Monday, September 23, 2013

Why Doctors Will Never Ever Like EMRs and How to Change That

EMRs are not designed for patient care. Is there anyone working in health IT who can honestly say that he or she never heard this statement being made hundreds or thousands of times? Is there any clinician actually working with patients and EMRs who can state that such thought never crossed his or her mind? This includes health IT evangelists and physicians spearheading IT initiatives at the most excellent of centers of excellence. People complained that EMRs are not designed for patient care seven years ago, when the first EMR certification body was created. They said the same thing four years ago when billions of dollars were made available for the purchase of EMRs. They kept insisting even as use of EMRs was becoming widespread two years ago, and the chorus remains unchanged today: EMRs are not designed for patient care.

Seven years is an eternity in the world of computer technology. Seven years ago Motorola and Blackberry ruled the world and the iPhone was getting ready to be born. Seven years ago something called Twttr was released and Facebook launched a high-school version of itself. Seven years ago Ken Jennings was undisputed king of Jeopardy and IBM’s Watson was wrong 85% of the time. We’ve come a long way, baby, but EMRs are still not designed for patient care. Why is that? The most common explanation is that EMRs were designed for billing and cannot be changed. But if a program designed to play Jeopardy can be expanded to practice medicine, surely seven years is more than enough to refocus EMRs on something other than billing. The second most common reason given for the inadequacy of EMRs is the inadequacy of those who build them; because we all know that all great programmers work at Apple, unless of course, they work at Twitter or IBM or somewhere in Verona, Wisconsin. More seriously, the third explanation for EMRs failure to help with patient care is the onslaught of government regulations for EMR design.

Many, including yours truly, are arguing that EMR vendors are so busy meeting regulatory mandates that there are no resources available to make customers happy. On second thought though, are we saying that giants like GE that owns half the planet, or McKesson with its astronomic CEO compensation, or that one place in Verona, are unable to spring a few bucks for half a dozen developers to make EMRs better for patient care? Are we saying that a market chockfull of very wealthy customers railing for a solution cannot attract even one manufacturer willing to solve the problem and collect billions of dollars in return? Surely we are not saying that seven years is not enough time for writing an EMR that is designed for patient care. On September 12, 1962, President John F. Kennedy, in a speech at Rice University, officially launched the race to the moon. On July 20, 1969, Neil Armstrong and Buzz Aldrin walked on the moon. It took seven years.

EMRs are not designed for patient care because our medical system is no longer designed for patient care. Our medical system is being redesigned to provide health services to consumers, and EMRs are morphing into superb tools for a service industry.
  • EMRs are designed to collect increasingly detailed customer information.
  • EMRs are designed to facilitate market research.
  • EMRs are designed to standardize and automate transactional complexity.
  • EMRs are designed to smooth handoffs across the supply chain.
  • EMRs are designed to orchestrate and monitor production lines.
  • EMRs are designed to minimize production costs and maximize revenues.
  • EMRs are designed to provide quality assurance based on exact specifications.
  • EMRs are designed to prevent and quickly detect malfunction and non-compliance with specifications.
To be clear, most EMRs can’t do all these things just yet, but they are being redesigned along these lines, because these new EMRs are foundational to what David Cutler, a Harvard Applied Economics Professor and one of the most influential health care policy makers, calls the “information technology revolution”. In a surprisingly candid article Prof. Cutler is describing the future health care system as designed by him and his distinguished colleagues, and as currently implemented by our government. The title of his article is self-explanatory: “Why Medicine Will Be More Like Walmart”. It is very possible that as EMRs are being carefully repurposed, they will also be made more intuitive, more iPhone like, glossier, faster, more colorful, and generally more appealing, because it is imperative right now that physicians use them consistently, and preferably without much turmoil. Why? Let’s hear from Prof. Cutler: “The introduction of information technology into the core operations of hospitals and doctors’ offices is likely to make health care much more like the retail sector or financial services. Health care will be provided by big institutions, in a more standardized fashion, with less overall cost, but less of a personal touch”. And, if I may respectfully add, increased convenience and instant consumer gratification to be balanced by lower quality, lower wages, rampant fraud and mass exploitation of both workers and customers. A veritable paradise for well-adjusted proletariat.

Yes, physicians will be using EMRs in larger and larger numbers, but there is zero probability that today’s doctors will ever like using EMRs, because nobody goes to medical school (or any school) hoping one day to land a job at a Walmart lookalike. So the logical remedy for doctors’ dislike of emerging Walmart EMRs is very simple: get rid of doctors. Right now we are told that there is a looming shortage of physicians, so we must find ways to deliver medical services without doctors, and hence we must automate, computerize and delegate medical care. Very clever idea, because once we downgrade services and have people accept this new paradigm, we can make the circular argument that we need even fewer doctors. Indeed Prof. Cutler goes on to prophesize the demise of small independent practice and small hospitals along with most conventional doctoring, which will be replaced by computer-aided self-diagnosis and crowd sourced clinical advice (something to do with Amazon, I think…). He still sees a need for a few doctors here and there, mainly “to direct patients to the right specialized resources, to reassure those in need, and to comfort the terminally ill”, which we are told “is a noble calling nonetheless”.  Noble calling indeed, but it should not require an MD or fifteen years of preparation, and hence it will not command much attention or compensation. The Walmart “doctors” in David Cutler’s future of health care will be happy to like their EMRs, or whatever else they are told to like.

Oh, by the way, no need for panic... I am fairly certain that they will have separate little venues serving Dom Perignon and Beluga caviar with Harvard Medical School educated physicians on the side.

20 comments:

  1. I guess this may be one way to lower the debt of graduating medical students. Great article...as always!

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    1. Thanks, Marly. Yeah, I guess it might lower the debt, but I wouldn't be surprised if they find a way to cut down on education and subsequent income, while keeping the tuition as is... :-)

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  2. Hard hitting insights from Margalit as usual!

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  3. This is the best article I've ever read on EMR and how it is destroying the practice of medicine. Barbara Roberts, MD

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    1. Thank you Dr. Roberts. I wish I didn't have to write this, and somewhere inside, I still have a little hope that we can do better.

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  4. Why do hospitals that employ physicians not care about lost productivity related to poorly designed EMRSs?

    Thomas Lindsay MD

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    1. The short answer, Dr. Lindsay, is that I have no idea. However, I would note that nursing staff is also losing enormous time to EMR work, which exacerbates the problem.
      I would venture a guess that the incentives/penalties (and perhaps future potential for revenues from data) surrounding EMRs outweigh clinical productivity (and quality) losses.

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  5. I will disagree with few statements of this article. First of all with a statement that EMR is not designed for patient care. In 2014 (if I’m not mistaken) patient portal will be mandatory part of EMR. So if you get into the ER for some reason all you need to give them is your username and password for the web portal of your primary care. ER personnel will be able to get all the info about your tests, drugs you take and don’t remember the names of, etc. How is it not about patient care? If doctor has been seeing particular patient for years and results of all the blood tests were properly entered in EMR it gives doctor better ability to draw the conclusions about dynamics of patient’s health. The other thing is that many doctors just type it in, and don’t enter results as they supposed to be entered. Ideally result goes from the lab right into the patient chart, but it depends how much particular EMR product is in love with software of particular lab. I can go on indefinitely, but what is important to understand, that EMR is NOT only about patient care. It cannot and should not be only about patient’s care. It also about efficiency and optimization of physician’s time, about optimization of billing, management and marketing. All this we can describe in one word – COST. This all is related to cost and hopefully will somewhat bring it down. If it happens it would be in direct relationship with care, because product should become cheaper. In my humble opinion this is not the way to approach cost reduction, but definitely will not hurt. After all it is not serious to carry around paper charts, which tend to get lost when moving form doctor’s assistant to doctor, to biller, to manager and to receptionist to be put back on the shelf.
    Main problem is that medical personnel just cannot utilize recourses of EMR properly. There are very good products out there. Thing is the more flexible is the product the more complex it is. And the simpler the product the less it fits the needs. Doctors are often just too lazy or don’t have enough time to pick the proper EMR product. Most definitely doctors have no clue which server to buy and what the heck is local network or what words “up” and “down” mean when applied to the speed of your internet. My point is that in the big organization, which has IT people, EMR can be successfully implemented and improve patient care as well as optimize processes within the practice.

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  6. Nauseous! Say it ain't so.
    Amazon killed most small, independent bookstores. Now, the ones emphasizing service are making a comeback. The medical practices that truly understand the meaning of patient-centric can be thriving underdogs. Assimilation is a choice.

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  7. Follow the money to understand why institutions are less concerned about physician satisfaction with EMR. The docs are typically paid $2-3/minute of work and generate revenue of $10-20/minute of work for the healthcare enterprise in today's fee-for-service system. It makes far more business sense to optimize the incoming revenue rather than to be focused on enhancing the doctor-patient relationship?
    However, if the system does indeed change to where the current revenue centers for healthcare systems increasingly become cost centers, and patients have increasingly higher deductibles, what's likely to happen?

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    1. Great point. So the $10-$20/minute will go down to $5-$10/minute and subsequently "providers" will be paid 50 cents/minute, and these cannot be doctors anymore. And just like Amazon needed to kill off the small and medium competition, large portions of the system will die off.
      After that happens, the boutique ones will make a limited comeback, I guess.

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  8. Many will not be able to make the switch to having a focus on what it costs to deliver each service rather than having a focus on maximizing the amount of revenue-services delivered. Most consolidating systems are not currently, actually lowering the costs. They are indeed vulnerable. Certainly, the days of having doctors spending more time creating data than seeing patients are numbered. That is a definition of waste and inefficiency.

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  9. In the models that rise to the top. The doctor will probably go from seeing 20-30 patients daily to 60-80, However, only 20 or so will be face-to-face encounters. Then about 20 will be seen by the care team and 20 encounters will be virtual.

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    1. On a certain level this does make business sense, if the 20 that are actually seen face-to-face, are the same ones that are being seen today because they actually need medical attention and can afford it.
      The other 40 to 60 that are "processed" could be people that are basically healthy and are non-customers today, but will become customers because everybody needs to be "engaged" (or risk assessed and medicated) in the future, or those who can't currently afford to be customers.
      Turning non-customers into paying customers, even if paying a lot less for a lesser product, is a type of Christensen innovation, isn't it?

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  10. Agreed, and to take it further... I think comparing Wal-Mart to medicine is a little misleading - Wal Mart sells things not services or information (for the most part) - true they have begun to branch out from the "thing" business to services - haircuts, eyeglasses, banking etc. to make use of the traffic flowing through their stores.
    Amazon is probably more applicable - they sell things but make more money off of the services they sell - Amazon Prime, AWS etc. At the same time Amazon has enabled 10's maybe 100's thousands or millions of smaller business to exist by providing "shelf" space, integrated ordering, tracking and shipping for companies who don't want to manage that portion of business. It's interesting that Amazon will gladly show you the price of used items right next to the new items they are trying to sell - I doubt Amazon cares too much about which one you buy. More interestingly, Amazon and others, have enabled entirely new industries - self publishing is now a very viable alternative for authors - the large book publishers don't particularly like this but we're all better off without the gatekeepers deciding what can and can't be published.

    Wal-Mart and the typical, large healthcare delivery system have limited physical shelf space so they are Gatekeepers - bow to them or there is no chance of your product making it onto their shelves. Amazon has unlimited shelf space and reach and thus enable a much richer and broader set of businesses to exist. Both are causing tremendous change and disruption to stores in the physical world and that is not fun if you happen to own one of those stores (or legacy medical practice) but it is generally good for everyone else. I would say that it is is Amazon and not Wal-Mart that is encouraging a resurgence in smaller mom/pop businesses - they just look different than they use to (as will the medical practices that thrive).

    The next generation hospitals/practices that set themselves up like Wal-Mart will probably not see the level of success they expect as they are physically constrained. I don't know how it will or would work but those that establish more of an Amazon long tail model will most likely represent the future.

    Blaming EMR's is simply misguided. They just happen to be the interface between the real world and the electronic one. They haven't caused any of this. The current EMR model in most systems is incorrect and poorly focused - largely, I suspect, because everyone is more focused on increasing reimbursement and not improving care. To improve care you have to have electronic helpers in the mix. The rate of knowledge acquisition, the complexity of the interactions and the need to collaborate is growing much too quickly to support any physical based medical record. As a patient, do you want a doctor who attempts to keep it all in their heads? Or, do you want interaction and expert services providing second opinion, etc.? Would you eventually want a Watson in the mix to assist? BTW, replacing a doctor with a Watson would be akin to replacing airline pilots with auto-pilots. Eventually doctors, like pilots will be complemented, not replaced, by assistance.

    Looking at it another way, writting computer program code is a simpler system than medicine. However, the number of people in the world who could program bare metal computers with no software help and build anything of any complexity are few. It's the software tools that allow us to focus on the more interesting and bigger challenges. It will be the ones in medicine that properly use new information tools and processes rather than the Walmeds that will thrive.

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    1. Yes, yes and yes.
      I do see a small caveat for the Amazon model in medicine though: you don't need to get naked (physically and otherwise) in order to obtain a service/product from Amazon or an unknown little seller in their stable... People may still prefer something more intimate for medicine, but I could be wrong seeing what folks post on the Internet nowadays.

      I like the auto-pilot analogy. Auto-pilots are designed to fly the plane under normal conditions. The presence of a pilot is assumed. Auto-pilots are not designed to make the pilot enter data for "research". The machine captures what it does and the "black box" captures everything else without taxing the pilot(s).
      If EMRs were designed with that paradigm in mind, I suspect most doctors would love to use them. Watson, renders all this structured data insanity pretty much useless anyway. Maybe not right this moment, but very soon. So it is incomprehensible to me that we use EMRs to turn doctors into stenographers (I think you solved that one :-)). If they tried anything remotely similar with pilots, the pilots would riot and the public would be appalled at the safety risks introduced by this. They would lose workers and business all over the place. It just plain wouldn't "fly" in aviation. So I'm wondering why on earth is this even mildly acceptable in medicine which is much more complex and fraught with danger than flying?

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  11. Thank you for this and other interesting articles.

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