There was a time, in my innocent youth, when the follow-up note for the average cancer patient (usually scrawled in quasi-legible doctorese) looked something like this:
S: No new complaints.
O: Px-unchanged. Responding on CXR. Labs OK.
A: Doing well
P: Continue Rx. RTC 3 w.
I thought of this recently when, preparatory to starting my new clinic at Stanford, I took Epic training. I had moved from a health care system that used Cerner, and of course when you know one electronic health record system, you know one electronic health care system. After spending some time getting access (yet another set of passwords and another user name), and getting “tokens” for my iPhone, my iPad, and my Mac, I spent an hour or so with a lovely lady assigned by the hospital to explain the new system, who then handed me a helpful booklet that would remind me when I inevitably forgot the lesson. Which I did, almost immediately.
Epic Systems is headquartered in Verona, Wisconsin, a sleepy town on the outskirts of Madison. My dad used to take me there for haircuts when I was a teenager, and so it is fitting that Verona continues to provide me haircuts via Epic. The cuts are now to my time, and my emotional comfort. I'm hoping both will improve as I become more at ease with the system, though I have yet to meet anyone (including hospital administrators) who thinks it will speed me up.
Epic is based on 1960s' MUMPS software developed at Massachusetts General Hospital. Think about that: a software system that pre-dates MS-DOS. It is (and this is not particular to Epic) loaded with excess clicks, small fonts, long scrollable lists of diagnoses in no particular order, and buried data sets.
The company was founded by a former employee of the University of Wisconsin's Psychiatry department, the sort of fact that is almost too delicious: Are we all part of some devious, extreme stress-inducing psychological experiment designed to increase the business of the psychiatrists? Well, that would just be paranoid, wouldn't it? Really, I'm not crazy. Really.
Comparing 1983 with 2013, the four lines of meaning mentioned above are buried somewhere in pages of cloned busywork stored somewhere on a server and accessed via a clinic workstation. Has the current electronic health record made us better health care providers, or more efficient at getting through the day?
That these are still arguable propositions (and they are regularly argued, at least in the precincts I hang out in) says a great deal about our tendency to adopt new technologies without putting them to the test.
Modern health care record keeping dates back to the 1920s, when the American College of Surgeons created the Association of Record Librarians of North America to “elevate the standards of clinical records in hospitals and other medical institutions.” ARLNA still exists, transmogrified to the American Health Information Management Association (motto: Quality Healthcare through Quality Information), with more that 64,000 members. But the records it shepherds are no longer primarily under the control of physicians, nor written on paper. Like the rest of modern society, they have gone digital.
What Has Driven Digitization?
What has driven the digitization of the current medical record is fairly straightforward. First, the need to document, for the benefit of the payers, that we are doing what we say we are doing. This is a function of the American health care system's radically dysfunctional payment scheme, with its a la carte menu approach, propagated by government but equally embraced by private insurers.
Second was the vision of the electronic health record as sovereign cure for our all our woes. This is related to, and at least partially dependent on, the documentation mandate, but was clearly something more. Back in 2005 the RAND corporation, one of our premiere think tanks, predicted that the rapid adoption of EHR technology would save the U.S. health care system more than $81 billion annually through improved efficiency. The number was not plucked out of the air: it was a reasonable extrapolation based on information technology's effects on other aspects of the American economy.
Politicians—both Republicans and Democrats—were quick to latch on to the latest promise to reduce health care costs. George Bush and Barack Obama considered it essential for American physicians to adopt EHR.
Earlier this year Arthur Kellerman and Spencer Jones of the RAND Corporation provided an update in Health Affairs. To summarize the health care savings benefits achieved through EHR adoption: NOT! Why not? “The disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT.”
The cost savings were illusory in part because, in contrast to other industries, EHRs are used by hospitals to help game the system, increased documentation leading to higher levels of billing. So while EHR systems are expensive to purchase and maintain, the return on investment for a hospital corporation can be impressive.
The ‘Not Easy to Use’ Part
I can certainly speak to the “not easy to use” part. There is nothing easy or intuitive about EPIC or Cerner or their kindred: they look like a Boeing 747 control panel. Actually, let me take that back—I cannot imagine that they are designed like a Boeing 747 control panel, because if they were, then there would be far more fatal airplane crashes than actually occur.
If EHR adoption has not improved physician efficiency or reduced health care costs, who has benefitted? EHR vendors lead the list, of course. The big EHR firms (Epic, Cerner, Allscripts) have all seen explosive growth in recent years. This growth is driven by federal government incentives (the recession stimulus package) and federal mandates (the 2015 deadline for meaningful use of EHRs).
Both carrot and stick were the result of heavy lobbying efforts by EHR companies, which like the pharmaceutical companies are now an integral part of the Washington “you scratch my back, and I'll scratch yours” reciprocal favor system. Allscripts' CEO visited the White House on seven occasions after President Obama took office in 2009, and personally made more than $225,000 in political contributions.
Epic saw its sales double in just four years to $1.2 billion in 2011. Cerner has revenues of $2.2 billion, and Allscripts comes in somewhere in the same range as Epic. EHR vendors never suffered during the economic downturn. These guys have done quite well for themselves, if not always for us.
The basic premise behind EHRs, and the reason no one wants to give up on them quite yet, is still sound: having all the data instantly available at your fingertips should make patient care safer and more effective. If this has not yet happened, it is in part related to lack of interoperability between the EHR systems. Crossing town from one practice or hospital to another is frequently to enter a deep electronic chasm. The best you can hope for is that you live in a place where monopoly prevails. Epic (and I really don't mean to pick on Epic) has the EHR franchise for Stanford, UCSF, and Kaiser Permanente, among other local concerns, so the Bay area is relatively integrated from an EHR standpoint.
But this is not the case everywhere. And without interoperability (which EHR vendors pretty much all passively or actively oppose) the promise of EHRs will continue to be largely theoretical. Gandhi's famous response when asked what he thought about Western civilization comes to mind: “It would be a good idea.”
ASCO has devoted significant resources (significant for ASCO if trivial for the EHR vendors) to creating CancerLinQ, its rapid learning health care system. My sense, in my brief experience with Epic and my older relationship with Cerner, is that the EHR vendors have not thought through the needs of specialties, perhaps because their principal relationship is to hospital corporations.
Electronic health records are an important component of any rapid learning system, perhaps the central component. CancerLinQ will ultimately need to interact with a whole slew of EHR vendors. Will it be embraced, or strangled? Or just ignored? We'll see. In the meantime, I will continue to plod through my dictations.
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