Nearly all of my physician friends and colleagues have entered the EHR world in the past few years, only to report that they just feel as if they are on the short-end of an escalating beat-down. The joy of patient care is being ripped away by increasing administrative demands that are often counterproductive and superficial. Many of my contemporaries who have incorporated their practices into a local academic hospital complex are being treated like titled grocery store clerks, forced to see significantly increased numbers of patients and/or generate specified levels of revenue, regardless of acute patient needs. Doctoring is being forced to become increasingly programmatic and color by number, dehumanizing the doctor-patient dynamic. Non-revenue generating counsel to patients, for example, important discussions of potential side effects or the impact to one’s quality of life, are de facto being badly punished. Most of my colleagues who are at least 60 years old are actively thinking of getting off of this treadmill in the near future, either by retiring altogether, or at least by leaving the practice or teaching of medicine. Who is winning? The hospitals (as a business); the insurance companies; the associated electronic software and Information Technology industry; and legions of administrative intermediates. Who is losing? Short term, doctors; longer-term, patients, because of the loss of continuity of care, of a doctor truly vested in them for an extended period, and because the incentives play against the doctor getting the care right, so long as the care is administratively plausible or justifiable. Unchecked, I foresee an acceleration towards two-tier medicine, and I do not believe that such a resolution was the intended goal, or in society’s best interests.
I certainly recognize the Realpolitik compromises needed on the part of the administration to get the insurers and IT companies (that created the EHRs) to the dance. The very fate of this administration’s signature policy initiative rested on this crucial pivot point, with huge political as well as societal ramifications. But although the basic structure of the Affordable Care Act brings both promise and humanity, the initial implementations, if continued for any extended timeframe, will destroy much more of lasting health care worthiness than it will create. There still is time, if we act expeditiously and decisively, to significantly change yet preserve the system while creating much better long-term outcomes for patients and doctors. And we can do this in a way that will still allow quite reasonable profits to be made by the business side of the model. How? Change electronic health records to incorporate the best features of both the VA’s VistA and the private EHRs. In particular, mandate a high level of user-friendliness for both doctors and patients, as VistA presently has, as well as significant functionality to broad health care as embodied by the Meaningful Use requirements. Impose a public utility structure on the EHRs, on the basis of Common Good, to ensure that these mandates be met, and also to ensure full interoperability, ASAP. Facilitate long-term continuity of care, rather than emasculating it by encouraging frequent or yearly changes of insurers (and docs). Impose sensible privacy policies that protect patients, with serious penalties for violations, not the cost of doing business. Record and centralize personal histories on all Americans. And recognize that doctors are not commodities, and that there is much more at stake than a budgetary exercise.
Is this achievable? I believe, or at least hope so, if there is enough political will, plus some cross-the-aisle recognition that both sides have much to gain (and much to claim) if the system is extensively altered for the better. So the opportunity still remains open, but the time is now, not in ten years. Bon courage!