A chance encounter with an unhappy reader (a physician) spurs a flood cliches about why doctors are "justified" in their refusal to move out of the dark ages
Michael S. Victoroff, MD
Homeland Security, take note: The other day, I was attacked in an airport. The attacker, in this case, was a friend of mine who serves on the Council on Ethics and Judicial Affairs of a prominent professional organization whose identity I am forbidden to reveal under HIPAA regulations; however its initials are "AMA."
We happened both to be meditating to the drone of that prayer wheel of modern transportation known as "the baggage carousel" when we noticed each other and passed what turned out to be the duration of an appendectomy in carousel-side consultation. Our encounter illustrated that at least one of the grand customs of a bygone era — professional courtesy — is still honored by some physicians of our generation. I say this because, although my friend was kind enough to provide me with some impromptu diagnostic services, he has not so far sent me a bill.
"Out of your mind"
His diagnosis was, essentially, "You are out of your mind!"
He was referring to an opinion I expressed a few months ago in this column, which I shall repeat: "In most settings today, a physician's failure to use an electronic medical record constitutes malpractice."
As a physician, I am permitted to make garish, categorical statements like this, and naturally I am used to being attacked for them. However, as an ethicist, I found myself nonplussed at the form my friend's challenge took: He began to invoke facts. Most readers understand that many excellent ethical arguments only become hampered by the introduction of facts.
In this case, my friend started to list reasons why electronic medical information systems were not ready for physicians, and why physicians were not ready for electronic information. Both of these points I cheerfully concede. Nevertheless, I don't see how the gigantic barriers to implementing electronic information systems excuse the woeful inadequacy of what passes today for medical records.
My friend's point, calmly and thoughtfully presented, was founded on the important ethical principle of utilitarian pragmatics. I can paraphrase it this way: "You'd have to be a moron to invite a million lawsuits over the damage created by lousy medical record keeping, when everybody knows it's the standard of care!" To illustrate why it's the standard of care (more's the pity), my friend, who is well versed in this topic, recited his own list of garish, categorical statements, all of which I accept as essentially true. Since I am the one doing the typing, I get to paraphrase them in my own words.
EMRs are too expensive for doctors. Well, not compared to, say [fill in some kind of fancy medical device for which there is a CPT code and which pays for itself in five months], but they're far more costly than, say, telephones, representing that horrid category — Unreimbursed Overhead. If "somebody" (payers, hospitals, the IRS) would "provide" (give us for free) EMR systems, they would be installed in every forward-thinking private practice overnight, even if no doctor ever used them. Until then, electronic information systems will remain an exotic technology only seen in every other industry in the civilized world — until some insurance company decides to pay for them.
EMRs don't talk to each other. This means, currently, that if a patient from an organization with electronic charts happens to transfer to another practice that also has an EMR, all the beautiful, legible data in the first record will probably not be readable by the second system, (statisticians tell me that the chances of this are roughly the same as those of Microsoft publishing the source code for Windows on Napster), and will have to be manually re-entered — probably under the wrong ID number. No, given our mobile population, it's safer not to get people started with good records, if they are just going to be wasted later on.
EMRs make mistakes. According to the famous Aristotelian principle, "garbage in — garbage out," we should be very cautious about entrusting vital information — say, a list of all of the patient's current medications — to the vagaries of a machine. Errors in data entry, storage and retrieval may occur at any level in the system, with the potential of causing harm if we begin to depend on it. No, it's much safer to stick with the current system of not having that information available at all.
EMRs are hard to use. Well, not so hard as [fill in some kind of fancy medical device for which there is a CPT code and which pays for itself in five months], but remember, doctors don't type, and everybody knows that typing is how you make computers work. I have personally talked to over a billion doctors who swear they are only waiting for the perfection of "voice input technology" before they install EMRs in their offices. These are idealists who labor under two catastrophic delusions. First, that a useable medical record can be created out of long strings of prose utterances, which it can't. Second, that their own particular prose utterances accurately reflect the thoughts and intentions in their brains, which they don't. Ask any professional transcriptionist how much editing and correcting has to be done before a physician's dictation is safe to print. Believe me, the last thing any doctor wants to see in court is an accurate record of what he or she actually said. No, it's much safer to stick with records that nobody can read.
EMRs can't replace professional judgment. Absolutely true. According to the principles of evidence-based medicine, the current evidence seems to be that lots of us, faced with a choice between hunting for the latest silly guideline made up by academics at the National Institute of Something or Other, versus just improvising, will typically do whatever we remember from our most recent imprinting from the pharmaceutical industry. Another reason why things are fine as they are.
Dealing with baggage
My friend went on in this vein for about another tonsillectomy and a half, demonstrating with one fact after another why most medical practitioners and institutions still don't use electronic information systems for clinical purposes. As our luggage arrived, I was convinced that he had conclusively shown how an entire industry can be guilty of malpractice.
Thus, from a purely factual standpoint, it's much easier to defend rotten, inaccurate, illegible, nontransferable, incomplete and misleading medical records — I'm just addressing the malpractice implications here — than it would be to start working on remedies for the admittedly daunting problems of present and future EMRs.
After all, if the profession will just stick together, we can always find room in the "standard of practice" for records consisting of illegible 3x5-inch cards.
I can see how it might create an awkward situation if we were to blame doctors for the persistence of what we all know, when we are patients, to be an intolerable state of affairs regarding the quality of our own medical records.
Building on my friend's analysis, it seems that lots of the impediments to EMR adoption have their roots in the incentives of that nonsensical, pay-as-you-go, piecework reimbursement system, "CPT-for-service" health care. (Don't confuse this with the slogan, "private practice," which I believe represents a collage of different things, some valuable.) Eventually I expect the CPT dinosaur to extinguish itself, except as a cultural relic in benighted preserves like Aspen, where they still don't have Wal-Mart. Until then, I guess we can agree that the real villains responsible for doctors' horrendously unsafe and ineffective record keeping practices are — yep — insurance companies.
Michael S. Victoroff, MD, is a family practitioner in Denver who has also been an HMO medical director.