This was my editorial at FierceHealthcare on Friday

This week I heard a very bitter physician complaining that using an electronic
medical record got between him and caring for his patients, and imposed
secretarial tasks on him. Then on Tuesday we got perhaps the most negative news
yet about a problematic CPOE installation at Childrens’ Hospital in Pittsburgh,
where after its introduction patient mortality increased. There was also news
about an emergency department in Arizona pulling the plug on its EMR.

Whatever the real reasons behind the data, it’s clear that simply installing
an EMR or CPOE system did not have the desired impact on patient safety. My
cursory assessment is that electronic records are vital in improving the
healthcare delivered to patients, particularly those with chronic illnesses,
over the continuum of care. But it’s clear that when they’re introduced to ICUs
or ED, where speed is the key and care processes are not well defined, things
may not be so successful. A real examination of the process absent the
technology, and a massive commitment from vendors to improve the human-computer
interface, is quickly needed before the movement toward CPOE and EMR is stopped
by these kinds of stories. After all, it’s easy for a hospitals or physician
groups to decide instead to do nothing.

Well, some people were reading. Kelly Clark a physician from Boston, recently relocated to
Louisville, wasn’t too impressed. She wrote to me:

Any time you want to hear a physician complain about using
CPOE/EMR, simply ask any clinician who makes their living actually treating
patients and billing insurance for their services. “Speed is key
and care processes are not well defined” as the default condition for the
current practice of medicine – it is in no way limited to the ICUs and ERs. 
A large amount of information on digital access is useful to care
coordinators who are salaried to manage a fairly small caseload of patients with
chronic conditions. The time constraints placed by the market on
the physician-patient encounter do not allow for the thoughtful assessment of
large quantities of historical data by a practicing physician. Physicians are happy with their CPOE/EMR system in the salaried and
subsidized world of the VA. Outside of that arena, the
administration and the 1-3 physician champions of EMR in each health care system
will be the primary sources of effusive positive regard for EMRs, but those of
us in the trenches are typically not quoted and not happy. Having
been forced to use these CPOE/EMR systems and seeing them severely limit the
efficiency and safety of medical care, as well as increasing error rates, I am
among the practicing physicians who can wax eloquent about their problems.

You are correct in the need for aggressive assessment of
the way medicine is practiced and huge investment in improving human-computer
interface systems in order for the EMRs to work well and realize any savings of
dollars or lives. However, I believe you are incorrect in
predicting that the stories you quote may result in stopping the movement toward
EMRs because it is “easier for hospitals and physician groups to do
nothing”. This is not true. The move toward EMRs is
not being led by physicians or hospitals, so our input is amazingly
irrelevant. The movement is largely based on a fallacy that
improved technology will lead to decreased cost, with a side bar of improved
quality of health care. It is led by business interests and
followed by the government – ie, the payors. Improved technology will be a huge
boon for consulting firms, administrators, and other types of technician and
advisors. It will absolutely not decrease costs. Only improved rationing of health care resources will do that. However, since no one wants to deal with the true issue, our current
resources have been diverted to The Holy Grail of Techno-Salvation. The interests behind this are well-entrenched and will not be stopped by
a few facts that contradict their ideology. This is evident with
the push to P4P, when there are almost no “performance” scales that are relevant
to medical care for real patients with real co-morbid
medical/social/psychological issues that impact their health and health
care.

It is not easier for hospitals to do nothing, because
Medicare continues to be a main player on their field, and the push toward
electronics by Medicare cannot be ignored by hospitals. As
economies of scale push toward large Kaiser-like systems and physicians move to
stable jobs being employed by large entities, EMRs will make more sense. In the meantime, the move toward these large systems of care, including
the fits and starts of competing EMRs, will lead to more wasted health care
dollars and worse medical care, as well as complaints by bitter physicians who
are being devolved from being professionals toward being marginalized purveyors
of a technical commodity.

I actually agree with much of what Kelly says especially about the lack of conversation about rationaing, although I’m not so sure that payors are leading the way towards EMRs, or that anyone is. I suspect that underlying the lack of appreciation of the EMR is the realization that it in fact only really makes sense for bigger organizations. What Kelly may be underestimating is the ability of the AMA and others to delay the imposition of IT, such as the rejection of the mandating of electronic prescribing in the House-Senate conference of Medicare Part D. But this debate and this process is by no means settled.