The most important issues with any system of health care today are money and health. Does any system that is put into place make people live longer, better and for how much money? I am a physician and I think electronic medical records in a private office fail on both counts.
First, do they make people live longer? I doubt it. How can a medical record make people live longer? In theory, if screening tests are done as recommended by numerous medical societies, there would be an overall population survival benefit. This is a big “possible.” Screening guidelines suggest women start getting mammograms by the age of 40. A recent task force came out and said there is no survival benefit until the age of 50. Prostate cancer screening has drawn similar conclusions in terms of lives saved. More testing leads to more false positives, i.e., the test is abnormal when it shouldn’t be. This leads to anxiety, further testing, therapy, doctor visits and a big waste of resources.
What about immunizations? Perhaps they will help get more people immunized because doctors and nurses will ask and then recommend the procedures. This is a question that will take 20 years to answer. In chronic diseases like asthma and hypertension, perhaps monitoring will help a small segment of the population who will take the time and effort to monitor their disease at home, get the information uploaded and share it with their physicians. Personally, I don’t think it will help much. Both in my office and in the general population, people are getting fatter and they don’t exercise.
How about cost savings? The government is giving incentive money to physicians to get the records set up. That money, in turn, goes to the company supplying the medical record services. This gives the big companies impetus to lobby the federal government to push this program forward. Companies like Cerner, IBM, and GE have a lot of money for marketing and PR. There is a lot of money up for grabs. Once the systems are established, there are maintenance and support fees that continue forever. Theoretically, an office can have a smaller office staff and save money in administration costs. I would say that it is bad because it puts somebody out of a job, but in my discussion with colleagues and in economic studies done, there have not been any staff reductions. So, doctors aren’t saving any money by putting in the systems.
Are doctors making money from them? Due to the way they are set up for office use, most doctors spend more time with EMR than they do with paper charting. It is not more time with patients. This leads to inefficiency. If a doctor in a five-person practice is on call and one of his partner’s patients calls up for a refill on their medication, he might know the correct one to order or he will have an improved familiarity with that patient. That is better service, which is always good. Otherwise, I see no incentive for doctors to have them in their offices outside of saving a medicare-imposed penalty for not having them.
Are the health systems saving any money? Again the theory is that if a doctor has all of the information on a patient, he doesn’t have to repeat tests. This is more theoretical than real. If you have blood work and then have chest pain and go to the hospital, most of your blood work is repeated. If you have a CT scan and get a biopsy for cancer and see your local doctor and then go for a second opinion at a university cancer center, they will likely repeat all of your tests. For “well” visits, the testing usually goes to your local lab or hospital. This information isn’t currently shared. Systems do not talk to each other. It’s going to take years for this to happen. There are a slew of privacy issues to deal with. If your doctor has your EMR, that is one set of security. If your doctor has an EMR that talks to other doctors, you need another level of security. If you want something national, then you have some real privacy issues.
But are health systems saving money? Well the insurance companies are already and they don’t need an EMR to do it. Expensive studies like PET scans, CT scans and MRI’s need prior authorization and they are often rejected. Some doctors don’t want to spend the extra time talking with a precertification physician from the insurance company to get that fifth MRI for chronic back pain.
What about the hospital systems? Possibly this is where EMR has a place. The security concerns are taken care of by established IT departments. They can put hard-stops in on order entry to prevent drug interactions and duplicate testing. The incentive in cost savings is in DRG payments. If the hospital gets paid a set amount for a diagnosis of congestive heart failure or emphysema, the least amount of testing they do, the more money they make. Also, they make information available to all of the doctors in their system. That increases the efficiency of the doctors working there. This hospital-based system translates into a cost benefit for doctors. Doctors can see more patients faster, not waiting for hospitals to send faxes of information over to them. They don’t have to repeat as many tests either. Has this translated into a shorter length of stay for hospital patients? This theory does not pan out.
Therefore, it is my conclusion that the EMR system in its current form is good for hospital systems and the doctors who are privileged there and is a waste of money in private offices. Any mandate set out by the government to make doctors use an EMR system is misguided and based on fantasy and magical thinking. In the case of EMR is here, it is a case of “the emperor has no clothes.” I just don’t buy the hype.