The Stockholm Syndrome and EMRs

First the definition:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Now, the health care connection.  As a result of the billions of dollars allocated by Congress to health information systems as part of the stimulus program, those companies who had a head start in implementing electronic medical records quickly found themselves in demand.  Of all those companies, Epic is the most successful. Forbes notes, “By next year 40% of the U.S. population–127 million patients–will have their medical information stored in an Epic digital record.”  Here in Massachusetts, the biggest convert was Partners Healthcare System:  “System development and implementation will occur over a 10-year period and represent a capital investment of approximately $600 – 700 million.”  Elsewhere, notes Forbes: “The biggest win: a $4 billion project to digitize medical records for health care giant Kaiser Permanente.”

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best.  For example, Partners said, “The new health care landscape will challenge us to engage in population health management, improve the coordination of health care, and accept financial risk for the care of our patients. This new system will enable us to meet those challenges.”

But it can hurt to go down this path.  In another article, Forbes notes:

Customers, such as New Hampshire’s Dartmouth-Hitchcock Medical Center are feeling the pinch. DHMC which implemented Epic last year at a cost of $80 million, expects a weak operating performance in 2012, partly because of expenses related to Epic.

Now, re-read the definition of the Stockholm syndrome and see if it isn’t apt.  But it doesn’t have to be this way, as I have noted in quoting an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:

It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn’t reside within single EHR systems, and there’s a clear path toward better, safer, cheaper, and nimbler tools for managing health care’s complex tasks.

Here’s the ultimate corporate risk for Epic.  Now that it controls this big a piece of the American market–paid for by federal appropriations–if something ever goes wrong (e.g., a coding or decision support error that results in harm to patients), you can expect a bunch of Congressional committees to come down on the firm like a ton of bricks.  It doesn’t matter which political party is in the majority.  People will ask:  “Isn’t an EMR as much of a medical device as the ones regulated by the FDA?  Isn’t the handling of prescription drugs by EMRs as much a part of drug dispensing as the drugs themselves?  Shouldn’t EMRs be regulated by the federal government for that reason, too?  How did this firm get such a big share of such a critical market with no government review?”

Paul Levy is the former President and CEO of Beth Israel Deaconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

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Natalie hodgeAlan GlickrbaerDirkDRajesh Recent comment authors
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Natalie hodge

Very interesting post… From the standpoint of business model, epic is utilized by physician employees, whereas private practice docs are using other systems, quite possibly the many newer better and also free emr systems ehich are rapidly evolving. Hospitals use epic to tie physicians to their entity and their use of ordering systems which continue to pad hospital bank accounts with cash from expensive procedure and tests…

But ultimately transparency will win, closed systems will fail, and a new health ecosystem will emerge through disruption…
Natalie hodge md FAAP

Alan Glick

Let’s hope that Epic or third party developers will make it cost-effective to achieve interoperability. I have often wondered why so many hospital CEOs choose Epic. Perhaps they are afraid that when these large-scale projects become inevitably difficult, over budget and behind schedule, they can say….”but everybody else chose Epic!”


@ Bobby Great response. Lots of food for thought. I’m not sure where to even begin … It’s clear that the liability issue is one that is going to have to be dealt with. Here’s one thought: if the gov’mt is going to be using all this supercool new trchnology to collect all of this useful performance data on physicians (a reasonable idea) and hospitals (also a pretty reasonable idea) shouldn’t they be doing the same thing with the technology itself? Can’t those log files be monitored? Shouldn’t some sort of large scale effort be kept on the performance of… Read more »


“Just another reason for docs to stay with paper as long as possible?”

Absolutely not!

But it is a reason to fear an oligopoly or monopoly in the EHR market.

And for taxpayers and their representatives to ask why there were inadequate plans to anticipate and address the inevitable issues that would arise as a result of HITECH.

Having the National Coordinator as Chief Health IT Cheerleader has both resulted in ignoring the sober realities of the job ahead and raised partisan hackles, neither of which will expedite actually gaining value or ROI from this massive public investment.


@ Bobby – can you tell us a little bit about what “forensic HIT data analysis” would look like? And what this technology is about?


Basically extracting and data mining the now requisite always-on audit logs that record things like userid, patient id, date-time that PHI were created, viewed, updated/edited, deleted, or transmitted. Necessary for breach investigation and accounting of disclosures. The audit log is at once a legal record of PHI transactions, and an information workflow record. In the “forensic” sense it would involve data mining of EMR audit log tables in conjunction with regulatory audits, or in the wake of Discovery subpoenas issued by lawyers. Extreme example: at 8:05 a.m., incoming electronic interfaced Quest lab data auto-populate a patient’s EMR record, appending new… Read more »

southern doc
southern doc

“It wil be hated, to be sure, but it will be happening.”

This development wasa completely predictable consequence of switching to EMRs, and no one should be surprised. If nothing else, it will certainly increase the billable hours in prosecuting and defending suits.

Just another reason for docs to stay with paper as long as possible?


“Extreme example: at 8:05 a.m., incoming electronic interfaced Quest lab data auto-populate a patient’s EMR record, appending new data (“transmitted”, “created”). Amid the results are an extreme value of life-threatening import. The doc doesn’t see these data ’til 4.15 p.m., and in the interim the patient cratered and died at the ER. Why was this adverse result not caught? EMR red flag bug? Or culpable inattention?” I don’t think that’s a great risk. Truly critical lab values are phoned in to ordering provider or covering MD. The more realistic problem is IMHO that provider(s) overlook some critical information that is… Read more »


semper fi.

“Here’s the ultimate corporate risk for Epic. Now that it controls this big a piece of the American market–paid for by federal appropriations–if something ever goes wrong (e.g., a coding or decision support error that results in harm to patients), you can expect a bunch of Congressional committees to come down on the firm like a ton of bricks.”

Not to mention the med liability lawyers, who invariably follow the money, “hold harmless” boilerplate notwithstanding.

One area I intend to pursue is forensic HIT audit log analysis.