Live Less and Falter: A Prognosis for American Health Care As We Approach the Rubicon. Prologue

Oh, look outside the window, there’s a woman bein’ grabbed

They’ve dragged her to the bushes, and now she’s bein’ stabbed

Maybe we should call the cops and try to stop the pain

But Monopoly is so much fun, I’d hate to blow the game

And I’m sure it wouldn’t interest anybody

Outside of a small circle of friends

— from `Outside of a Small Circle of Friends`, by Phil Ochs (1967)

ologue: Why I Left Electronic Medical Recordkeeping

I was unsure whether to expect the best of times or the worst of times with my introduction to electronic medical records (EMRs). My group practice of obstetrics and gynecology had been considered a premier group in our town for many years, and we were supposed to be excited to have been selected as among the first private offices to join into Yale-New Haven Hospital’s conversion to the Epic Systems Corporation (Epic) EMR. For years, I had heard numerous positive comments from colleagues and residents who used VistA, the EMR of the Veterans Health Administration. By all accounts, VistA was quite user-friendly, easy to learn, well-supported, and an overall plus for both physicians and patients. In contrast, more recently, I had heard lots of negatives about academic hospital-based EMRs, that they were dysfunctional, a huge time sink and a pain to use. The benefits of the EMR, for example, that all of your medical information would be instantaneously accessible to of all your care providers, certainly have been prominently trumpeted.  So I approached `opening day` with cautious optimism, yet with eyes wide open.

On the very first day of my orientation, a giant red flag immediately emerged. We had been told that `experts` had tailored systems to a physician’s particular specialty and needs, which I was quite pleased to hear. A technical specialist was showing my group our `specially designed` order set, which was supposed to streamline the ordering of tests that obstetricians and gynecologists would regularly request. My hopes were smashed, alas, when I saw that the second test item listed on the specialized gynecological order set was for `Bence Jones proteins`. This was like seeing a lobster soufflé as the second menu item at the new McDonalds in town. Bence Jones proteins are a test for multiple myeloma, a hematologic disease of the bone marrow. Now indeed, I had ordered that test once, in 1975, when I was an intern in internal medicine. Not only would no gynecologist in the United States ever natively order such a test, but indeed many would never have even heard of these proteins. Clearly, no meaningful ob/gyn input had been implemented — so much for `user-centered design` here. I felt both bemused and betrayed, and my antennae went on high alert.

My next enlightenment was in the realm of patient privacy. One of my patients came in for an examination while I was away at a conference. The patient had a fairly minor problem with a vaginal infection, and she felt perfectly comfortable seeing a partner in my group, who treated and cured the vaginitis. My patient had been consulting with me for years about her lack of libido. Indeed, that was the principle reason for her several most recent visits to my office, and the diagnosis of decreased libido was listed as one of her primary diagnoses. My office staff appropriately entered the details of this current visit, along with other recent visits into the Epic system.

Several weeks later, the patient went to visit her dermatologist for a chronic problem with eczema. The dermatologist is one of the most eminent and respected physicians at the Yale School of Medicine. At the end of the appointment, my patient was given a summary printout of the visit, which is standard protocol in this system. Included on the printout was a listing of all of her primary diagnoses, including the diagnosis of “decreased libido.” She called our office and yelled at my office manager for 15 minutes, “How dare you write that I have decreased libido? It’s none of Dr. So and So’s business, and it’s all over the chart!”

But if that’s your diagnosis, it’s in your chart. All culture results and medications are part of the EMR, too. So if you happen to have a positive chlamydia culture for which you were prescribed azithromycin, it’s right there in your chart, for all with access to Epic to read. Certainly it is appropriate that other physicians who might prescribe medications be made aware of possible drug interactions, to avoid unwanted side effects. But does a patient want to allow a former partner or a potential employer to learn that she has an STD, either directly or through the grapevine?

Physicians have good reason to dislike the implementation of the EMR as well. Although physicians are mandated to switch to the EMR by many hospital and insurance systems, minimal technical support has been provided, particularly to affiliated private practices. When we were slated to start using the Epic EMR, I tried diligently to enter 30+ years of chart information for each patient into the computer forms. As I quickly learned, and had been warned, these forms were hardly designed to be user-friendly to physicians, unlike what I would have expected from VistA. It took me anywhere from 30-60 minutes per chart; I was up all night doing this, and none of this time was reimbursed. So I started having our staff technicians enter this chart information into the computer, as did everyone I know. These technicians are certainly well meaning and earnest, but their medical knowledge is very limited. For example, I would find in a chart that a patient carried the diagnosis of osteoporosis. I knew that she did not have osteoporosis; she had been TESTED for osteoporosis, and the bone density test was normal. However, in the computer she was then listed as carrying the diagnosis of HAVING osteoporosis. Of course this is inadequate, but then what were my alternatives? Was I now expected to pull all-nighters for months on end, again without any payment, to convert all of my charts to a non-intuitive and constricted database?

As I wrote up top, a heavily promoted benefit of EMRs is that having your health care data in a computerized system would be terrific, because your data could be instantaneously accessed from anywhere. For example, what if you have chest pain while you are visiting in San Francisco, and your regular care is in New York? Wouldn’t it be great to be able to retrieve your baseline cardiogram from the computer? It certainly would be grand! Unfortunately, as I was very disappointed to learn, at present this is a major misconception. Currently it is very unlikely that the computer system that your physician or hospital in San Francisco is using could “speak” to your local New York system. A large and growing number of totally different, discordant EMR systems are in use across the U.S., so much likelier than not, your cardiogram would be inaccessible from afar. Even the major hospital systems within the small state of Connecticut cannot communicate with each other — New Haven, Danbury and Hartford are about an hour apart from one another, and are on entirely distinct and incompatible systems.

Along these lines, sometimes even sharing a street address is not necessarily good enough. One of my colleagues recently told me a story about her mother, who had been admitted from the Emergency room of a major metropolitan hospital to the hospital’s intensive care unit (ICU). Unfortunately, the ER and the ICU in THAT hospital used different computer systems.  The ICU folks thought that her mother had been admitted for a kidney stone, rather than a kidney infection, and they started treating her with pain medication instead of antibiotics. Her mother spent a very sick month recovering from sepsis, which had worsened because of the lack of communication. Ultimately and fortunately, my colleague was able to intervene once she realized the breakdown that had occurred.

The importance of interoperability, this ability to electronically share records at a distance or across systems, powerfully hit home with me a few years ago, when I learned of the death of an eminent colleague whom I had known for a very long time. She was at the peak of her career, by all accounts quite healthy, and on vacation 2000 miles from home, when suddenly she became acutely ill, apparently out of the blue. Within 72 hours, she had died. At her Memorial Service, most of us were still stunned, incredibly sad, and wondering `What if?` It is exactly this type of setting when interoperability would be most utterly crucial, when someone is far from home, unknown to anyone local, and suddenly requires emergency care. The development of a highly functional EMR network that could provide essential health information in this scenario would go a long way towards justifying the premise and promise of EMRs. But again, such a network is certainly not here today, and from what I’ve both read and heard, won’t be in place anytime soon. Full interconnectivity of EMRs needs to be established as an indispensable and highest priority requirement, just as it is for telecommunications.

However, what finally clinched my decision to abandon the EMR is that I really like listening to my patients. I like to look at them when they are telling me their problems; it gives me a lot of information, so that I may be of use to them. But if I were required to use Epic, I would be a servant of two masters, with the computer designated as the dominant party. If I were forced to enter data into the computer non-stop, I could not pay my patients nearly the attention that they deserve. And unlike Truffaldino in Goldoni’s play, my role as the servant would then lead to a tragic, not a comic ending, according to my value system.

So I have elected to remain a dinosaur, and have exited from the EMR-business complex. I tell my patients that I am maintaining my office charts. What goes into my record stays only in my records, unless my patients tell me otherwise. I’d rather spend that extra time listening, so that I can be their best doctor possible, at least during the next quarter – quarter-century, that is.

But I could not go gentle into this good night without trying to be of further use. I felt a moral and a personal obligation to dig into matters somewhat more deeply, on two counts. First, I wanted to connect the dots and clarify to myself and to others how and why the practice of medicine is evolving so rapidly now, and identify the most essential pressing issues.  Second, I wanted to foresee how recent systemic changes would more likely than not play out over the longer term if they were left largely unchecked. I am very concerned that a series of short-term directives will lead to many unintended consequences and a badly fissured health care universe within a few years, barring substantial changes in the implementation details of the Affordable Care Act (ACA).

With apologies to Michel de Montaigne, I will try to convey my viewpoints and discoveries as best as possible in a series of essays. The next entry provides very brief mini-Abstracts for each essay. Some of what I discovered was quite illuminating, and in some instances, shocking to me.

As a sidebar, I’ve included a short Cheat Sheet that should help to elucidate some core background and related terminology on the HITECH and Affordable Care Acts that underpin much of the recent flux in health care. Part of this includes the `official` word on the distinction between the terms `electronic medical records` (EMRs) and `electronic health records` (EHRs). Although most physicians whom I know tend to use EMR in a generic sense here, as I do above, the current preferred term for broad context is the electronic health record or EHR, which I adopt in the essays below.

Finally, I do believe that it is still possible to improve the landscape significantly, both for patients and for doctors, without dismantling the core framework and paradigm of the ACA. However, time is very much of the essence, as is substantial political will. So with that optimism in mind, I will also attempt to propose a few suggestions that could potentially be helpful to the cause, or at the very least, kindle or catalyze a couple of new approaches.