Posted by: notdeaddinosaur | August 19, 2010

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.)


  1. Dr Dino – you & I don’t agree often, however, we agree completely with this!

    eprescribing will eventually fall on its face unless & until the medical record can go back & forth between providers.

    I’ve never had so many dangerous & potentially fatal prescribing mistakes until eprescribing took hold.

    I even had one of the IT MDs from a large (>300) MD practice come to my pharmacy to see what the problem was. He/she had no idea what is involved on our end & the number of ways a mistake can happen.

    This is a disaster waiting to happen & perhaps the large multipractice corporations can absorb the liability (after all – 5% of errors are accepted as the cost of doing business – nuts!). But, the small practitioner cannot afford this.

    The only example I am aware of is in psych practices where everything is generated on a pc – history, exam, assessment, etc. The rx is also generated on the pc, prints out on the printer & is finished off with a few handwritten, required notations & the electronic copy of the rx is in the record. But, none of these psychiatrists see inpts, so, no big deal.

  2. Gee, and it came from your favorite journal, too. And you’re right, this is the same load of BS they gave us back when the hospitals all thought they could run our practices better than we could (we thought not, and resisted, as you did, to our benefit). My thought is that since I’m 10-12 years from retirement (I hope!) I would be better off taking the penalty than spending a boat load of money to slow down my patient flow/make my staff crazy/give me a stroke which would ruin retirement anyway.

  3. Hi Dr. Dino,

    First of all, I respect your opinion immensely and event want to agree with it. Secondly, I don’t have a whole lot of expertise in this area except what I’ve heard speaking to people in the field of EMR implementation.

    When I mention your post, they rebutt it with the comment that having a practice on paper records would lower the efficiency of the entire system by making it less easy for hospitals (who are on EMR) to receive a patient’s health records if you were to transfer them to that hospital.

    What do I tell them?

  4. Excellent, excellent post.

    Every good family doc I know whot is running a successful (medically and financially) practice feels the same way.

    “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.”

    My rule is a little simpler:

    If the AAFP is in favor of it, it’s a VERY bad idea.

  5. From a patient’s perspective I like EMR. I live in a large US city and I recently had the opportunity in my family to deal with the two largest hospital organizations in town, one of which uses EMR and the other one does not. At least one of my doctors is affiliated with both organizations.
    With the organization that already has EMR implemented, I liked simply being able to say: “Dr. Such made the referral.” They had my personal and insurance information, knew why I was there, what was ordered, and all I had to do was sign the HIPAA form and see the doctor.

    With the non-EMR organization, for each new doctor I was presented with three to five pieces of paper, asking very similar information on most of these pieces of paper, for each new and exciting practice I visited. It felt redundant and stooped. At the very least they could have entered my name, DOB, address, and insurance information which they already gained during the appointment phonecall (are you feeling my excitement yet?) so I didn’t have to write that down three times for each practice.

    The way Linda describe EMR, in the phych practice, is similar to the way my family practitioner/pediatrician/Imaging practices work together. They’re bigger than a single practice, but share records, billing, and it’s nice for me as a patient.

    I like EMR.

  6. I had an EMR in solo practice and I am on the hospital IT committee.

    One hurdle for sharing information is HIPAA compliance!!! Now with the Feds allowing lawsuits for HIPAA violations (and the State of CA also getting into the act) the software has to be as tight as possible to avoid even accidental release of personal and medical information.

    So you have one arm of the Fed saying we need free and easy information sharing and another arm ready to chop our heads off if we allow free and easy information sharing.

    Pick one. You can’t have both.

    And no software maker yet has an interface which allows a wide variety of practice styles and is completely unobtrusive in getting the exam information into the EMR. Either the system molds the doctor into fitting a template of some kind or you have a scribe or transcriptionist doing the note (which defeats the purpose of having an EMR in the first place!!!)

    Voice recognition has gotten better but the software and the doctor need at least a month or more of training. It also is an additional cost over and above the EMR software and you pay again with every upgrade (typically yearly).

  7. Just remember folks. If other doctors and hospitals can get your information, so can just about anyone else.

  8. As an MT for many large acute care hospitals, please allow me to inform the populace of a few things:

    1. VR and EMR (for acute care hospitals) still go through an MT “editor,” and more than 50% of the “editors” are located in India and Pakistan.
    2. No, it’s not against the HIPAA “law,” and no one apparently cares.
    3. Again, in the acute care setting, “scribes” are now hired to dictate, which are usually NPs, ARNPs or the usual residents. MTs still do the actual transcribing.
    4. EMR/VR/Dragon, etc. will NEVER be successful in to transfer via computer in a fragmented digital world. It has to be centralized. The only way it will be centralized is, _____ (fill in the blank).

  9. Pardon my “in” typo.

  10. IANAD, but a long career in IT suggests a web-based system may be the best bet. PCs are not expensive and a number of web-based EMR vendors will specify and set up the PCs, network connectivity, security, etc. for their respective services. Of course, practical matters like blocking USB ports so people can’t scrape information off the local drive, encrypting the drive, removing unnecessary material like games, and limiting the websites where low-level users can visit are all too infrequently done, even in medical institutions that should know better. (Disclaimer: Consulted in the IS department of a community hospital for a while.)

  11. Dr. Dino and friends:
    As I analyze health data for a large pharmaceutial company, I would love to have my hands on EMR data to assess patient outcomes. However, as a patient, EMR eliminates the whole point of “patient care”. Having recently relocated and found a new practice (*sigh, tear*) the whole exam process is the quietest thing I’ve ever experienced. My MD and nurses spend more time in front of the computer typing in stuff for which we haven’t even had a discussion than we do discussing why in the world I’m there in the first place.

    As for the poster who mentioned going over the same info multiple times….at least then I know the doc is synthesizing what’s being said. Who knows if they even read the history on the EMR.

  12. SusieQ324:
    I did not write ‘going over’.
    I wrote:
    “asking very similar information on most of these pieces of paper”

    There is a difference. ‘Going over’, I’m ok with. It means that somebody is actually reading and processing my data. In several instances they didn’t even notice the fact that I put three different phone numbers (all valid ones) in for the ‘home phone’. It was careless (like: I don’t care about you, the patient) on their part.

    The only thing they all made sure to get correct is the insurance information. They copied the insurance card, in addition to asking for all the information on another piece of paper.

  13. […] to $44,000!” Here’s the problem with that figure, though, including how it breaks down (source here): [M]aintaining [an EMR] costs multiple thousands of dollars a year. Bear in mind that they’re […]

  14. […] to $44,000!” Here’s the problem with that figure, though, including how it breaks down (source here): [M]aintaining [an EMR] costs multiple thousands of dollars a year. Bear in mind that they’re […]

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