EMRs Again: The Sky Still Isn’t Falling

Dr. C. Little, Family Practice Department Chair, continues at each monthly meeting to exhort us to purchase and implement electronic medical records immediately. This cannot wait until next year; it cannot wait until next month; it cannot even wait until next week. We need to go back to our offices from this meeting this very afternoon and begin the process of selecting an electronic medical record. Right now!

The meeting is followed up with an email containing essentially the same talking points, but including this line:

A reminder….all the studies have indicated using an electronic medical record results in better patient care.

Hm. I’ve read a lot of studies about EMRs. Very few have been done in the outpatient setting, and I do not believe any of those to date have specifically looked at solo or very small practices. Hey, no one’s actually defined what “better” patient care means. As Dr. Bob recently put it so well, promulgating Performance Measures and calling them Quality is terribly paternalistic. Are patients happier? (I know many would be happier if they could get amoxicillin for colds and unlimited vicodin, which I refuse to do just to pad patient satisfaction scores.) Are their chronic diseases better controlled? Is it because clinical feedback from the EMR somehow magically makes diabetics more likely to follow diet and exercise prescriptions? Does it really matter to the patient whether I’m writing in a paper chart or typing into a computerized one? That just doesn’t make sense.

I’ve been around long enough (and am smart enough) so that if I don’t understand something — and if no one can explain it to me in a way that makes sense — then it’s probably bullshit. I survived the great “vertical integration” push of the 1990s without selling my practice to one of the hospital systems using this rule, when it served me very well indeed. Most of the docs who sold out were royally screwed four years later when their initial contracts expired, and were either forced out of business or had to buy back into their own practices, wiser but way poorer.

So I decide to take twenty seconds out of my life and respond to Dr. Little, requesting references for even one study demonstrating better patient care with EMRs in the outpatient setting. Back came this.

Let’s see: a review article that actually evidence-based at all. It isn’t even a “study”. It’s just the opinions of 2 people, one of whom (Bates) has significant HIT industry ties (“paid lecturer for Eclipsys and as a consultant for MedManagement and Alaris”) and Atul Gawande, a subspecialty surgeon working mainly in large hospital systems. Only 2 or 3 of the article’s long list of citations are less than 10 years old.

The whole thing is full of “shoulds” and “ought to”s. It outlines the ways in which the authors believe EMRs will reduce medical errors and improve communication, without actually documenting any of it. In fact, it’s also full of “more research needs to be done” comments. If you were to replace “EMR” with “HRT”, and “medical errors” with “cardiovascular disease”, the thing would read like a treatise on Premarin. Also like bone marrow transplants for metastatic breast cancer, it makes sense that it would work. Unfortunately, as both those clinical examples showed, when actually studied, things didn’t turn out that way at all.

In fact, there have been plenty of articles — here, here, here, and here, for starters — questioning the utility of widespread adoption of EMRs by physicians at this time.

“But what about the money?” responds Dr. Little. “$44,000 from the federal government to help pay for the EMR. If you don’t get started now, you’ll miss out on that, and then you really won’t be able to afford one.”

Hang on just a second: Implementing an EMR costs way more than $44,000.

Not only are the upfront costs higher than that, but maintaining one costs multiple thousands of dollars a year. Bear in mind that they’re not talking about a lump sum payment of $44,000. It’s $18,000 the first year, $12,000 the second year, $8000 the next, $4000 the next, and then $2000, for a total of $44,000 spread over five years. FOR A SYSTEM EXPECTED TO COST AN AVERAGE OF $10,000 PER DOCTOR PER YEAR, not counting the start up costs, which run in the vicinity of $50,000. $44,000 over five years for something that will cost us $90,000 over the same period? And that’s even if they actually get around to giving out the money in the first place! According to this, in order to qualify for “meaningful use,” EMRs must be used for ePrescribing, for communicating with other EMRs like labs and hospitals, and for transmitting information on performance measures (the paternalistic proxy for “quality”) to the government.

ePrescribing is one of those things that sounds like a pretty good idea in theory that falls on its ass in five minutes of real life. Even if every single local pharmacy is set up for it, patients have to know where they want the prescription sent, AND the pharmacy has to know who the hell the patient is. Not everyone is all set up with a regular pharmacy before coming to the doctor. Others want to shop it around looking for the best price. So much for “paperless”, and so much for ePrescribing. Communicating with other EMRs is laughable. That can’t happen until the adoption of some kind of universal standard. Without that, these expensive EMRs are nothing but silos of isolated information that have to be printed out on paper to transfer from one place to another anyway. As for transmitting quality information to the government, that program (PQRI) has already started. How much extra money can I get from that? 2% of my Medicare total estimated allowed charges for the year. Let’s see: I got about $10,000 from them last year. That adds up to a whopping $200. (Coincidentally, that’s the same as the penalty in 2015 if I don’t adopt an EMR by then. I think I’ll take my chances.)

You may think doctors are dumb, but most of us can count.

Dr. Little is nothing if not persistent:

“This is clearly the way medicine is going. You have to start thinking about this now. The hospital is looking into ways to help you do this.”

And they are. They’ve allocated money towards it, and are researching which vendor(s) they’re going to work with for us. I’m sure their motives are pure. I’m pretty sure they really think they’re trying to help us out. Then again, Dr. Little also did a presentation on Accountable Care Organizations as the recipients of prepayments for services to large populations as a new model for more economical health care.

Hm. Let’s see.

Say the hospital helps me out, say by providing me with half the initial cost of an EMR. Say I adopt one. Say my income fails to increase enough to cover the extra maintenance costs (with which the hospital cannot legally help). Say my practice fails financially. Say I am forced to close my independent practice and look for a job as an employed physician. Oh, look! The hospital just happens to be hiring primary care physicians to staff its new Accountable Care Organization that’s raking in the newly available bucks from the ACA.

I’m not saying that the hospital is urging family docs to adopt EMRs they can’t afford to drive them out of business in order to hire them and consolidate its referral base. Then again, it’s an interesting plan for world domination. I wonder how many of my colleagues are falling for it.

From the deafening silence at the meetings, I’m guessing not too many.

Not to worry, Dr. Little. I don’t think the sky is falling just yet.

(My previous takes on EMRs: here, here, here, and here.)