I was sitting in class the other day learning about the fine points of one of the electronic medical record (EMR) systems I would be required to work with and being spoken to like I was in second grade. I had to tab from screen to screen, click various radial buttons—no, not that one!—and try to comprehend a workflow that had nothing to do with the way I process information. Over the next few weeks I would be spending hours creating my own personal lists of standard statements to ‘save me time’ and ensure maximal coding potential. I would be helping create records that meet the payers’ expectations—records that are so voluminous in size and so excruciatingly detailed, and so impersonal and repetitive, that paradoxically they will have lost much of their clinical utility.
I am representative of a torrential movement within medicine—to standardize, to automate, and, ultimately, to depersonalize.
If I try to unravel how we got here, I have to go back about 20 years. The EMR, as it currently exists, is simply a direct but unintended consequence of the relative value unit (RVU) payment system. I was a medical resident when the RVU system was proposed and published. I still remember intently reading the article in the New England Journal of Medicine outlining the rationale for the approach. I had no idea I was witnessing the beginning of the end of medicine as I had experienced it to that point.
Everything about the RVU system appeared well-meaning at the time—finally, cognitive work would be valued on a par with technical work. However, little did we know that the devil was in the implementation, and that unintended consequences were inevitable.
It is easy to prove that you have done something technical—a patient either did or did not have his or her knee replaced. It is much harder to prove that you have spent time and effort thinking. So, although it takes as much education and experience to recognize amyloid cardiomyopathy as it does to learn to set a bone, the act of arriving at a clinical diagnosis is not as amenable to counting or timing (as you can with various procedures) for purposes of equalizing work units.
So, the act of thinking had to be deconstructed into chunks of data that contained enough buzzwords to satisfy a reader (without any understanding of the clinical dilemma at hand) to judge whether or not any, a little, or a lot of effort was put into a patient interaction. Synthesis of data was no longer prized—indeed, it could cost you valuable coding points and could make you vulnerable to accusations of fraud and abuse. What was prized was proving that what you did was hard and took time.
It is obvious, of course, that the mere fact that a patient is referred to a cardiologist (for example) should suggest to someone that the patient’s problem is complex enough to require specialty care. Whether or not the cardiologist documents checking the patient’s ears for wax is actually not germane to this consideration. That patient’s problem was difficult enough, scary enough, unusual enough, or recurrent enough that the referring physician felt compelled to seek care assistance. The problem is by definition hard, and it will take time to see the patient.
However, we did not recognize the downstream consequences of not standing up for a more thoughtful approach from the get go, and we all began to dutifully comply with the documentation requirements. At first it seemed logical to write down what we were actually doing and thinking so as to create a more complete record. Some shift in this direction was probably a good thing. However, the task became progressively arduous and time-consuming as the documentation needed to be progressively modified and expanded to comply with evolving standards tied to reimbursement. Medical errors did not decrease, and patient care did not improve. Instead, we were writing or dictating more and more and more while effectively saying less and less and less.
Enter the EMR. Billed as a godsend to physicians, these systems were supposed to make documentation easier, make patients safer, and increase reimbursement. The cost equation for EMRs is favorable overall, with most systems reducing overhead costs and facilitating higher coding levels (because along the way we were forced to hire more transcriptionists and because coding became a bureaucratic nightmare). However, the rest of the godsend promised leaves much to be desired. Adoption is painful, and not just because it is something new: adoption is painful because the vast majority of EMRs have not been built by physicians and do not follow the logic of a medical mind. They are built first and foremost to assist the billing and administration of the practice and to ensure compliance with everything that requires compliance. The doctor part is a means to an end, not the end itself. So, we click through monstrous forms and find applicable sentences from giant pull-down lists, because documentation (not care) is now king.
I am frankly too young to be a curmudgeon, but I can still remember the time when writing ‘normal’ was adequate for an echocardiogram report. One word. Six letters. Infinitely meaningful. That one word told you everything you needed to know about the test and was extremely helpful in transmitting information quickly and efficiently.
The echo report today has to state that the aortic valve was normal, that the mitral valve was normal, that the tricuspid valve was normal, that the pulmonic valve was normal, that left ventricular (LV) chamber size was normal, that right ventricular (RV) chamber size was normal, that left atrial size was normal, that right atrial size was normal, that LV systolic function was normal, that LV diastolic function was normal, that RV systolic function was normal, that the pericardium was normal, and that the ascending aorta was normal—and that you know this because you utilized 2D, M-mode, color, and pulsed-wave/ continuous-wave Doppler to perform the test. Today’s report may better document what was done, but the information presented actually becomes a barrier to appreciating the overall study findings (which may not even be outlined on the report output), diminishing clinical relevance and utility.
As a result, charts are now full of echo reports that take two pages to say one word. They are also full of office visit synopses that are near carbon copies of each other, even though significant health alterations may have occurred. Indeed, it can sometimes take a detective to determine what has actually changed in a patient’s condition. Some medical errors have been reduced (largely because we no longer rely on deciphering physicians’ handwriting and are now relatively free of transcription gaffes), but when they do occur they are more easily promulgated through the system, making them potentially more toxic and with a greater impact.
What started as a good idea—payment for thinking, not just for doing—has devolved into a bureaucratic nightmare supported by an elaborate web of technology. Although I am hopeful that this will improve over time, the transition to the ideal—an integrated universal documentation system linking patients and providers in a seamless, logical, and efficient manner—is still years away.
Hindsight is always 20–20, which is why it is so important to analyze carefully the various possible downstream effects of any change. We might not have been able to envision the existence of EMRs at the time that RVUs were introduced, but we certainly should have anticipated the suffocating documentation burdens that would result. The best chess players are the ones who already know what the end of the game will look like after their first move, but healthcare seems mostly devoid of those types of player.
This brings me to wonder what the unintended consequences of the current healthcare law will be.
We may already be witnessing one major effect: the segregation of healthcare consumers into very clearly defined ‘haves’ and ‘have nots.’ Prior to enactment of the healthcare reform bill, few physicians would have contemplated entering concierge care or dropping Medicare beneficiaries. However, as the debate about costs intensified, and as the ‘doctor fix’ (the correction of payment calculations, the need for which surfaces every year because the original formula that determines payments was flawed from the start) kept getting put off so as not to affect the cost calculations of the Congressional Budget Office, physicians became increasingly concerned about their immediate fate. Reimbursement for care became a hot potato and tore apart the remaining shreds of trust doctors had in the political system.
The reimbursement quagmire remains unresolved to this day, with meaningful reform probably summarily off the table. Ongoing temporary patches are likely to be the norm, because tackling the underlying problem of the formula means adding significant additional burdens to an already stratospheric budget deficit. No politician can risk voting to add a quarter of a trillion dollars to the national debt tab and expect to be re-elected, and the White House cannot afford to reveal that its original healthcare cost projections were based on smoke and mirrors. The revised numbers already put the costs much higher than originally presented at the time of the passage of the bill.
At some point, many frustrated physicians decided to walk away from the fray altogether. Unable to make accurate fiscal projections, doctors found they simply needed to take matters into their own hands and take control of their financial futures in order to survive.
Although the US is repeatedly compared with countries with apparently flawlessly functioning nationalized care systems, the comparisons are mostly misleading. The timing of implementation has a marked effect on whether an initiative will actually work or not. Unlike national healthcare systems in other countries, which were embraced by their local physicians decades ago, the US is introducing its version at a time when it simply cannot afford to pay doctors enough. Under such circumstances, counting on physicians to stay in the system is pure folly.
Eroded physician enthusiasm for universal care is not an issue just facing the US. All countries are in the same pickle—rising life expectancy, more and more expensive and elaborate therapies, and consumer desires, all wrapped up in an iron-clad system of intertwined entitlements. There is no other solution than to either cut costs or raise taxes—and both approaches affect physicians directly.
When Medicare was introduced, the payments physicians were promised were comparatively generous, making doctors willing allies to the process. If Medicare were introduced today (with its current reimbursement structure), it would be universally shunned by all physicians. The same can be said for payments tied to universal care systems in other nations.
So, in the US (as in other countries), physician retainers and agreements that patients pay directly at the time of service (with the burden of insurance reimbursement shifted to the care recipient) are becoming more commonplace. In return, patients willing to pay more are allotted more time with their doctors, and those doctors now take on a greater advocacy role with respect to the health status of their patients. This essentially ensures that those individuals who can afford it will experience attentive, courteous, and thoroughly personalized care; it is highly likely they will also experience better health.
The best and brightest physicians will gravitate to this payment model because it simply makes sense. Obviously there are not enough individuals who can afford these types of financial arrangement, so not all patients will be able to migrate to these models with their doctors and not all doctors will be able to attract these types of patient, but there will be enough of a shift to significantly affect physician availability. Layer this on top of another 30 million patients entering the full system and you have a giant physician shortage on your hands—but one that is not experienced by all.
Therefore, a more stark division in care will emerge compared with the one that exists today. There will be one group of patients who will have ready and unrestricted access to a cornucopia of expertise, technology, and the most up-to-date breakthroughs, and a large underclass cared for by an underfunded, crumbling infrastructure overseen by bureaucrats and employing predominantly mediocre physicians who have even less time to spend with patients, and who have access to fewer resources. Yes, we will ensure access to care for everyone—it just will not be very good.
Today’s system is far from perfect, and I am not defending the status quo. However, at least today if you are sick, you still have a reasonable chance of seeing the best and brightest physician in the field, and your scan will be taken on the same machine that just evaluated the millionaire in the next cubicle. In 20 years, the scenario will be vastly different—you will get care, but you will also get exactly what you paid for.
When unintended consequences become reality, it is often too late to unravel the damage. The EMR is here to stay, warts and all. Every healthcare encounter ever written about me going forward will (hopefully) say that my pupils are symmetric, that my affect was pleasant, that I am 5’4” tall, and that I experienced mumps as a child. The fact that I was seeing the nurse practitioner for a sore throat will be mentioned somewhere in there, and that statement will be pulled from some list of common reasons people go to see a provider. My anonymous data will be a resource to some data miner who is specifically interested in 5’4” females with equal pupils who once had mumps. Maybe something useful will be learned—but probably not, because I have been reduced from a unique individual to sliced and diced metrics, even though we all know that when it comes to medicine, the whole is always more than the sum of its parts.
So, we will soldier on with the recently enacted healthcare reform, even though there are many other better solutions to our current dysfunctional healthcare system—ones that recognize the financial realities of all constituent groups, ensure price transparencies, reward innovative care and pricing models, allow co-operation between various healthcare entities, and help motivate patients and providers to achieve better health results. However, ‘better’ is not what we signed up for this time. We predominantly signed up for making sure that we now openly pay for the care of an additional 30 million healthcare consumers without any thought as to what this actually means downstream. Buyer beware.