I read a blog post by Andy Kessler today, who has written a book called The End of Medicine, which I have admittedly not read as of yet. The post alleges that the medical industry has created a complete boondoggle of finances, and if we were to employ electronic medical records and their efficiencies, physicians would suffer and therefore, the emphasis and resistance to EMR is merely doctors protecting their own. (Or that’s how I read it.) While the Oliver Stone conspiracy theory plays well to an audience who has increasingly less and less trust in authority, it’s not even close to the facts of the matter. Let’s start out with a few basic facts:
– While many medical technologies like ultrasounds are slowly being digitized, there is no standard language or interface that makes this information easily accessible in a secure form. For example, an ultrasound machine does not automatically save all images onto a SD card and you can’t upload the images easily to Flickr. Add to this that small distortions can be indicative of disease and change a diagnosis, and you have a problem- not only that of having to retool and replace thousands of very expensive diagnostic equipment in every medical practice and hospital across the country, but how do we ensure that these images maintain fidelity when they are transferred between a doctor, a hospital, or over the net? Let’s not even alk about the fact that different EMR’s on the market do not as of yet interface smoothly with one another, let alone the labs- there are not, as of yet, any web-like standards for medical EHR.
-Part of the problem caused by EMR is that the data needs to be measured the same between doctors and institutions. The quality of the data- not just your hemoglobin, but measurements of say, fundal height, are not nearly as standard as one may assume. Data fidelity is as much an issue as is accuracy. Without more investment in standardization of data collection, sharing data between providers and institutions causes more problems than it solves.
-Paper records are sometimes better at flagging problems and inconsistencies than EMR. Some physicians I know were recently discussing a case where the blood tests of a woman showed conflicting Rh factors between what was in her office chart and what was in the hospital’s chart, which was an EMR. It was a problem tracked down to an error in the lab- but the problem was almost overlooked because there’s no way to put a big yellow post-it note, yet, on most EMR’s to make sure, without a doubt, the physician notes this sort of minor, but critical discrepancy. We need to make sure EMR’s are not just a sea of numbers, but that there’s some reasonable attention-getting mechanism so inconsistencies are readily apparent.
-Kessler talks about the problems that could be solved if all the data were gathered in one place. This is very true. But between HIPPA laws to protect patient privacy and the use iof their data in any sort of medical research, and the thorny issue of who would own, maintain, and allow access to this data, let alone pay for its creation, this is not an easy problem to tackle. A physician I know well just went to ask for some of the stimulus money to help start a data storehouse to solve some of these problems in respect to pregnant women. If the NIH and government own the data, there may be more equal access to it, than say, if a private healthcare company or drug company owns it, and creates an access and monopoly issue- can they cut off access to their competitors? How much money would a project need to buy access to the data? Who pays for the accumulation and submission of the data? How does it get stored? How are redundancies built in so the data is backed up and resilient from both unauthorized access and failure in the event of an emergency? How do you make sure smaller, poorer hospitals have enough data infrastructure to interface with larger, referral centers, especially in times of emergency?
Healthcare is fragmented more so than our financial services and banking ever have been. Individual practitioners are like individual small businesses- asking them to create and adopt an EMR for all their patients is like trying to make sure that Target and Kmart communicate to one another regarding your buying preferences, and then provide that data to your favorite pizza joint and dentist. We’d like our cardiologist and internist to have the same system, but if they do not have hospital based practices, this is highly unlikely at this point in time.
I appreciate the frustration that Mr. Kessler and others feel with the slow transition from paper to pixels in medicine, but the issues are WAY more complicated and nuanced than he lets on. This is not a conspiracy like the JFK assassination, nor is it a plot for doctors to secure their position as high earners. Most docs I know and I am married to one, would love for the data to be easier to centralize and maintain. But look at how data fidelity errors could cost people their lives- small errors propagating poor decisions in a diagnostic tree- and look at how fast incorrect data can spread- like the rumors of celebrity death on Twitter- and ask yourself if you want fast, or you want accurate when it comes to your health care.
Ask why doctors make a decent salary- could it be 8 years of advanced education, plus residencies of an additional four or more years, plus the responsibility for the health, well being and very lives of their patients- and ask yourself if you would take on that responsibility for minimum wage. Not me. We want doctors to still be magic, yet be as concerned with customer care and treat us like family, yet we want them to do it as cheaply as possible.
My secret concern is that our third party payor system insulates most money issues from coming between a doctor and patient- a doctor can assume he will be paid for his work without running a credit check on you first like other businesses. But then again, the office, insurance and the hospital are in charge of the billing and negotiating payment, and he may sincerely not know if the meds he is prescribing or the sutures he is using are more expensive than alternative options- they use what is the standard of care, or what the hospital stocks in the OR. A doctor himself may have very little idea what his patient pays, and while that makes for inefficiencies and possible overuse of more expensive treatments, we have traditionally taken on these costs to prevent ability to pay from determining which tests a doctor may use, and somehow using less sophisticated and cheaper tools for patients of one economic class over another. Money is important, to be sure, but we all want chemo when we need it, regardless of our ability to pay out of pocket. We already know people forgo treatment of illness and injury if they can’t pay for it, often making their condition worse and more catastrophic.
I don’t think we really want doctors spending all their time constructing a consumer reports of medical equipment, looking for the cheapest stuff available- we want them to use reliable equipment at a reasonable cost, to do their jobs well. If we add the burden onto docs to be full time cost containment vehicles, what will we be losing as a result?
The health care problems in this Country are thorny at all levels. I just think all of those who think the answers are as easy as putting your med records into a word file or in the cloud don’t know enough about medicine to appreciate some of the more difficult issues out there. It’s only by having doctors and geeks in the same room that we’ll be able to solve these problems globally. That, and making sure we have some data standardization that all ancillary medical equipment businesses would be willing to adopt, so the infrastructure works well. Until then, we have a mess of puzzle pieces that don’t easily fit together.