What! EMRs don't help patients? If this is the case, why is President Bush pressing for wider adoption of this technology and why are all of the large healthcare systems spending millions of dollars for EMR deployments? Why are so many consultants feeding at this trough? A recent article by Dr. Michael Wilkes in the Sacramento Bee web site (see: So far, electronic records don't help patients much) contains some food for thought. Below is an excerpt from his opinion piece (boldface emphasis mine):
Why the push for the EMR? In theory, the EMR will enhance quality of care, improve communication between health-care providers and reduce medical errors....Admittedly, other industries have seen large cost savings from computerization, but health care is different. First, the health-care system is hardly a system. It is hundreds of thousands of doctors and thousands of hospitals all practicing medicine their own unique way -- and the EMR will not change that....Each [hospital] has purchased a system, at huge expense, from a vendor who is in competition with other vendors and unwilling to work from a common language....Not surprisingly, the one thing studies have shown is that the EMR does increase the amount a doctor can bill by improving documentation. But documentation is where I have my biggest concern....[The electronic template] approach to documentation has a potential for electronic forgery and dishonesty that allows for increased billing, and quick note production, but may do nothing to improve patient care.
I have the following reactions to Dr. Wilkes' lament about the EMR not enhancing the quality of patient care:
- I think that every physician needs to keep in mind that the primary goal of the paper medical record, and more recently the EMR, is to generate a patient bill that can be defended when challenged by payers. And challenge they will. A new software industry has arisen called "denial management" to support provider payment claims. Most physicians do not view the EMR in this light but they are also not the ones pushing for the deployment of these systems nor are they the ones paying for it. It's the C-level hospital executives.
- I am intrigued by the reference above to "electronic forgery and dishonesty" by the use of templates used for EMR documentation that may not necessarily reflect actual work performed. Physician order sets are another example of an automated feature of the EMR that can go awry. On one hand, they provide a rapid-fire way for a physician to generate his or her preferred set of, say, admission orders for a patient including lab tests. On the other hand, once such order sets are established as part of a CPOE system, I believe that there will be inertia on the part of the physicians to modify them even when some of the orders become outdated or unnecessary.
- Another EMR problem that has gotten little attention is the requisite updating of those systems that are plagued by periodic "unscheduled downs." I have made references in Lab Soft News to a couple such cases, notably the Kaiser HealthConnect system and the Shriner EMR that runs centrally for all of the hospitals in the system. If and when the EMR, the source of clinical truth, becomes inoperable, the default status for clinical record-keeping will be paper records. The task then falls to the nursing and physician staff to update the EMR when it comes back live based on the temporary hardcopy documents, distracting them for their ongoing clinical responsibilities.