Electronic Medical Records: Bad for Health?
Electronic medical records could let patients travel freely to doctors of their choice, improve their odds of getting the right care in emergencies and reduce medical errors, duplicated tests and unnecessary prescriptions. They're also the standard in most industrialized nations as well as U.S. healthcare systems such as the Cleveland Clinic, the Mayo Clinic and the Veteran's Administration hospital system.
Yet while the move to digitize all those color-tabbed folders filled with illegible, hand-written patient records has barely gotten underway in the U.S., the backlash is already here.
This morning, for instance, the WSJ asked the scary question: "Are Your Medical Records At Risk?" (The WSJ Health Blog also offered a summary of the article.) The story summarizes several recent cases of hospital lapses that may have exposed electronic patient data to outsiders, although the only concrete evidence of harm -- if you can call it that -- involved the recent gawking at Britney Spears' medical records by staffers at the UCLA Hospital System. Nevertheless, reporter Sarah Rubenstein concludes that a "steady stream" of privacy violations "threatens to undermine the health-care industry's effort to adopt electronic medical records."
Privacy concerns, of course, are real, and there's no excuse for medical centers that don't better protect the security of patient records. The simplest way to do that is probably to make them liable for any serious data breach -- perhaps by requiring them to pay for lifetime care of any patients whose data is misused.
But it's clearly an overstatement to write, as Rubenstein does, that security concerns have been a "major barrier to health-care digitization." Only 14 percent of all U.S. physicians use electronic records in the first place, and one major reason is that digitizing paper records and subsequently retraining doctors, nurses, technicians and office staff to use the new systems usually costs far more than any individual doctor's office or hospital is likely to save over the short-to-medium term.
According to an article last year in the NYT, doctors actually reap only about 11 percent of the savings from electronic-medical record systems, with the rest typically flowing to insurers. "The doctors bear all the costs, and others reap most of the benefit," David Brailer, a former Bush administration czar for health-information technology, told the newspaper.
A second shot at digital records came last week in the New England Journal of Medicine, where two doctors at Beth Israel Deaconess Medical Center fret about the limitations and potential downsides of electronic record systems. (The paper by Pamela Hartzband and Jerome Groopman requires an NEJM subscription.)
Part of the problem, Hartzband and Groopman write, lies with the ways they've observed other doctors using -- more to the point, abusing -- the systems:
Many times, physicians have clearly cut and pastedlarge blocks of text, or even complete notes, from other physicians;we have seen portions of our own notes inserted verbatim intoanother doctor's note. This is, in essence, a form of clinicalplagiarism with potentially deleterious consequences for thepatient.... This capacity to manipulate the electronic recordmakes it far too easy for trainees to avoid taking their ownhistories and coming to their own conclusions about what mightbe wrong. Senior physicians also cut and paste from their ownnotes, filling each note with the identical medical history,family history, social history, and review of systems. Thoughit may be appropriate to repeat certain information, often theprimary motivation for such blanket copying is to pass scrutinyfor billing. Unfortunately, these kinds of repetitive notesdull the reader, hiding the important new data.In other cases, the problem is that the electronic record includes too much information:
Similarly, electronic medical records can reproduce all of apatient's laboratory results, often dropping them in automatically.There is no selectivity, because it takes human effort to wadethrough all the data and isolate the information that is pertinentto the patient's current problems. Although the intent may beto ensure thoroughness, in the new electronic sea of results,it becomes difficult to find those that are truly relevant.The digital records also risk distracting doctors and obscuring their ability to focus on their patients' problems:
One of our patients hastaken to calling another of her physicians "Dr. Computer" because,she said, "He never looks at me at all -- only at the screen."Much key clinical information is lost when physicians fail toobserve the patient in front of them.Hartzband and Groopman are most concerned that electronic records encourage a form of "cookie-cutter" medicine, in which doctors rely on digital templates and computerized diagnostic decision trees in place of their own intuition and experience. (Groopman expands upon this theme in his recent thought-provoking book, How Doctors Think.) This is definitely an issue worth cogitating about, although my suspicion is that the major problems of U.S. medicine are more likely the result of too little standardization and dissemination of "best practices," not too much.
While these issues are all real, it's still important to recognize that electronic records can be misused the same way as any other tool, particularly by those not properly trained in their use. Any new technology involves a learning curve, and that's especially true if the underlying tool isn't particularly flexible or user friendly, as many electronic-record systems undoubtedly are not.
Recognizing that fact should lead to an argument for better standards, training and interfaces -- and to their credit, that's more or less where Hartzband and Groopman end up by the close of their essay. But the average doctor reading their NEJM piece could be forgiven for drawing an entirely different conclusion -- and if enough were to do so, that really might be a "major barrier to healthcare digitization."
Screenshot of a Second Life EMR simulation by john-norris, CC 2.0
