Photo: Bumrungrad International Hospital, Bangkok
Electronic Medical Records and the Cost of Health Care
I read recently about a marked increase in “medical tourism” by Americans. Patients travel to foreign countries for hip replacements, cardiac by-pass surgery, plastic procedures, gallbladder removal etc. India, Thailand and Malaysia are favorite destinations. It is claimed that the quality of care is on par with American health care, but the costs can be as little as 10% of the costs here at home. How can other countries using the same equipment and technologies that we have charge so much less. The answers can be complex and I intend to write about this in a future column, but much of the cost of medicine in the U.S. has little to do with costs of services or quality of care. American hospitals and doctors are saddled with many expenses that designer hospitals in India and Thailand are spared: oppressive government regulations, mandates to provide “free care” to everyone that refuses to pay (somebody has to pay), massive bureaucracies, malpractice claims and inflated costs for supplies are a few of the major factors. Soon a new financial millstone will be hung on the necks of health care providers in the name of efficiency and progress.
In less than two weeks the hospital that I work for will roll out their new, highly-touted EMR or electronic medical records system. Soon to be mandated by most states and nationally by 2012, EMRs are being promoted as a panacea to many of the problems now facing delivery of health care in the US.
Once complete nationwide, everyone’s health record will be permanently encoded in some computer server and will be readily available for review by any doctor that a patient may see. Can’t remember when you had your last tetanus shot? No problem, I’ll just check your information in our data bank. Had a bad reaction to some medicine eight years ago? Let me have a look at your EMR and I’ll be sure not to prescribe that for you again.
Of course, the value of the information depends upon the accuracy and completeness of what has been entered. Since this will be a compilation of information from different offices over your lifetime, it is likely that a great deal of misinformation, errors, omissions and incorrect opinions will accumulate in everyone’s record. You think doctors have lousy hand-writing? You should see most of us use a computer!
Besides the fear of “big brother” potentially having access to a centralized data bank of personal information, there are other issues that must be considered as we leap headlong into this brave new world. In our facilities it is estimated that “production” (i.e., number of patients seen) will drastically decrease while we learn to use the system. In our primary care offices a drop of 60% is anticipated for the first six months, then only 30% by 20 months! That means that an office that cares for 100 patients per week will only be able to see 40 patients, and then perhaps be up to 70 patients two years later. It is doubtful the system will ever allow doctors to see the volume that was seen pre-EMR. This is happening all over the country at a time when demand for health care continues to rise 10% per year in many parts of the country. How are doctors going to accommodate the demand while being limited by a system that is enigmatic and tedious for most of us?
All our doctors had to spend two days in training with the new EMR a few weeks ago in preparation for the big day when we will dispose of our pens, note pads and paper charts and go to a tablet notebook computer. Each patient will have to have several parts of the patient’s personal history, family history, social history (smoke? alcohol? employment? diet? exercise?, etc) completed before the program will allow the doctor to proceed. Much of this is not needed for simple problems such as sprained ankles or bladder infections. I can evaluate and treat an uncomplicated patient with a simple bladder infection, or UTI, is mere minutes, perhaps ten if I take some time and ask about the family or what do they think about the Colts this year. Using the new EMR system in a mock trial during training I could do it in 40 minutes! Now that will undoubtedly improve some with practice, but not that much.
So what is the incentive for hospitals and doctors to use a system that will decrease the number of patients that can be seen (and billed)? First, the government wants it (more on that in a minute). Second, by forcing us to fill in all the superfluous information the billing code can be “up coded.” That means that a code can be used that allows greater reimbursement from individuals and third-party payers. We can charge more because we supposedly have done more, even if it is only filling in useless information. Also, by having the doctors enter all this information, order lab tests and x-rays, write prescriptions on-line and digitally enter all the patient information, an army of ancillary personnel are no longer needed. Many fewer transcriptionists, unit secretaries and medical coders are needed. The labs, x-ray departments and pharmacies will need fewer people since all the clerical work will be done by the ordering physician.
The state and federal governments want this system for a number of reasons, but the one that concerns me most is that almost all the information that I enter on a patient is chosen from drop-down menus. In this way each fact in the history and physical exam will be recorded as a discrete datum point, as is the information on assessment and treatment. Thus, medical records will be easy to scan and analyze and profiles can be generated of exactly what Dr. Theo does for a given problem, what kinds of test he orders, what treatments he recommends, etc. This information will allow the insurance companies and government agencies to make decisions about reimbursement, licensure and certifications based upon whether I have followed the “guidelines” imposed by bureaucrats. Physicians will be required to practice according to the “guidelines” thus reducing medicine to somewhat less than a science and very much less than an art. Mediocrity will pay. There may even come a time when computer programs can be written that generate treatments without any professional decision-making. “Cookbook medicine” will have arrived. It may only be accurate 80% of the time, but, hey, that’s close enough for government work.
The Gods of Liberalism Revisited
The lie hasn't changed, and we still fall for it as easily as ever. But how can we escape the snare?