Random Thoughts from a Restless Mind

The eminent philosopher Yogi Berra has captured the essential problem with the current fascination among our legislators and government bureaucrats with Electronic Medical Records (EMR or EHR). “In theory, there is no difference between practice and theory. In practice, there is.”

In my mind I have an image of the well-intentioned men and women who are developing the next generation of EMR. I see them as this generation’s equivalent of  a pre-Foundation Bill Gates, or Steve Jobs before the black mock-turtle tee shirt. All nerdy and earnest, focused on the software solution to a problem they’ve read about. They peer out at the world beyond their screens, convinced of their ability to solve a problem they view from 30,000 feet, perhaps dreaming of becoming wealthy should they succeed.

I also have a picture in my head of the legions of un-elected bureaucrats in state capitols and in Washington who have latched onto this notion of EMR as the panacea, the magic solution to the American “Healthcare Crisis”. Equally earnest, white-paper educated omniscients convinced that a technical solution is all that is missing from the equation. They deal each day in the business of spending tax revenue and the legislative give and take that eventually results in a state or federal budget.  Their time is spent with eyes glued to their laptops and their Blackberries, only seldom establishing eye contact with another of their kind ,and only then if absolutely necessary.

In THEORY this EMR thing is a no-brainer, isn’t it? Who wouldn’t think so? A true EMR is a system of record keeping for medical data in which all of the information is entered digitally and stored in hard drives instead of paper charts. Every time a patient is seen by a doctor or a nurse-practitioner his entire medical record is there for the viewing. No lost pages. No missing data. No struggling with the abysmal handwriting of the busy specialist who saw him for an emergency at 4:00 AM. What’s not to like about that?

In THEORY a universally applied EMR should also create some economic advantages in our healthcare system as well. We would theoretically need fewer billing assistants since all of the charge information would flow automatically from the medical record to the billing system, and from there straight to the payer. There would be few, if any billing errors since the coding and reporting requirements for each insurance company (or the federal government) would be built into the software. Since all of the information about medical outcomes would now be instantly available we would now be able to evaluate competing treatments and determine objectively which ones work and are therefore worth their cost to provide.

Unfortunately it turns out that Yogi Berra is not only a philosopher, but in this instance he is also a genius. You see, in PRACTICE all of this theory falls apart because of a rather messy and unpredictable variable in the system that the EMR designers and the all-knowing bureaucrats just can’t remove from their programs or their systems: all of the patients and all of the healthcare workers are PEOPLE. People who are sick and become patients. People who don’t want to be sick and try not to be patients. People who come to work fresh and adequately caffeinated, and people who are really patients that particular day and don’t know it, spilling their Starbucks on the keyboard.

Computers and the software that runs computers reduce work and increase efficiency in their optimum usage. They enhance the experience of all who encounter them “in the wild” when they fulfill their potential. At the same time that we have all of this talk about the urgent need to get every doctor’s office and hospital computerized coming out of one side of the collective mouths of the “reformers” we also hear out of the other side of the need to improve the patient’s experience when she goes to see her doctor or when she is in the ER. Those same bureaucrats and policy “experts” scampering through the legislative ant hills who extol the virtues of computerized efficiency also demand more time for patients from doctors and nurses, time  spent one-on-one in providing medical care. Not too much time, though; these budget-watchers  also bemoan the existence of so-called “concierge” practices, the ultimate expression of patient-centered medicine, because this model reduces the pool of doctors available to provide care.

The only conclusion that one can reach is that none of these EMR developers or policy developers has ever been a patient in an office or a hospital with an EMR!

The most important entity in the exam room or in a hospital room when an EMR is in use is the computer. The bigger the institution the more this is true. Mandatory questions must be asked in sequence and data entered in order. Imagine your doctor or her nurse as the best-educated data entry clerks in America and you get the idea. And it doesn’t matter whether it’s a computer and a keyboard or some sort of handheld gadget, the eyes of the doctor is on her screen, NOT her patient. The doctor has a relationship with her computer; the patient has a relationship with the back of the doctor’s head.

And you know what, it takes time to enter all that stuff. Much more time than it takes to jot down a couple of notes or a little data. Where will that time come from? Well, either it comes out of the time devoted to looking and listening, or it comes from decreasing the number of patients a doctor can see each day. Fewer employees necessary to run the computerized office? Really? What other customer service business has successfully reduced the number of people involved in providing that service to the satisfaction of its customers? It’s also really expensive to buy and implement and maintain an EMR. We’re talking about Billions of dollars up front and every year hence. Where will this money come from as doctors and hospitals struggle to remain afloat?

The EMR fails “in the wild”. It fails in PRACTICE to do either of it’s most important tasks; it neither increases efficiency nor does it improve the experience of the user. An EPIC fail (pun most definitely intended for you Epic users).

In the end the only winners in this EMR game at the present time are regulators and third-party payers. When we put all of the advantages of EMR in THEORY  into PRACTICE the losers, once again, are patients and their doctors.   With the present state of technology we will spend more money to buy systems that will decrease our efficiency and reduce the quality of experience that both our patients and doctors will  have when healthcare is provided. And we haven’t even touched on the difficulties of maintaining the confidentiality of all of that information, or whether or not you can really pigeon-hole all of those messy, unquantifiable individual patients into tidy little  treatment groups.

I have another picture in my mind, a picture of Yogi Berra in his doctor’s office. Yogi’s getting on in years you know. Probably has a couple of medical problems; probably taking a couple of medicines, too. Can’t you just see him, all ears and nose and those huge glasses underneath a vintage Yankees hat?

“Doc. DOC! Who ya lookin’ at? Hey. HEY DOC! I’m over here!”

This entry was posted on Thursday, September 3rd, 2009 at 10:02 am and is filed under Health Care, Healthcare Economics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.