Tuesday, February 17, 2015

Euphonic and Dysphonic Electronic Health Records

It’s not as bad as it sounds.

Mark Twain on Richard Wagner’s music

Electronic health records (EHRs) may not be as good as they sound (Jeffrey Singer, MD, “ObamaCare’s Electronic Debacle,” Wall Street Journal, February 17, 2014).

To Washington policy makers who created the the $800 billion 2009 stimulus bill, EHRS sounded good, felt good, and therefore had to be good.

EHRs were objective. EHRs produced data – fuel for Internet geeks and policy wonks. EHRs told you what was done. EHRs allowed you to track physician performance and patient outcomes.

Above all, EHRs were “evidence-based.” What was not to like?

Furthermore, EHRs had been tested in the real world. Organizations like Kaiser Permanente and the Veteran’s Administration were using EHRs to coordinate care, connect all participants in that care, vertically integrate that care, and, it goes without saying, manage that care.

EHRs were perceived as the solid management foundation on which to rest federal health reform. Management dogma proclaimed, if you can measure care in real time, you can form negative and positive feedback loops, you can track doctor and patient behavior, and you can improve both.

Sound too good to be true?

According to Jeffrey Singer, MD, a general surgeon in Phoenix and an adjunct scholar at the Cato Institute, EHRs are not as good as they are cracked up to be.

EHRs distract from patient-interaction. EHRs split attention between the computer screen and the patient. You cannot look at both at the same time. Doctors in one survey say they wasted 48 minutes a day entering data or complying with EHR instructions.

EHRs cost money, $162, 000 to install for the typical 5 person group, and $85,000 to maintain the first year.

EHRs are not “user-friendly.” In a 2014 Medical Economics survey, 67% of doctors found EHRs to be dysfunctional . Yet the government will penalize doctors who do not use EHRs when treating Medicare patients by cutting reimbursements 1% in 2015, increasing to 5% by the end of the decade.

These factors are driving doctors into hospital employment where the hospital installs and maintains the EHR. In addition, fees for patients going to hospital-employed doctors rather than independent practitioners are significantly higher, sometimes as much as 50% higher.

Finally, there’s a “quality “ problem if you define quality as spending time with patients or having access to doctors. Doctors working for hospitals often switch to hospital employment so they have a more “balanced life style,” which translated, means more time spent with family, on personal matters, or in a 40 hour work week, rather than the average 53 hours in independent practice.

To contain costs, health plans are narrowing physician networks. This makes it harder for patients to find doctors. To compound the problem, because of lower Medicare, Medicaid, and health exchange reimbursements and the increased costs of mandatory EHRs and other regulations, doctors are accepting 20% to 50% fewer patients in federal programs. As many as 20% of primary care physicians are switching to direct care, concierge practices to escape the rigors, expenses, and other time consuming costs such as EHRs and ICD-10 coding, another federal requirement.

Where have all the doctors gone? They have gone to spend more time with EHR data entry, more time with paperless records, more time in hospital employment, more time with their families and personal lives, or more time in concierge practices where they can spend more time with patients.

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