Thursday, March 6, 2014

Electronic Medical Records, not what it's cracked up to be

Posted by Stephen Weinberg, MD FACC FACP
Electronic Medical Records (EMR) are digitized versions of  paper charts that physicians and hospitals have been using for many years. About five years ago, the federal government mandated a program to transition paper records to digitized records. Medicare developed a financial incentive program along with penalties for physician practices and hospitals to foster the purchase and implementation of these systems.
The theory was that EMR's would save the practices and hospitals money by reducing paper needs and storage, reduce personnel, and improve overall office/hospital efficiency. Studies have not proven any cost savings and in fact, in most instances, the costs have increased. On the plus side however, the government is paying part of the cost of computerization over the course of several years provided the practices and hospitals perform certain activities related to the computer. The amount paid by the government is not enough to cover the entire expense of purchase and implementation and certainly does not pay for the ongoing costs involving maintenance of hardware and software, hardware replacement costs, personnel for help desks, upgrades for software, costs to integrate with hospitals and other practices, conversion of paper charts to digital, reduced efficiency for at least the first year of conversion, just to mention a few issues.
These systems were also supposed to improve patient care quality and safety. It has been expected that there would be computer coordination of diagnoses and tests ordered to provide more efficient workups and treatments. In addition, diagnoses and drugs should be coordinated to be sure the best possible medication is used. Drug interactions should be automatically evaluated and notifications should be provided for patient protection. Recent previously performed tests should be available to avoid repetition to save money. Dangerous tests for a patient's condition should be identified and avoided. Testing should be suggested based upon the history and physical. Blood test results should be saved in a longitudinal fashion so that comparisons can be easily made. We were supposed to have automatic access to information and tests performed by all labs, hospitals, physicians involved with a patient's care to be sure physicians see the big picture. NONE OF THIS HAS OCCURRED.
The current systems are nothing more than expensive electronic filing cabinets. All the data found in the EMR is entered by hand meaning the tests are manually downloaded into the patients' files. It is no more efficient than sending or receiving a fax or letter and placing into a paper chart.
Every lab, hospital and physician's office has different computers and it takes the creation of specific interfaces for each of them to communicate with each other. Regional health information networks (that could have accomplished coordination) were attempted and generally failed for lack of money and coordination. These would have created a common computer language so that all the regional providers could exchange information seamlessly. This does not exist and there is no national network either.
Rather than jumping in to the EMR program nationwide, the government should have done more research and put in place standards for coordination and transmission of information between providers and define the artificial intelligence required to truly improve care rather than trying to do this after all the computer systems have been deployed. The additional expense to provide these services will be born by the providers and not the government.
Additionally, the costs of the computer systems are being born by the providers and not the stakeholders. The real stakeholders are the government and the insurance companies since they will benefit from any savings resulting from improved quality and reduction of duplication of services. The government is providing some upfront money, but the insurance companies are paying none of it.
Once again, the government has mandated an extremely expensive program without appropriate forethought and planning, with non-stakeholders paying the freight. Does this sound reasonable?

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