PHYSICIAN POV

Electronic Medical Records: Panacea or Plunder? Dispelling the myths about cost savings with electronic record keeping.
By Mitchell E. Stashower, MD, FAAD

The current administration seems poised to undertake a review and “overhaul” of the healthcare delivery system in the U.S. Electronic health information technology investment is listed as a top policy initiative. Politicians and healthcare pundits seem to have recently adopted a synchronized call for the implementation of a standardized national electronic medical record collection and retrieval system (EMR). The electronic transformation of our medical record system is being touted as an advance in care and a major cost savings initiative.

Proponents claim that an EMR system will save large sums of money by reducing the overhead in medical practices, reducing medical errors, and reducing spending on duplicate tests. They also state that EMR will generally improve the quality of care that patients receive. I strongly disagree with these assertions. I believe that paper medical records have become a scapegoat and a distraction from a real evaluation of the much deeper and greater ills in our medical system and our society. I will attempt to dispel what I believe are the myths used to justify the urgent need to convert to a national electronic medical record system.

My biases and disclosures: I am the owner of a two-physician private specialty practice in suburban Washington, DC. I practiced in the U.S. Navy’s federal healthcare system for 10 years, having used their extensive electronic medical records system. I do not currently utilize an EMR. I am familiar with many of the current available commercial EMR systems.

Myth #1: The high cost of healthcare in the U.S. (compared to the rest of the developed world) is the result of duplication of tests. False.

Duplicated medical tests are indeed a waste of money, and standardized, centralized EMR will likely reduce duplicate tests. But the high cost of healthcare is really the result of waste caused by unnecessary tests. U.S. doctors are forced to practice overly defensive medicine because our medical malpractice tort system is severely flawed. It rewards and encourages doctors to perform tests and prescribe treatments that they know are not really medically indicated. Doctors do this out of the very legitimate fear that lawsuits might be brought against them. The training of physicians in the U.S. emphasizes the very need to practice defensive medicine.

A much more difficult pill to swallow involves examining the more painful reasons that the cost of healthcare in the U.S. (compared to the rest of the developed world) is so high. It is really because of the poor lifestyle choices that too many Americans make. Our system is failing at primary prevention—preventing diseases before they occur. It’s absolutely the main cause of most of the expensive diseases that we get. The U.S. population is obese, and our diet is too high in fat, sugar, and salt and too low in fruits and vegetables. Too many Americans lead an unhealthy, sedentary existence. One has only to visit a European or Asian country to witness the dramatic contrast in lifestyle there. Furthermore, the healthcare and societal costs of tobacco and excessive alcohol use far outweigh any waste on duplicated tests. If our patients didn’t eat, smoke, and drink so much, they wouldn’t need so many tests in the first place. EMR systems sound good in political speeches, but they do not address any of these root problems.

Myth #2: The high cost of healthcare in the U.S. results from inflated overhead in the provider’s offices, and EMR will reduce overhead. False.

I believe that EMR will increase overhead in most offices. The costs associated with implementation of EMR are very high for a typical medical practice. Startup, training, and maintenance are expensive. The implementation is time consuming and inefficient and requires large investments in technology that rapidly becomes obsolete. EMRs don’t save any money, but they do allow the doctors to capture their reimbursements more efficiently by making sure that all the necessary coding requirements are met for each level of service. In fact, that is the major selling point for companies that make these systems. They promise doctors increased reimbursement.

Many small offices that have instituted these systems do so with the goal of bringing in more money to the practice. This would have to be the case, in order to justify the very large expense of bringing their offices “online” with EMR. All small businesses desire to make their collections most efficient. EMR does not reduce costs for the patients or the “system” at all. It does, however, increase the profit margins of inefficiently billing providers. Fact: EMR has never been shown in any study to lower costs when compared to traditional paper records. There are absolutely no good data to show that total healthcare spending was lowered or that medical spending was used for more efficient purposes. To undertake a multi-billion-dollar program and institute a national EMR system without the requisite high level of proof is frankly foolish.

Myth #3: EMR will reduce most medical errors. False.

Medical error is a serious problem that needs to be addressed. The current EMR systems are not designed to aid a physician’s judgment; they are information collection and management tools. Most medical errors are made because doctors fail to correctly interpret and act on the available information, not because the information is unavailable. Sources of medical errors are complex but include deficient knowledge, deficient judgment or cognitive skills, failure to recognize limits in ability, equipment malfunction, external systems failure such as inadequate staffing, inadequate or inaccurate data, inaccurate medical history reported by the patient, miscommunication, verbal order confusion due to similarity of names, failure to convey empathy, poor patient compliance with follow-up and treatment recommendations, and cavalier personality. One can see from this list that many of these important sources of medical error will not be addressed with EMR.

Paper records have served us well since the inception of healthcare. The costs associated with maintaining paper records exist, but they never “crash,” are not subject to power outages or viruses, and don’t suffer the same privacy risks as electronic records. They do take up more space and certainly some practices will find that the benefits outweigh the costs. But undertaking a forced wholesale conversion to EMR at this time is ill advised because the data and theoretic basis are severely lacking. The huge expense involved in a conversion to EMR would be better spent on addressing the larger societal and systemic flaws in our healthcare system.

My affinity for paper medical records is more than just a sentimental longing. I suspect that when doctors hold paper medical records in their hands, their sensitivity and empathy may be increased. We all want to be recognized as individuals—not just medical record numbers. Doctors are humans too and to a degree are also subject to the same environmental and emotional factors as patients. We should not discount the emotional attachment and comfort factor of holding a newspaper in front of our eyes or the feel of the paper in a good book. Can anyone disagree that it feels so much more impersonal and colder when we read something on a computer screen? Until more convincing data are produced that EMR improves outcomes and saves actual healthcare dollars, I stand opposed to their widespread use. I prefer instead to advocate embracing the humanity of patients and doctors, which will return far more investment in the long run than technology.

Who’s Gone Electronic?
An SK&A Information Services survey released last month showed that 67% of medical offices with four or more physicians do not currently use electronic medical records (EMR) software. Other results reported include:

• In larger practices with 26-plus physicians, 39% have EMR systems.
• In practices with three exam rooms, 34% have EMR software, whereas in practices with more than 11 exam rooms, nearly half do.
• In physician offices with a daily volume of 1 to 50 patients, 30% have EMR software. Of practices with a daily volume over 100 patients, 39% have EMR systems.
• The specialty areas with the highest adoption rates include anesthesiology, emergency medicine, and internal medicine.
• Specialties with the lowest adoption rates are urology, psychiatry, and plastic surgery.

REFERENCES: 1. Obama, Barack; Biden, Joe (2008). Plan to Lower Heath Care Costs and Ensure Affordable, Accessible Health Coverage for All, barackobama.com. 2. Girosi, Federico; Meili, Robin; and Scoville, Richard (2005), Extrapolating Evidence of Health Information Technology Savings and Costs. RAND, page 36.

Dr. Stashower is in private practice and is Assistant Professor of Dermatology at the Uniformed Services University of Health Sciences, Bethesda, Maryland. He has worked as an investigator, consultant, and adviser for multiple pharmaceutical companies.