The Case Against the Electronic Medical Record
By David J. Gibson, MD and Jennifer Shaw Gibson
PRESIDENT BARACK OBAMA convened a healthcare summit in Washington on March 5 to identify programs that would improve quality and restrain burgeoning costs.
His flagship proposal was national adoption of the electronic medical record (EMR). This, he said, would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.
The point of this article is to discuss the value of the EMR itself. But it must be pointed out that none of the President's assertions is true.
Obama has based his proposal on a now discredited 2005 RAND study on EHRs. From the time of its publication to the present, there has been no compelling evidence to support the study's theoretical benefits.
If, as RAND asserts, the EMR improves efficiency, enhances productivity, decreases overhead cost and improves the quality of health care, why are only 4 percent of doctors using functional electronic records that can provide any kind of clinical recommendations, and why are only 1.5 percent of nearly 3,000 hospitals currently equipped with comprehensive electronic records?
As a group, health care professionals have been on the forefront in embracing information technology, including beepers, fax machines, cellular phones, desk top computing, data mining and the use of the Internet for both personal and business use.
Yet there is a gap between information technology's deployments in health care as opposed to most other industries. There are several reasons for this.
The Technology Issue.
EMR systems are difficult to maintain in the small practice setting.
Furthermore, most studies document a reduction in physician productivity following installation of EMRs. These systems generally add a half-hour or more to a physician's day for tasks such as electronic ordering, and responding to the false alerts that all of these EMR systems generate.
Physicians need an EMR that does not yet exist. They need a mobile, voice-activated, heuristic, architecture-based system rather than a keyboard and mouse-based interface with the EMR. A friend of ours once made the observation that "information technology does not require subsidization unless it is not ready for deployment."
The Business Model Issue.
For hospitals, declining revenues and deteriorating investment returns, coupled with accelerating capital costs, make investing in EMRs problematic. . .
A new report by Avalere Health, an information company serving government and the health care industry, found it would cost about $124,000 for a single doctor or small practice to upgrade to electronic health records over the five-year period (2011-2015) during which the stimulus bill offers incentive payments of up to $44,000.
In 2015, Medicare penalties start to kick in for doctors who haven't switched to electronic record-keeping. The projected starting penalty will be $5,100 a year - far less than the cost, less the incentive, to install and maintain an electronic health system.
EMR Veracity is Compromised.
The secret generally unknown outside the health care industry is that the only real business model case that resonates for the EMR in medical practices is the support for documenting (and occasionally up-coding) billed charges. Interest in the EMR was generated by the threat from the Centers for Medicare & Medicaid Services (CMS) that physicians needed to adequately document patient visits.
Remember the Evaluation & Management (E&M) Code controversy that arose with the 1996 passage of the Kassebaum-Kennedy Bill? The purpose of the bill, which criminalizes any miscoding of medical services, was to control fraud and abuse in the Medicare program. To no one's surprise, the documentation to satisfy E&M coding requirements fit neatly into a computer coding system - the EMR was born.
A decade later, another reason for adopting electronic recording of clinical information developed. In 2005, "Pay for Performance" (P4P) was introduced by the health insurance industry. These P4P plans - which pay doctors, hospitals and other providers more meet certain goals - were seen as a way of boosting health quality. Recent evidence is that P4P plans are ineffective in achieving any of their original goals.
Researchers at the RAND Corporation studied a P4P program started in 2003, involving seven major California health plans and 225 physician groups caring for 6.2 million people. The study found that the programs appear to be speeding adoption of information technology such as electronic medical records, but these changes have not improved quality.
There are now rather unpleasant consequences emerging as a direct result of E&M codes, P4P and the evolving deployment of EMRs: The veracity of the medical record is being compromised.
An associate who teaches at a medical school told us that he observed frequent EMR chart entries using macros (one or two key strokes that perform a series of actions) for components of the physical exam that have not been performed.
"Mary, it says here you did a neurological exam and it was normal. I was there with you and didn't see you do a neuro-exam."
The student's response, "I inserted a macro for my physical exam."
Another associate who practices in a large medical group relates that padding of the chart with superfluous, macro-based information is rendering the chart irrelevant.
As this checklist, cut-and-paste, or macro-insertion behavior spreads, the veracity of the medical chart becomes profoundly compromised. How can an attending physician finding neurological deficits ever rely on the recorded clinical findings six months before if there is a possibility the reported data are compromised or, worse, "dry-labbed"?
The answer is they cannot. So the only believable data in these EMRs will be derived from the lab and the objectively recorded diagnostic studies.
Quality of Care.
There is also no evidence that the EMRs improve the quality of health care. A 2008 study published in Circulation assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that "current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems."
Similarly, researchers from Brigham and Women's Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. They concluded, "As implemented, electronic health records were not associated with better quality ambulatory care.". . .
One of the oldest of computer problems - "garbage in, garbage out" - exacerbates liability exposure. Once a misdiagnosis enters into the electronic record, it is rapidly and virally propagated. A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer - 48 compared to seven in the paper-based cohort.
Propagation of mistakes is not limited to misdiagnoses. Once data are keyed in, they are rarely rechecked for accuracy. Entering a patient's weight incorrectly will result in a drug dose that is too low or too high, and the computer has no way to correct such human error.
Recent studies suggest that adopting computerized systems has not helped but harmed patients. After the Children's Hospital of Pittsburgh added automated prescribing recommendations to a commercial electronic records system, it documented more than a threefold increase in the death rate of child patients. Another leading system contributed to more than 20 different types of medical errors.
Once the medical record is in digital form, a couple of mouse clicks on a computer that is connected to the internet can propagate the most private of information to a worldwide audience.
Furthermore, not every health care professional with access to the EMR system should have access to every record within the system. Once cleared for record access, not every professional should have access to every part of the record. This conundrum of layered security level setting has not been resolved.
Current concern over confidentiality of data is not spurious for providers. The liability relating to disclosing personal health Information (PHI) now stands at up to $1,500,000 per occurrence.
A Tool for Rationing.
A new concern has arisen with the administration's EMR initiative. Some have speculated that patient data collected in national electronic health records will be mined to assess cost effectiveness of different treatments.
This analysis could then be used to dictate which drugs and devices doctors can provide to patients in federal programs like Medicare. Private insurers often follow the lead of the government in such payments.
The fact is there is no objective peer reviewed and published evidence that EMRs improve quality or reduce costs.
What lessons can we learn from all of the above? One is that public policy should not drive market development before thorough pre-deployment testing has determined effectiveness and detected unintended consequences.
It should be noted that though we are critical, we are not opposed to the EMR - in fact, we recognize clear benefits from deploying an EMR in the clinical setting. Today, patients are frequently seen without physicians having access to the patient's paper records.
With EMR, health professionals can readily access all information on their patients from a single site. Particularly helpful are alerts in the system that warn of potential toxicity in prescribing certain drugs for a patient already on other therapies.
Rather, our objection is to the opportunistic and abusive use of discredited data and bogus projections for political purposes. The cynical presentation of unsubstantiated or, worse, known inaccurate cost savings and improved quality of care data being used to justify breathtaking increases in taxpayer funding for increased health care spending by the government is patently disingenuous.
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Jennifer Gibson traded energy commodity futures on the Chicago Mercantile Exchange. She is also an economist who trained at the London School of Economics and now specializes in evolving health care markets. David Gibson is the C.E.O. of Reflective Medical Information Systems, a software development and consulting firm.