The tragedy of electronic medical records

It wasn’t supposed to work out this way.

Digitizing medical records was supposed to transform health care—improving the quality of care and the service provided to patients while helping cut out unnecessary costs. Just like IT revolutionized all other industries.

Perhaps they still will. But lately, electronic medical record systems are getting nothing but votes of no-confidence from physicians, hospitals, insurers and IT experts.

Dr. Clem McDonald, who did more than anyone to advance electronic medical records during his 35 years at the Indianapolis-based Regenstrief Institute, called the 5-year, $27 billion push to roll out electronic medical records “disappointing” and even a “tragedy” last month during a talk with health care reporters (including me) at the National Institutes of Health in Bethesda, Maryland.

“It’s sort of a tragedy because everybody’s well-intentioned,” said McDonald, who spearheaded one of the nation’s first electronic medical record systems at Regenstrief and what is now Eskenazi Health. McDonald’s work in Indianapolis on the electronic exchange of medical records put patients here at least a decade ahead of those in most of the country in benefiting from the technology.

(For my summary of Regenstrief's accomplishments with electronic medical records, go here.)

McDonald now has a nationally influential post to promote electronic medical records, as the director of the Lister Hill Center for Biomedical Communications, a part of the National Library of Medicine, which is one of the National Institutes of Health.

During his talk, McDonald released his latest research survey, which found that electronic medical records “steal” 48 minutes per day in free time from primary care physicians.

McDonald is still optimistic about the technology, which I’ll get to later. But since his talk, I keep seeing evidences of what he’s talking about.

Electronic medical records seemed to play a role in Texas Health Presbyterian misdiagnosing Tomas Eric Duncan’s case of Ebola. The initial report from the hospital was that a nurse entered Duncan’s recent travel to Liberia into the hospital's Epic electronic health record system, but the physician who diagnosed him didn’t have that note in his or her normal workflow.

Later, the hospital said that was not the case. But that still doesn’t mean the electronic medical record systems played no role in the misdiagnosis, concluded David Carr at Information Week.

“Despite that backtracking, the facts of the case align with a common pattern of medical errors where the use of EHRs is, if not the sole cause, often an aggravating factor,” Carr wrote, citing an analysis by one of the top chief information officers at the Veterans Administration, one of the few places using electronic medical records effectively.

McDonald’s study lends support to that idea. One-third of physicians surveyed said it took longer to find and review medical record data. One-third also said it was slower to read other clinicians’ notes.

“Some docs don’t even read reports any more. This is a perverse side effect,” McDonald said, noting that the electronic reports have so much information in them, that they become “endless and mindless.”

A more subtle case came up when Indianapolis-based health insurer Anthem formed a joint venture called Vivity with seven hospital systems in Los Angeles. The hospitals are going to use WellPoint’s computer systems—not their own—to exchange information with one another.

“It spoke volumes about the state-of-play in the health IT industry when Vivity's partners announced they would initially rely on Anthem's claims records to coordinate care,” Merrill Goozner, editor of Modern Healthcare magazine, wrote in an editorial.

Indeed, Anthem CEO Joe Swedish—a career-long hospital executive—has made information technology a core strategy of the health insurer, which would hardly make sense if providers were using digital records effectively on their own.

More bad news about electronic health records came out this week in a new research study. It found that physicians using electronic medical records spend an extra 16 minutes per day, on average, doing administrative tasks than their peers who still use only paper.

The study relied on data from 2008—which when compared with McDonald’s study suggests EMRs are now consuming more of doctors’ time than they were before the federal push to expand their use.

“Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork, we found the reverse is true,” wrote study authors Steffie Woolhandler and David Himmelstein.

So with so many so upset with electronic health records, why is McDonald still optimistic?

He thinks the problems folks are having aren’t inherent to the technology itself, but are instead caused by overly restrictive rules coming both from the federal government and from hospital systems.

Hospital systems, knowing that more information can be recorded now that it’s electronic, have insisted that doctors do more documenting. McDonald cited one research study that found that documentation requirements have doubled in the past decade.

“I think they’ve got to ask less,” McDonald said of hospital administrators. “Nobody has any idea of the time-cost of one more data entry.”

Coincidentally, Indianapolis’ Dr. Rich Gunderman, a professor at the Indiana University School of Medicine, made a similar point in a piece in The Atlantic earlier this year.

“It is easy for many healthcare leaders to forget that doctors go into medicine not because they enjoy entering data into complex electronic health records and ensuring that their employer gets paid for everything they do, but because they want to make good diagnoses, prescribe appropriate treatments, and help patients,” Gunderman wrote, noting that this approach has left doctors “deeply discouraged.”

And they’re not the only ones.