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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