Sunday, July 15, 2007

Electronic Medical Records - Physicians Go Haywire with EMRs, Critic Says


Try to Patch Practices Together with Paper Charts


“Haywire,” according to Microsoft’s Encarte World English Dictionary, means:

1) Functioning Erratically, or not at all.

2) Behaving Oddly, behaving unpredictably or extravagantly.

Webster’s New World Dictionary defines “haywire” as, “A logger’s term for a camp with poor equipment held together with haywire. Out of order, disorganized, confused. Crazy, as, to go haywire.”

In a June 27 Healthleadersmedia.com entry “Healthcare Crisis: EMR Non-acceptance in the US, ”Bill Bysinger, principal of WGB Advisory a health care and technology management consulting company and co-founder of eMRnet, an EMR services company, implies American physicians have gone “haywire” when it comes to EMRs.
Physicians, he says, simply do not know what is good for them or their patients electronically.

Bysinger’s June 27 essay opens:

It has been almost 20 years since electronic medical records systems were introduced into medical practices, yet we have the lowest adoption rate of all the developed countries in the world. Most of Europe, Japan, China, Australia and even Russia have adoption rates above 50 percent and in many countries above 90 percent
We are supposed to be the world leader in adopting technology, but recent studies have put our practice EMR adoption rate at somewhere between 15 percent and 18 percent.
I submit the root cause of the problem is the culture of the health care industry. Health care in the U.S. especially at the practice level is a cottage industry. Medical practices don’t make business decisions based on productivity or process improvement, which dominates other industries. Instead, they make decisions based on how much money do they have to spend and what will it do for the providers personally (and immediately).


Bysinger closes:

We cannot be proud of the fact that we have the best physicians in the world and are ignoring the value of electronic medical records as an enabler of better care.
The U.S. is the leader in applied information technology in most industries in the world, and we stand in last place in applied health information technology among developed countries in the world. This makes me ashamed of my industry and more focused on evangelizing change in our broken practice paradigm of paper records and manual clinic information processes.


After reading Bysinger’s opinion and pondering his conclusions, I ran across an article by John Stossel, a conservative journalist who hosts ABC’s 20/20 and who is the author of Give Me a Break, The article “Live and Let Live” is carried by the Creators Syndicate.

Here’s what Stossel has to say:

There are only two ways to get people to do things: force or persuasion. Government is all about force. Government has nothing it hasn't first expropriated from some productive person.

In contrast, the private sector -- whether nonprofit or a greedy business -- must work through persuasion and consent. No matter how rich Bill Gates gets, he cannot force us to buy his software. Outside government, actions are voluntary, and voluntary is better because it reflects the free judgment of creative, productive people. As I wrote in Give Me a Break: "If government would just back off, the private sector will provide many of the same services faster, better, and cheaper." There are plenty of examples that should astound the socialists, like better private water works, ambulance services, roads, even air-traffic control.

Of course, I'm talking about a private sector that gets no privileges from the state. That doesn't describe our private sector now. For years government has bestowed all kinds of favors on special interests, from trade restrictions on foreign competitors to cash subsidies and cheap loans to corporate tax deductions for health insurance. People in and out of government have conspired to pollute the voluntary private sector with force and regimentation. That's why we have a mixed rather than a free economy.


Stossel’s comments caused me to go back to Bysinger to see if he would “force” or “persuade” doctors to embrace EMRs. As you might expect, Bysiner’s message to doctors to encourage them to adopt EMRs mixes force and persuasion.

1. Provide immediate tax incentives for a dollar-for-dollar write-off against the cost of electronic medical records for every practice in the country. (This is another proposal that has been talked about for over 10 years without action.) Here Byzinger stresses “persuasion.”

2. Provide higher levels of Medicare and Medicaid reimbursement for those practices that can demonstrate the use of electronic medical records. Here, Bysinger mixes “force” and “persuasion,” i.e. if you want to get paid more, adopt EMRs.

3. Create state tax and licensing incentives for physicians that use electronic medical records. This is mainly a “force” argument. If you want to be taxed less or get licensed, get on board.

4. Create a mandate among every medical society to promote the use of electronic medical records and provide cost incentives on membership and services to those physicians that use and promote EMRs. When you run across the word “mandate,” you’re talking about government use of “force.”

5. Make health plans require physicians in their networks to be on electronic medical records by a specific date. Force again. The operative word is “require.”

6. Medical liability carriers should provide significant premium discounts to physicians who use medical records due to increasing patient safety and insuring better clinical documentation. Back to the use of “persuasion” in the form of “sweeteners.”

Maybe Bysinger’s six steps will bring doctors, who have haywired their practices together with paper charts, into the electronic age; jar them to their senses and consensus; and create order out of confusion.

I do not know doctors will react to this mix of force and persuasion. It is a matter of conjecture. It depends on what doctors perceive is in it for them, and on how one defines “digital.”

7 comments:

Unknown said...

I really like the framework you used of force vs. persuasion. I think too many in the health policy field rely on force-- leaving us with a group of highly talented and dedicated, yet frustrated and demoralized group of physicians.

Where I would like to hear more is the purpose for physicians offering EMRs. There have been some studies where offices using EMR have been less effective than those without.

Ultimately, we should incent the outcome desired (i.e., better outcomes for diabetes care, better sugar levels, etc) over the process we think could help get us there-- and show how proper use of the desired process helps to achieve the desired outcome.

Having been a consultant for many Fortune 500 companies (and smaller ones), I fear that with process metrics people focus on form, not function-- installing an EMR becomes more important than designing a great clinical pathway to engage diabetics-- which takes us only partially toward the outcome we hope to achieve.

I discuss this on my blog: http://consumerfocusedcare.blogspot.com

Richard L. Reece, MD said...

Dr. Goel:

I've read your post, and it's quite good. Others should read it. As a consultant to many Fortune 500 companies ans a physician yourself, you clearly grasp what's going on and what's at stake. You're right. There are 2 kinds of metrics - process and outcome. You can measure and control process until the cows come home, but that will not necessarily improve outcomes one whit. Doctors know outcomes may be largely uncontrollable. And they know EMRs are largely for the benefit of payers -- for tracking the behavior of doctors and documenting what they do or don't do. Tracking outcomes, which largely occur outside the reach of the physician, is a different kettle of fish. It will take years to determine if EMRs have much effect on mortality, morbidity. nad patient hehavior.

Richard L. Reece, MD said...

Vijay, could you send me your phone number. I would like to chat with you. After reading your blogs, it's clear you and I are on the same wave length. My phone in Connecticut is 860-395-1501.

Richard L. Reece, MD

Unknown said...

Richard,
I appreciate your kind words. I've sent my phone number to you in an email. Please let me know if you didn't receive it. Looking forward to speaking with you.

Best,
Vijay

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