The transition to electronic medical records—the digital versions of the paper charts, billing, prescriptions, and lab work used daily in medicine—is a contentious issue among physicians.
When they were first introduced, EMRs, also referred to as EHRs (electronic health records), were seen as having the potential to transform health care, improving safety and streamlining patient treatment across different hospitals and fields. In many ways, that has been the case. Doctors who use them can now check lab reports and read patient charts from anywhere with the click of a button, and it is more difficult to misplace or misread information.
But multiple reports have shown doctors in the US do not want to switch over, finding the digitized records a less efficient, more impersonal, and error-ridden alternative to the paper system they know. Doctors complain that clunky "meaningful use" requirements, which were force doctors who accept Medicare to show that they are making use of the EMRs by recording a minimum number of "objectives," slow down their practices and drastically reduce the number of patients they can see.
"One of the worst aspects of it is the mandated Meaningful Use records," said Dr. James Paul, a surgeon in Iowa (disclosure: the author is related to two of the doctors interviewed for this piece). "I might have someone who just came back from the ER who cut their thumb off––the only way I can get money from the government for the procedure is by recording "meaningful use" criteria in the EMR. For example, if your BMI is above a certain amount I have to counsel you about weight loss, even if you are in the ER for cutting off your thumb."
"Another major problem is that individual EMRs don't automatically communicate with one another. It's like using a key to a different car."
Even though many doctors complain about the EMRs, more and more people in health care are making the change, either by choice or by necessity. A 2014 report showed that in 2013, 78 percent of office-based physicians had adopted some form of EMR system, and 48 percent of all physicians had an EMR system with advanced functionality––double the adoption rate in 2009.
Doctors who can choose their own EMRs without the constraints of government regulations find that they can cater their systems to their needs and are happier with the end product. But now, as part of the Affordable Care Act, doctors who do not switch to electronic medical records by the end of 2015 will start to get docked on Medicare reimbursement.
This has forced doctors to either make the switch, face the fines, or retire early to avoid the whole situation. Some doctors are also no longer taking Medicare because of this, leaving more vulnerable patients without healthcare.
The real-world consequences of a policy like this are not always obvious when the law is being written, so we asked nine doctors: are EMRs GOOD or BAD?
Amit I. Patel, MD FACOG, Modern Gynecology, PLLC - Plano, Texas: GOOD
EMRs are good for health care overall. The government mandating how physicians use them and using those mandates to penalize doctors through reduced reimbursements is bad.
Doctors have several frustrations with EMR––the main reason is that it takes longer to document in EMR than it does on a paper chart. Number two, electronic medical records increase the cost of practice because they are more expensive to maintain than charts are. Number three, EMRs fall into one of two categories—they're ready out of the box, you start up with them and you have to make do with what they have and there's not much customization, or they are really customizable and as a result you have to spend a lot of time on the front end getting things set up. So that's a lot of time away from the practice.
Another major problem is that individual EMRs don't automatically communicate with one another. Many patients think, "Oh you have EMR, you should be able to see what my doctor in X place prescribed last month." But it's like using a key to a different car.
"There might be an improvement in quality of care, but for sure it is increasing the cost of care."
You are going to get a lot of people at the ends of the spectrum—you're going to get a lot of people saying they are no good and useless, and other people finding them useful. It depends how well they've adapted their practice to using the EMR. Once you get used to it, some doctors find that in general it can make life easier. The bottom line is, though, if you own your own practice it is going to increase the cost of care. There might be an improvement in quality of care, but for sure it is increasing the cost of care. I don't think anyone is going to argue that fact.
In general, I think EMRs are useful. I used to be in the Air Force; they have a global military medical record system. It is a cumbersome system but it does achieve the ability to access someone's medical record electronically anywhere in the world. I don't think we'll ever get to the point where we will get people's medical records on one system, but there is a lot of data that has to be collected in terms of lab values and diagnostic studies and things of that nature.
Younger doctors who trained with EMR will be more okay with it. Older doctors grew up under the paper chart system are going to have more negative things to say about it.
John Maa MD, FACS Past President, Northern California Chapter of the American College of Surgeons Board of Directors, San Francisco Medical Society, General Surgeon: GOOD and BAD
I believe that there are both good and bad aspects of EMRs, as they have the potential to both improve and worsen patient care. They are likely a step forward but also a work in progress, as there are perils lurking. The key for the health care profession is to continue moving forward by recognizing the vulnerabilities and remedying them, rather than ignoring them.
I was in DC for a sabbatical on health care policy, and I saw a lot of the discussion on electronic records. We've realized the potential they offer. There is a bit of disappointment because the electronic medical records are not interoperable—the ones from different hospitals don't talk to each other––they can use the same vendor but they can't communicate with each other. What happens when they implement it at different hospitals, they take the basic software and customize it, and once they do that it makes it difficult for it to interface with other places.
Another aspect is that it is intergenerational—there are some older clinicians who have been using written records for decades. Some people are actually retiring early because of this, because they're being forced to change to EMR. They're great doctors but they don't feel the desire to transition. The other extreme is millennial doctors wanting to find ways to use phones and iPads. A lot of them are very excited about being entrepreneurs in this space.
"Some people are actually retiring early because of this, because they're being forced to change to EMR."
There are also people like me: I'm 46, I trained in the era before EMR, and I there are so many good things about EMR. Many things are easier now: we don't have to go down to radiology to look at CAT scans, you have all the info in front of you at the click of the mouse.
One of the concerns I have is that the computer is interfering with patient doctor relationships. Doctors are becoming more separated and disconnected. When you are seeing a new patient, you can just look at the note somebody else wrote and copy and paste. Sometimes erroneous info gets propagated from note to note. There are these perils to EMRs as well.
There is one dominant platform called Epic. We need to ask the leading manufacturers to work together to solve this problem of why their systems dont talk to each other––there must be a way to bridge all these different systems. There are too many different silos.
Richard Weinstein, MD, MBA, Orthopedic Surgeon, White Plains, NY: VERY BAD
EMRs in their current state are very bad. I think there is tremendous potential for them to be good, helpful and improve health care and efficiency, but the way the government is mandating them and the way they're currently being used, they're very bad.
I've used several EMRs and I'm currently partially on one of the EMRs called NextGen—I was previously Athena. So I have quite a bit of experience using different systems.
Athena, I actively hunted down the right EMR system and bought it based on my research. Aside from being an MD I'm an MBA and I looked at the costs and features of different systems. The Athena system I was very happy with, but I switched practices and I'm now very unhappy with NextGen.
"Most EMRs are not designed with the doctor and patient in mind, they're designed to make it searchable for numbers and data by entities that want to control what we do."
It makes seeing patients very ineffective, it slows me down dramatically, it does not improve the system at all. It is of absolutely no benefit to patients––and not only does it not benefit doctors, but it hurts doctors. It forces them to allocate time, money, and resources into something that doesn't benefit our patients. A key of good health care is to provide a value product—to get patients in quickly, out quickly. But most of the government regulations slow us down and prevent us from what we should be doing, which is spending more time with patients.
Athena was designed to make the health process more efficient and work better. Overall it's designed to make things more efficient. NextGen is designed to meet government requirements. Most EMRs are not designed with the doctor and patient in mind, they're designed to make it searchable for numbers and data by entities that want to control what we do.
In my opinion the government has never proven it is able to help the private sector to be more efficient or be better for patients. Medicare is going bankrupt. There are EMRs out there that can help doctors.
I love business and I enjoy the business of medicine but this is regulatory hell when they're forcing us to document things that are unimportant.
I saw a study recently that 40 percent of doctors are burnt out. We love what we do, we love fixing people, but we are spending so much time now in meetings talking about the medical records, so much time generating these terrible notes that I am wasting my time and my patients' time. The people who like EMRs tend to not use them. I don't think I've ever met a doctor who said 'I love EMR, it's great.'
James Paul MD, MS, DDS, Plastic Surgeon, Oral and Maxillofacial Surgeon, Davenport Iowa: BAD *
EMRs are bad because they are not up to speed and they have been forced upon physicians despite increased costs, decreased efficiency leading to decreased volume in patient care, therefore fewer patients are able to be seen and treated in the face of an already existing backlog.
The concept could be good but it doesn't work in reality. It inhibits the normal doctor-patient relationship and creates inefficiencies. Multiple longitudinal studies have been done that show it decreases productivity by surgeons by up to 30 percent per year.
It's inefficient and slows you down––now instead of waiting for 90 days, people are waiting for 120 days to get an appointment at my office. You cannot see as many people a day with EMR, whether you're an internist or a surgeon, no matter what you are.
One of the worst aspects of it is the mandated Meaningful Use records. I might have someone who just came back from the ER who cut their thumb off––the only way I can get money from the government for the procedure is by recording "meaningful use" criteria in the EMR. For example, if your BMI is above a certain amount I have to counsel you about weight loss, even if you are in the ER for cutting off your thumb. You have to do it and document it. If they smoke, I have to counsel them about smoking and document it. If someone has breast cancer and high cholesterol I have to counsel them about their cholesterol.
It's irrelevant and completely ridiculous—but when you have government health care or government-controlled industry, you have these outlandish requirements that are not tailored to the efficiencies in the profession they're trying to regulate.
"I've seen cases where the patient is dying on the table, going through anesthesia and in the Pyxis EMR system you have to go through a series of passwords to get the drug out, and it isn't working."
Now hospitals are being forced to hire scribes because people are spending so much time typing. If you think of a small emergency room, that has 12 doctors in a given 24 hour period, they are now hiring a scribe for earch that follow the doctor around and write down everything. that means 10-12 scribes per day, and each is getting around $40,000 a year plus benefits. How is that saving money? And who is paying for that? It's the taxpayers.
I've seen cases where the patient is dying on the table, going through anesthesia and in the Pyxis EMR system you have to go through a series of passwords to get the drug out, and it isn't working. I know, that is a big shock, right? Sometimes computers don't work. In the real world, that's what happens.
Usually people who espouse the virtues of EMR, they are lawyers or politicians. If there were one that was efficient, everyone I know would be in favor of that. But all of these things that sound really great to implement in a real world don't really work.
David Paul, DO, Orthopedic Surgeon, Kansas City, Missouri: BAD *
We have tried to institute EMRs in our office three times, and I believe and they are horrible, especially for orthopedics. I guess every specialty would be different, but in orthopaedics the ones we've tried to institute did not work. Because there are so many diagnoses in orthopedic surgery––every bone has different parts and names, so it's very complex.
We've tried different systems and none of them have worked well, and the times we have tried to institute them in my practice I had to cut my patients down to a third of what I would normally see in a day. So a patient who would normally wait six weeks to see me will wait three to five months. This is because the time I would normally spend with patients I would spend sitting on a computer putting in information.
A lot of it has to do with government intrusion and the fact there are so many things the government asks us to do and document multiple times. It's not enough we do it once or twice they want it replicated a thousand times so we can meet their criteria. All of the information is in there, but they want us to duplicate our work over and over again so its easier for them to search, but it does nothing for our time management or patient care.
Meaningful Use is the most asinine thing in the world. It is a regulation that absolutely cuts into your practice, and it is so time consuming, and so ridiculous, and does not improve patient care. You have a bunch of attorneys in Washington who know nothing about medicine deciding what is best for patients.
I think it really cuts down on quality of care and time you can spend on a patient, and the number of patients you can take care of, which is bad because we have a doctor shortage right now.
Mike Zalis, QPID Health co-founder and CMO & practicing interventional radiologist at Mass. General Hospital, Boston, Massachusetts: GOOD, HOWEVER
EMRs are necessary, and so I would say they are "good." We need health care to join the digital age and EMRs support communication among patients, providers, and other stakeholders.
However, they were designed for a wide range of administrative and clinical functions—much like the enterprise resource planning (ERP) systems of the 90s—and rammed in at a rapid pace. So some of the unique requirements for specific users are missing and the interfaces are clunky. The opportunity now is for solutions that enhance our ability to leverage the information in EMRs for quality improvement and communication.
There are several main issues clinicians face. One issue is that there's been an effort to make all EMR structured—the potential value is that if you have structured information, like a text box or pull down menu, there's a very precise, crisp clarity as to what is meant by the choices you can select. The trouble is in practice, people don't think and don't tell their clinical stories through checkboxes and radio buttons. That's not how people operate. That's true for patients and clinicians, there's a lot of nuance that is lost when we structure it this way.
"In general, clinicians see EMR as a necessary thing that's in a primitive status."
Another thing clinicians say is two major items: The medical record of each patient is growing rapidly each year—average patient record grows by about 80 mb of data per year. That becomes a lot of info, and the end result is clinicians spend more and more time having to sift thru larger and larger pile of data to find those key pearls that allow them to see the patient in context of how they are right then and there.
Also, clinicians are spending more and more time on the computer. It breaks the clinician patient relationship. If you aren't feeling well, you want to see eye contact, physical contact, the sense someone is really listening and keyed into how you're doing. If they are looking at a screen they seem distracted.
The final piece is that the public appropriately is demanding greater accountability for the huge amounts of money we spend in this country. We spend 17 percent of our GDP on health care and yet our outcomes are no much greater than countries that spend less. Appropriately the public are all demanding and increasing an agenda of quality metrics to measure care and how we do care and quality and safety of the care we deliver.
In general, clinicians see EMR as a necessary thing that's in a primitive status. It's good to have things in an electronic form––it's better than paper, but the current form is primitive, time consuming and clunky. I'm a geek so im sort of open to these kinds of digital changes, but I can understand someone comfortable with doing things their way finding EHS systems to be overwhelming.
David Gross, Opthamologist, Merrillville, IN: BAD
I use EMR at the hospital where I work and it's about to go live in my private practice next week. In order to avoid substantial penalties and remain a Medicare provider you have to be on EMR this year. If you don't participate in 2015 you will get docked a percentage of your Medicare in 2017.
I think when you add all the factors together of declining reimbursement and increasing overhead, the hospitals are not willing to add more staff. If you had data entry clerks alongside nurses instead of nurses becoming data entry clerks, it wouldn't affect patient care as much.
"I see all the time nurses taking care of a patient who don't know anything about the patient because they're so busy putting in data."
I see all the time nurses taking care of a patient who don't know anything about the patient because they're so busy putting in data, and that isn't one brand of a system over another, that's just the nature of the system. I call it the hourglass effect. When you're looking at a computer screen instead of waiting on the patient, that cuts into personal care.
The system is very flawed. I think it can work in certain instances and not others, but I think the biggest flaw is the fact the government is dictating it. I don't think the government does a good job of running its own business let alone businesses it doesn't know anything about. That is affecting the care people in America are getting. EHR are just part of that. I have friends who are just opting out and taking the financial hit and I know people who are retiring far earlier than they were planning to originally. There is going to be a shortage of doctors in America when that happens.
Jorge Scheirer, MD, Internist, Chief Medical Information Officer at Reading Health System, Reading, Pennsylvania: GOOD
There is no question electronic medical records are good. Could you point to EMRs harming patients? Yes. But you could find examples of that with paper systems. EMRs aren't perfect, but on a whole we are in a better place today than five years ago.
We went from a system that was fragmented, on paper, and people hand wrote things that were illegible. Pharmacists were left with the decision to figure out what it was the physician wrote or call them to ask, which is an inefficient dangerous process. For society and health care, this is for the greater good, and improvement on the previous paper systems that we had.
There's a whole continuum of concern about EMR, depending on who the physician is, how computer savvy they are, whether they're a millennial. We have young physicians who are very tech savvy and couldn't dream of taking care of patients in any other way because they've only trained with EMR and don't have experience with paper. We have it running the other way where people did all their training on paper and were introduced to EMR very late in their careers. The people who talk the most and loudest are the people who are the most unhappy. If you do a true survey throughout the continuum I think you'd find most physicians are satisfied with EMR.
We've been live on EMR since February 2013. Certainly for most of the functions we do now with EMR people wouldn't want to go back to paper just because of the efficiency of it.
"We have young physicians who are very tech savvy and couldn't dream of taking care of patients in any other way because they've only trained with EMR and don't have experience with paper."
A lot of older physicians were very comfortable with the paper system or dictating. When you introduce EMR, the way the work flow for many EHRs is that the physician is doing all of those things, the things he or she previously delegated to someone else they are responsible for now, like for entering the order, the diagnosis, the medication. They're upset about having to do something they didn't have to do before, and they're finding it less efficient.
There's no question for many physicians the advent of EHR has meant more stress, doing things they didn't do before, but there are a lot of benefits. I've been in practice for more than 20 years—it was not uncommon you couldn't find a patient's chart when they got to the office, or it wasn't updated in time. That is a really rare occurrence now because a patient can go this morning to the lab to get their blood test done and it will be in their chart by the afternoon. The information is there at the click of the button. When I'm on call, when patients call me the first thing I do is log onto their record to see what they came in for, their history, their allergies, etc. The media likes to fan the flame of negativity but there have been a lot of good things to come out of EMR.
Dina D. Strachan, MD board certified dermatologist, New York City: GOOD
Saying you don't like EMR is like saying you don't like a sandwich. There are all types of EMR and it depends on what it does for you. If it makes your life easier, you want to use it, but if it doesn't, you don't want to use it.
I found one that for the most part, it made running my practice easier. I was happy to switch to it because it was reasonably priced and it actually did all the things I needed it to do for it to be of service to me. It helped me streamline some operations, to address issues of joint charges. Billing was very easy. All of these things were super easy with the EMR I ended up using.
"Saying you don't like EMR is like saying you don't like a sandwich."
It's how an individual person interfaces with technology. There are EMRs where you type, and people who don't like to type won't like it. There are some with click boxes and I hate those, those are designed by people who don't practice how I practice. The bottom line is people don't want to use things that don't make their jobs easier.
* Disclosure: The author is related to two of the doctors interviewed for this piece.
Modern Medicine is a series on Motherboard about how health care and medical technology can move forward so rapidly while still being stuck in the past. Follow along here.