcomes. As patients move from advantage to disadvantage, the outcomes are shaped more by the patient factors and less by physician or clinic factors.

    Outcomes measures almost always favor those who care for the advantaged
    and those who most exclude those with any factor related to disadvantage
    – those who have lesser outcomes.

    Our design has already resulted in lesser clinician concentrations where
    disadvantage exists, and it will get worse by these new designs. Pay for Performance, Readmissions, and Value-based will send less to the least and most to those getting the most – by design.

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