The Trillion Dollar Conundrum

In Tuesday’s Wall Street Journal Op-Ed pages, physicians from Harvard and University Pennsylvania Medical Schools criticize subsidies for expanding the use of health information technology (HIT). The physicians cite a recent review article that failed to find consistent evidence of cost savings associated with HIT adoption. If true, this is bad news for the health economy, as supporters claim that HIT could cut health spending by as much as $1 trillion over the next decade.

How can something that is so avidly supported by most health policy analysts have such a poor track record in practice? In a new NBER working paper by myself, Avi Goldfarb, Chris Forman, and Shane Greenstein, we label this the “Trillion Dollar Conundrum.” One explanation may be that most HIT studies examine basic technologies such as clinical data repositories, while most of the buzz about HIT focuses on advanced technologies such as Computerized Physician Order Entry. In our paper, we offer a rather different explanation for the conundrum, one that would have eluded physicians and other health services researchers who failed to consider the management side of HIT.

My coauthors on this paper are experts on business information technology. They are not health services researchers. When I approached them to work on this topic, they insisted on viewing HIT much as one would view any business process innovation. As I have learned, this is by far the best way to study most any issue in healthcare management. Those who advocate that “healthcare is unique” – usually by ignoring broadly applicable theories and methodologies—often strain to explain data that are easily understood using more general frameworks. Such is the case with HIT.

Health services researchers have analyzed HIT much as they would analyze a new medical intervention. Some patients receive the treatment, others receive a placebo, and the treatment is deemed “successful” if the treatment group fares better than the control group and the difference passes statistical muster. While this methodology inspires a certain level of confidence in medicine, it has a critical shortcoming that has only recently been addressed through “personalized medicine.” The intervention might be effective for only some of the treatment group, and might be harmful to others. The typical research design masks these heterogeneous effects.

Our study articulates why we would expect heterogeneous effects of HIT and finds strong supporting evidence in the data. The key is to view HIT as a business process innovation. Like other such innovations, successful implementation requires complementary human capital. In other words, HIT does not operate itself. Skilled individuals must install it and train hospital personnel on how to use it. Hospital personnel must learn how to use the software and how to adapt it to their idiosyncratic needs. Not surprisingly, some individuals are better at this than others.

We argue that complementary human capital is most abundant in areas where there is a strong general IT presence – think the Bay Area or Seattle. Thus, El Camino Hospital near Palo Alto was an early and successful adopter of HIT. At the same time, hospitals located near the headquarters of major HIT firms, are more likely to get better vendor support. Thus, hospitals in Milwaukee have been very successful with the Epic system. (Epic is located near Madison.) Finally, hospitals with experience with primitive HIT are likely better prepared to take advantage of advanced HIT.

We find strong evidence that human capital is vitally important to the success of HIT. We find that hospitals adopting advanced HIT experience, on average a 1-2 percent increase in costs (including amortized HIT costs.) But this masks heterogeneous effects. Hospitals lacking complementary human capital see their costs increase by 2-4 percent, while those with complementary human capital enjoy cost savings of 2-4 percent. All of these findings are statistically significant.

The most exciting thing about these findings is that complementary human capital is not static. All of us are improving our general IT capabilities just by using our smart phones and the like. Hospital staff will, over time, improve their HIT-specific human capital. The benefits of HIT enjoyed by hospitals fortunate enough to have complementary human capital will almost surely spread to most hospitals. We would be foolhardy to promise $1 trillion in savings, but we do expect substantial savings. It is far more foolhardy to claim that the tepid average performance to date is the end of the story.

Postscript: Next week I will attend the Annual Health Economics Conference at Stanford. I have the privilege of discussing a new paper by Jeff McCullough, Steve Parente, and Bob Town that studies the impact of HIT on outcomes. Most studies have failed to find any benefits for the average patient. After interviewing many providers, these authors conclude that the benefits are likely concentrated on patients whose care requires substantial coordination and information transfer. And they find this — HIT improves outcomes (measured as mortality in this paper) for the minority of patients likely to enjoy the benefits of HIT but are otherwise unchanged. As with my own paper, this study shows that HIT is complex and the benefits are likely to be heterogeneous. I do not believe it is a coincidence that both of these studies were conducted by management professors.

David Dranove, PhD, is the Walter McNerney Distinguished Professor of Health Industry Management at Northwestern University’s Kellogg Graduate School of Management, where he is also Professor of Management and Strategy and Director of the Health Enterprise Management Program. He has published over 80 research articles and book chapters and written five books, including “The Economic Evolution of American Healthcare and Code Red.” This post first appeared at Code Red.

61 replies »

  1. “my reply will continue to be that the USA healthcare system is absurd”

    Agree completely on that. I would only say that EMRs as currently designed and used serve to preserve and to strengthen the absurdities, not to address the fundamental problems.

  2. Last comment from me. Patients, qua consumers, will start to expect test results, physicians’ notes, etc. to be provided electronically before meeting another physician. Needless to say this will not happen immediately, but it will eventually become routine.

    If a patient has had a test done or anything else that provides information to a subsequent physician, particularly if the patient is paying out-of-pocket for services through a co-payment arrangement with an insurer, the availability of data electronically will lead to the elimination of duplication. It is a complete waste to the patient/payer and he or she knows it.

    And yes, my reply will continue to be that the USA healthcare system is absurd. It has always been and continues to be heavily skewed to the benefit of suppliers into the market for medical services and against the masses of consumers of those services.

  3. You’re a moving target.

    You say: The perennial problem of patients having tests duplicated . . . is obviated.

    I say: EMRs have nothing to do with the cause of or the solution to the problem of unnecessary testing, and they have been shown to increase the number of test ordered.

    You reply: USA healthcare system is absurd.

  4. “Tests are repeated because the patient’s condition has changed, because previous testing indicated the need to repeat it, or because someone is making a buck by repeating it.”

    These and the other related points have to do with the absurdity of the USA healthcare system, both delivery and payment. Nothing to do with EMR systems.

  5. Also: what about the liability aspect of acting on tests ordered by someone else if you are now the physician of record? Just wondering.

  6. Disagree with about everything you say, but just one point:

    Tests are repeated because the patient’s condition has changed, because previous testing indicated the need to repeat it, or because someone is making a buck by repeating it. Show up in the same ER once a month for the next year complaining of the worst headache of your life and you will get a new scan every time. Send a non-Medicare patient to Mayo with complete records and every test get will get repeated two or three times. EMRs make all this easier, not more difficult.

    The “tests are repeated because old results are not available” is a species rarely seen in captivity.

  7. “digging ditches and the feds told me I had to do it with a stick of butter, I’d say the stick of butter stinks.”

    Overstatement to say the least.

    I stick by my assertion regarding the active disdain – based on lack of experience and knowledge – of far too many physicians regarding the value of computer-based technology for clinical data recording and manipulation.

    “I don’t think that’s true.”

    The advantage of digitally available clinical unquestionably advances the health status of patients.

    The perennial problem of patients having tests duplicated and relevant data not communicated from one physician to another promptly and accurately, or in some cases at all, is obviated. Information and data at anyone’s fingertips are invaluable for better decision-making. Therefore ultimately they lead o better health outcomes. This will only increase as more and more clinical data are recorded and made available electronically.

  8. Maybe I misunderstood you. I was responding to “that otherwise advances currently . . . the health status and economy of patients.” I don’t think that’s true.

    I never said I was ever in software development. I was answering your statement that “current physicians by and large are neither that comfortable with the use of such technology or more likely simply do not want to devote any time to effective use.” I threw out the fact that I had been using computers since 1965 (all I remember about that first one was that it was exactly the size of a coffin!) as evidence that there are many docs who are comfortable with technology who think current EMRs stink as far as improving patient care. Not because they’re badly designed, but because they’re designed for other purposes. If my job were digging ditches and the feds told me I had to do it with a stick of butter, I’d say the stick of butter stinks.

  9. I appreciate your observations. And I am no unreflective choirboy for HIT.

    I bite the hand that feeds me with regularity. Openly.

  10. southern doc: Statement is not comprehensible. Please elaborate. Also no answer to question regarding your software development experience from youth to the present.

  11. You’re really saying that patients are healthier now because of EMRs (and by healthier, I mean actually healthier, not that their doctors have achieved certain insignificant measures of quality)?

  12. You miss the point completely.

    Polemics for the sake of polemics do not advance anything practical (EMR system use) that unquestionably has defects, but that otherwise advances currently and materially advances prospectively the health status and economy of patients.

  13. Wendell,

    I agree that the time wasted by patients is vastly greater than that wasted by Doctors, Nurses, etc. But I am NOT responsible for the time wasted by patients dealing with Hospitals, Insurance Companies and Medicare.

    However, unless EMRs reduce the time wasted by patients (do they?) then your point seems to be – “don’t complain so much, others have it worse”. That is equivalent to saying to a patient that has had a minor heart attack – “don’t complain so much, my last patient died of cancer” – not likely to be all that compassionate or reassuring.

  14. Useful example, but please keep in mind there are many similar examples of wasted time by patients dealing with insurance intermediaries and with service providers, aka physicians practices or hospitals, on any number of issues. As BobbyG notes, many of the “problems” associated with EMR systems relate to the poor overall healthcare system in the USA. mostly in regard to the financing and payment parts of that system.

    They are absurd, byzantine, counterproductive, etc. for providers of services and consumers of services alike.

    The example of a hassle for Mr. Legacy pales in comparison.

  15. One more example of the time wasting caused by EMRs

    Yesterday, I received a notice of “delinquent unsigned orders” from St. Elsewhere and was told to correct this. ( I cover this hospital remotely. I have never written or given any verbal orders at this hospital, in fact I have never set foot in it.)

    Here is the reason why: “St. Elsewhere has discovered a large number of unsigned orders lingering in the background of the EMR dating back to it’s (sic) initiation. St. Elsewhere realizes many of these are errors in routing but still have to clean it up for regulatory reasons”

    In other words, for years this hospital has erroneously been putting my name on orders that I did not give. (Malpractice Risk?) Now that they have discovered this problem, they want me to go back in and sign or “re-route” these cases elsewhere.

    Ordinarily, I would not object to signing or re-routing a few cases if I was in house. However, this hospital is about 45 minutes away and it would represent an extra trip – a good 2 hours of my time spent correcting their errors.

    Alternatively, I could sign or “re-route” these cases electronically. However, since I currently don’t have remote signing privileges, I would need to be set up as an authorized signer. Based on my prior experience at other hospitals, this process could take up to an hour including downloading Citrix, setting up passwords and changing them, etc. etc. Then I would be able to spend whatever time it took to sign or re-route these cases.

    The hospital had the choice of having their clerical or IT/employees correct this problem on the hospital’s time/dime. Instead they chose to try to force me to do this clerical work because my time is free – TO THEM!

    This, in a nutshell, is the problem with poorly designed and poorly managed EMRs. My time is being wasted to make up for their shortcomings.

  16. Sorry, Margalit: should be Gur-Arie. But, hey, Hebrew does not insert vowels in writing, they are understood by the context, so “u” rather than “a” and vice versa could theoretically be right. Correct?

  17. My perspective continues to be the sturm und drang from some physicians regarding EMR systems is far too much ado about very little.

    From Dr. Mike’s comment, it appears that BobbyG is a regular commenter. His comments in this weblog posting appear to me to be accurate and pertinent.

    Regarding the inevitable hype from commercial vendors of medical devices, it is up to physicians, as buyers, to determine whether a particular device is useful or not. Given that physicians practices or hospitals or other medical service providers do not operate on the basis of a competitively-determined market, the selection of equipment or of devices by those providers is itself ultimately not competitively determined.

    The point is that many “bad” choices are made that simply add to the cost base of medical service delivery without any other positive outcome.

    EMR systems have marginal and more or less irrelevant characteristics in common with devices used clinically. In essence they are a significantly better substitute for hand-written, physical, paper-based records. FDA evaluation and approval of medical devices, an issue about which I know next to nothing, are not relevant to EMR systems any more than to paper-based clinical data repositories.

    The issue of the large positive externality of digitized records is the most important. Unfortunately, medical personnel have to bear some of the cost of data input. On the other hand, patients, by and large, bear historically and still currently a much higher cost of the use of paper-based records.

    In other words, physicians should do their best to select EMR systems that work best for them – that is an investment in time of course, but also a necessary step – then get on with using them. This, rather than constantly complaining about aspects of such systems that will gradually become less burdensome.

    In addition, it looks as though Margalit Gar-Urie continues to write intelligent and accurate essays on EMR and related computer-based systems, so skeptical physicians should read those.

  18. I did some research on Coriolanus, both the somewhat or mainly mythical figure and on Shakespeare’s use of the story in his play. The play apparently was recently filmed by the British actor Ralph Fiennes using a modern setting, but I do not know the details on that.

    Yes, you are correct, the Romans went grovelling to Coriolanus after his expulsion (more or less) from Rome and his later alliance with the erstwhile enemy, the Volscians. Somewhat convoluted story in that he was reputedly accorded the name, Coriolanus, from successful attack on the Volscian settlement Corioli. The Shakespearean play focuses on the subsequent exile, command of a Volscian army, threat to Rome by that army, entreaties to him by Roman representatives, including by his family, and subsequent murder by his Volscian rival. Now I better see why you focus on the grovelling part as basis for use of the moniker.

  19. It was not that your experience has no value, it was that your experience with EHRs does not automatically trump the opinion of an actual end user of the tool (EHR). You discounted their opinion without cause, and I simply and sarcastically called you on it, as you deserved.
    Your insight and opinion are very valuable on this blog, but you are not immune to the very errors you seem so willing to point out in others.
    That EHRs have faults, even if not of their own making, is by your own admission plain fact. So too is the over-promising and under-delivering that pervades the marketing of these medical devices.

  20. You’re confused. Which is why you comment anonymously. They do not all suck. The payment paradigm is what sucks.


  21. There’s also fast-and-easy documentation of things never done, a “moral hazard.” This is especially true when docs are being graded as “taxpayers” (revenue generators). The NYT quoted a patient who found many of the claims made as to what the docs did was fictitious.

  22. Southern doc is likely a lot more savvy than most IT personnel regarding medicine – which is – null.

    I observed that lack result in IT personnel putting patients in danger. See here for example: http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU

    IT personnel need to be kept on a very short leash by medical personnel, especially if (like most) the IT personnal have no biomedical informatics education and expertise.

    I need to point out that HHS/ONC now consider those attrirbutes essential for health IT leadership (see http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html).

    Further, most physicians don’t give a darn about programming. They just want information systems that support clinical care.

    (I learned PDP-8 assembler at 13, PL/I and IBM370 assembler at 18, Sybase/4D RDMS at 33, and authored EHRs supporting research collaborations in birth defects with a Middle Eastern oil-producing country some time after that.

    I’m also an extra-class amateur radio operator.

    Does that count for anything?

  23. The elephant in the living room is that today’s health IT is largely “bad IT.”

    Good health IT (GHIT) is IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s or other clinicians’s hands (or eyes) and facilitates better practice of medicine and better outcomes.

    Bad health IT (BHIT) is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, or otherwise demonstrates suboptimal design and/or implementation.

    The health IT industry is a rogue industry that produces lousy software and gets away with it due to lack of regulation.

    Health IT will never be “successful” until bad IT is replaced with good IT.

    For a technical analysis of bad IT, see this: A study of an Enterprise Health information System , http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146

    I find it amazing that this analysis has never been refuted, just ignored.

  24. Wendell,

    You say: “(1) too much vocal resistance from a small number of physicians for poor reasons to EMR system adoption”

    From what I understand, it is NOT a small number of physicians but a LARGE number. And from what I understand the primary objection has to do with how unwieldy the systems are and how they slow down the process of seeing patient – this is not a “poor” reason, but an entirely valid one.

    You say: “(2) an unwillingness, again regrettably on the part of physicians as opposed to others, to make some effort to intelligently consider available EMR offerings and view them as a tool for enhancing quality of service.”

    I suspect that when/if physicians have been significantly involved in choosing an EMR, they have a better opinion of the EMR. If, on the other hand the EMR has largely been chosen by a combination of IT and Billing – as I suspect is often the case – acceptance will be worse.

    I will relate an anecdote about my groups choice of a PACS system that may explain some of the frustrations felt by physicians in these choices.

    My group wanted to be involved in the choice of a PACS system (as opposed to what you imply above). Management (reluctantly) agreed to let us help make the choice. They set up a “show and tell” at a motel in which 5 vendors (of their choice) brought their systems in to be demonstrated. 10 Doctors from our group took time off from their work to attend the demo. 3 Doctors from an affiliated group in Upstate New York flew in to attend the demo.

    The doctors went from room to room looking at the various systems, spending a good half hour looking at each. At the end, our doctors conferenced with each other and submitted a list to Management of our choices in order. Management then went on to choose a DIFFERENT vendor who had not participated in the “show and tell”. The only salient virtue of this company was that it was probably cheaper.

    – Who was not making an effort to “intelligently consider” these PACS systems?
    – How much time did our physician group waste (not to mention the docs from Upstate NY)?
    – With what enthusiasm should our group free up docs from their work schedule (which uses up vacation days since we can’t/don’t cancel office or hospital appointments) for future “show and tells”?

  25. “But the Romans came grovelling to him.”

    I understand the concept, but keep in mind “Coriolanus” was a name granted to Gnaeus Marcius, a Roman general who sought a consulship, who overran the Volscian city Corioli, thereby “earning” the added name for that city.

    It was the Volsci who reportedly (the current sources for the story are Plutarch, writing much later, and a later Roman historian) later avenged the assault on their city by killing Gnaeus Marcius Coriolanus. I believe that his soldiers gave him up when surrendering to a Volscian army, but I would have to check that.

    In any case, yes, I understand you are waiting for someone, anyone, to come groveling to you. That I understand. It is the “coriolanus” bit that is puzzling.

  26. Mr. Legacy: There are many misconceptions out there regarding standards. There have long been standards for information exchange in healthcare aside from DICOM, all of which are integrated into most EMR systems. If your are interested in the technology of DICOM there are several good books that cover it. One outstanding book is by Oleg Pianykh who was and probably still is a specialist on DICOM at Harvard Medical School.

    Needless to say, there are many similar resources on other standards.

    The issue of computer applications that are written in a particular computer language, run under a particular operating system, etc. has long been accommodated by various techniques. The most widely technique for data exchange now is web services. I frankly do not know the capabilities of data exchange in current EMR systems, although I suspect that most, fi not all, “expose” as the jargon goes, internal functionality and access to data to external systems through a defined web service.

    Also I am not trying to defend poor design or time-consuming user interfaces for EMR systems. Those systems are a product like any other. Competing products should constantly be improved to better satisfy the needs of the user/customer/purchaser. I agree completely in that regard.

    My concerns regarding criticism are the ones already noted: (1) too much vocal resistance from a small number of physicians for poor reasons to EMR system adoption (2) an unwillingness, again regrettably on the part of physicians as opposed to others, to make some effort to intelligently consider available EMR offerings and view them as a tool for enhancing quality of service.

    On occasion, being human, I cannot resist provoking the more vocal and recalcitrant of that group. Nonetheless, I agree in principle with the criticisms, once one removes the sound and fury that tend to envelop the criticisms.

  27. Wendell,

    I googled you and saw that you do indeed have considerable experience in the area of developing software for physician use. I hope the software that you develop works well and satisfies its users – I am not trying to bash what you do. Unfortunately, it appears that much of the EMR software does not work well.

    I have considerable experience as a user of a form of EMR called PACS – as well as voice recognition software. Both have improved greatly over the past 10 to 15 years and are now quite useable. In fact, the combination of PACS and voice recognition has allowed increased productivity. And as opposed to many other areas, doctors in Diagnostic Imaging (including me) have pushed for the adoption of PACS. This is not because we are smarter that other docs but merely because PACS actually works!
    By the way, all of this was accomplished without any subsidies or penalties. I tell you this because I want to make it clear that I am not a Luddite.

    One of the important differences between PACS and other EMRs is that it was conceived and built using a common standard called DICOM which allowed data from different machines and manufacturers to be read on any PACS system.

  28. Wendell: “They are not” (coerced to use EMRs)

    Oh really? What about the payments now and fines later?

  29. Until these devices are vetted for safety, efficacy, and usability, and undergo surveillance subsequent to being activated, there will not be improvements in out comes or costs.

    HOWEVER, the cut and paste technology and other EHR gimmicks facilitate widespread upcoding, enabling doctors to recoup the $ millions they have wasted on the devices and wasted time from the slowed workflow controlled by these devices.

  30. “Worth it because of the huge positive externality of having data digitized and stored in manipulatable as service is rendered in any form”

    Just keep telling yourself that when you’re sitting in front of your doctor telling her you’re so depressed you want to die, or you have crushing chest pain radiating into your arm, and she has her head buried in her laptop.

  31. What is your expertise in software development? Substantial
    Have you designed any software that you loved but the consumers hated? No
    How did that work out for you? N/A

    “I think the most telling point is that physicians have to be coerced to use EMRs.”

    They are not.

    Time for bed otherwise, but more tomorrow, assuming some discussion.

    Oh, where, oh. where is the ultimate arbiter, Ms. Gar-Urie, or at least her husky?

    Margalit: is your writing in Hebrew as good as your writing in English? Believe it or not I have been working (very slowly) on knowledge of Hebrew (and Arabic). Still in the script recognition phase in fact.

  32. “What is your expertise in software development to make this statement?”

    I have none. I am judging the quality of the product based on what it does for the user.

    I think the most telling point is that physicians have to be coerced to use EMRs. When was the last time you received a payment to buy a car instead of a horse, or a refrigerator instead of an icebox, or a laptop instead of a typewriter?

    The product is not ready for prime time. When it truly becomes useful, it will be adopted. Until then, it is an effort by the government, etc. to force busy people to spend more time as unpaid data entry clerks.

    What is your expertise in software development?
    Have you designed any software that you loved but the consumers hated?
    How did that work out for you?

  33. “I plead guilty as charged.”

    Reportedly Coriolanus of antiquity was killed by the Volsci after he led the attack on Corioli. On the other hand, I do not know whether he ever explicitly stated “guilty as charged” himself.

    “Medicare Bills Rise as Records Turn Electronic”

    I may have read this, but I do not recall. The issue of EMR system adoption by medical service providers, notably physicians practices, is a complicated one, so that fact that some measured costs rise in tandem with medical record digitization is not surprising. But again, costs, cause/effect, changes over time and so all have to looked at carefully to draw meaningful conclusions.

    “to have expertise in software development to criticize”

    My question was in response to the assertion that the software is poorly written. That means the architecture, design and programming (coding) are poorly done. Evaluation of those requires knowledge and experience in doing them, hence experience and knowledge of software development.

  34. @WM: you do not need to have expertise in software development to criticize the quality of software (even though there still may be reasonable and unreasonable crticism) – similar to the fact that you do not need to be a chef to judge the quality of a meal, or a sarcastic person to judge the quality of sarcasm.

  35. LOL.Yeah, I got lambasted in another post for calling out a “doctor” who claimed unhelpfully that “the EMRs I have evaluated” basically sucked, and that, by extension, they all suck.

    How scientific.

    I see the gamut; systems that do in fact suck, systems that work fine. Docs who hate ’em, docs who love ’em.

    But, my critic asserted that since I am not a physician, I just “play” with EMRs, I have never actually used one in the course of doctoring. Consequently, my experience with the approximately 40 systems my REC supports is of no value.

    The fact that EMRs are of necessity suffocatingly code-heavy with billing logic is neither the fault of either the HIT vendors nor their end-user clinicians. People do precisely what they’re incentivized to do.

    BTW, Google THIS:

    “Medicare Bills Rise as Records Turn Electronic”
    NY Times.

    More fuel on the fire.

  36. “That’s what all the smart docs are doing.”

    “smart” is not the operative word here. Arrogant and self-interested are the appropriate adjectives.

    I do not question the fact that data entry at “point-of-sale” is a hassle, but it is minimizable. Worth it because of the huge positive externality of having data digitized and stored in manipulatable as service is rendered in any form.

    The nay-sayers on the use of information technology among physicians are of course the loudest complainers, because they are the least flexible and the least willing to look on their occupation as one that should be patient- rather than -self-oriented.

    Physician: heal thyself psychically.

    What is the bit with coriolanus by the way? Roman aristocrat by that name, perchance? Modern-day Umbrian? Sole remaining native of Corioli that is otherwise of location unknown?

  37. “The reason is that most EMRs are poorly written pieces of software and were never intended to assist Doctors and Nurses take care of patients, but were instead designed to improve billing and record keeping for the Hospital Admin.”

    Just change “poorly written” to “well written,” and leave everything else the same.

    ‘My internist, who is my age (late 50′s), has a well thought out and coherent approach to EMR adoption in his office based on his experience with his hospital’s EMR. “I would rather pay the fine that get an EMR. I can’t afford it and I don’t want to waste all the extra time an EMR requires.” ‘

    That’s what all the smart docs are doing. One of our patients was the head of design and installation for the EMR at a top 20 med school/hospital, and he’s thrilled with our decision to stay with paper.

  38. “The reason is that most EMRs are poorly written pieces of software”

    What is your expertise in software development to make this statement?

  39. Dranove is an apologist for the “Health Care IT/Industrial Complex” and he blames the users for the fact that EMRs are mostly bad, time wasting pieces of version 1.0 software. How else could he respond as a “Distinguised Professor of Health Industry Management”?

    The reason is that most EMRs are poorly written pieces of software and were never intended to assist Doctors and Nurses take care of patients, but were instead designed to improve billing and record keeping for the Hospital Admin.

    And the belief that EMRs would save money was part naivete, part political spin and in large part due to political contributions from IT companies that saw a coming windfall.

    Nobody with any brains would ever have allowed incompatible systems to be put into place. Handwritten data – which is what most hospitals still rely on – is very hard to integrate with EMRs. Physicians reasonably resist attempts to make their life harder by forcing them to take 2 minutes extra (hundreds of times a day) to do something electronically that they used to do on paper quickly.

    The sad truth is that it will take decades for the “loser” EMRs to be weeded out, the “winner” EMRs to be refined to where they don’t actually waste time and compatibility issues to be addressed. And during the “evolutionary” process, billions of EXTRA dollars will be spent.

    My internist, who is my age (late 50’s), has a well thought out and coherent approach to EMR adoption in his office based on his experience with his hospital’s EMR. “I would rather pay the fine that get an EMR. I can’t afford it and I don’t want to waste all the extra time an EMR requires.” Until the consumers of the product have a better opinion of its useability, EMRs are an Edsel that could only exist due to Governmental coercion.

  40. “There is one simple explanation for rising costs with EHR use – fast and easy documentation of complete evaluation.”

    Some of us call that lying.

  41. There is one simple explanation for rising costs with EHR use – fast and easy documentation of complete evaluation. Using EHRs and software programs – such as instant medical history which allows patients to enter complete medical histories – doctors can generate a detailed evaluation including a complete medical history in an instant, commanding a higher paying evaluation code with a single click, I write about this today in my blog, medinnovation, under the title “Revenge of the EHR Nerds”.

  42. It matters not shich info system I use to save money when the MediCare crowd can come in any time they wish ad extract healthcare from the system. I am at my urgent care clinic today, Saturday. I am seeing a spectacular array of walkers and canes and wheelchairs. These people need healthcare today like the Tinanic needed deeper water. They are completely out of control with their demands and spending. It is not their money, but it is their entitlement. It must stop. It must be their money; then they will change their consuming ways.

  43. Margalit,

    This is the best thing you have ever posted here. It is perfect and perfectly correct.

  44. FYI, what’s the story with banishment? Are we in Germany circa 1938?

  45. Glad to see a message the “goddess” herself, Margalit. I have an Aetna PPO. The only data I look at on Aetna’s website are payment related. Very good for that. There may be clinical data available as well, but I have not checked for that. Interestingly, I received a notice about an index for one of the test done on a blood sample from Aetna that is related to therapies to keep in mind due to the level of the index. That is the only clinically-related information that has been issued by Aetna without prompted by me.

  46. Well, thank you Wendell for the kind words, but I’m afraid I’m no sage. Not even close. Anyway, let me take a shot at this.

    Are there older physicians that don’t want anything to do with computers? Yes, there are, here and there you’ll find a few that have that mind set, but it’s a very small minority.

    Should physicians be expected to be technically inclined to use an EHR? I don’t think so. Good software should not require that the user has programming skills or anything of the kind. It will however require training and learning just like any new instrument does. Doctors are pretty good at that, judging by the ever increasing amounts of medical devices and equipment.

    EHRs were never intended to save doctors time or money, regardless of what the ads say. Initially EHRs were intended to increase billing revenue, and according to the latest reports, they were exceedingly successful at that. We need to remember that EHRs did not create the billing rules. EHRs did not make doctors click those E&M boxes. They just made the boxes available to be clicked. And when you make useless boxes available for clicking, it by definition, detracts from elegance and clinical imperatives.
    Now we have MU, which has created yet another set of boxes that EHRs must make available for clicking, which detracts even more from so called usability.

    Doctors hate the billing rules and their boxes and find MU boxes equally distracting from patient care, but very few would consider buying an EHR that is not certified for MU and cannot capture E&M justifying data. So what is it exactly that we want software vendors to build? A million dollars masterpiece that nobody buys?

    EHRs have been the tool by which external stakeholders enforce rules and regulations on physicians, and they are even more so now than before MU. They were/are intended to save money to payers (public and private). Is it really so surprising that docs dislike these tools?
    BTW, I think someone should do a little study on payer MLR and EHRs, but that data is probably very hard to come by, and it is probably too soon to tell anyway.

    Southern doc is right. When physicians become hourly workers, the grumbling will cease…. and so will many other things….

  47. If Mr. southern doc is a physician, he is an anomaly in regard to being savvy about computer use, not to mention computer programming.

    What computer language did Mr. southern doc use at 12 and what did the program do? Has he done any other programming since then?

    What EMR systems does he use? Does he have experience with other EMR systems?

    “do things that are of absolutely no value to me”

    If this is in fact the case: (1) who made the decision to implement that system (2) why not find an EMR system that is of value (3) how is the value to “me” defined, (4) might there be value to others, specifically the customer = patient?

    What are the key 2-3 functions that would make an EMR system of value to Mr. southern doc, if the one Mr. southern doc uses now valueless to him?

    Might the value be system-wide, rather than specific to Mr. southern doc? I.e. yes, a drag to enter clinical data at point of sale, so to speak, by the “salesman”, but once digitized the data are then available in digitized form for use and transmission by everyone.

  48. agreed. total baloney.

    if any other industry blamed its customers the way these guys do, they’d be run out of town on a rail ..

  49. “Current physicians by and large are neither that comfortable with the use of such technology or more likely simply do not want to devote any time to effective use at this stage in their careers.”


    I wrote my first computer program at age 12 at the University of Virginia, and I despise the currently available EMRs. Not because I can’t use them, but because I’m forced to use them to do things that are of absolutely no value to me, my staff, and my patients. I consider that a very positive and admirable attitude.

    Future generations of physicians will use EMRs because they’ll all be hourly employees and what they think is best for themselves and their patients will be completely irrelevant.

  50. Prof. Dranove is a good scholar, but this missive misses the point.

    No attempts at showing a reduction in cost or enhanced health status of the population through any kind of academic study will reveal any current value for the adoption of computer technology into the recording and electronic manipulation of clinical data.

    As an aside, just ask the sage Margalit Gur-Arie, who may still be an active participant to this weblog. She is not a native English speaker, but her prose is often better than mine and her knowledge of healthcare issues, including healthcare-related information technology is excellent.

    I am convinced without need for an attempt at a “controlled” study to show that the key impediment to (1) adoption and (2) effective use of computer technology by medical services providers, primarily physicians whether primary care or specialist, is purely generational.

    Current physicians by and large are neither that comfortable with the use of such technology or more likely simply do not want to devote any time to effective use at this stage in their careers.

    The attitude is not particularly positive nor admirable, but it is understandable.

    The point is, let’s wait 10 to 15 years until the current generation of physicians (and ancillary personnel) is retired, then see the effect on health status and cost of the adoption and use of computer technology in clinical care for patients.

    In brief, the subsidy given to providers as part of the ACA was a gift not so much to the providers themselves as to the commercial suppliers of software. Much more could be written on this topic, but desist at the moment.