Should I be Human, or a Computer?
We discuss the effects of EHR record-keeping on the doctor-patient relationship, especially in the face of severe pressures for physicians to constantly interact with a computer during consultations. The relative diminution of face-to-face contact and of careful and layered listening and observation can significantly hinder effective diagnoses, and lessen mutual trust and openness. A reexamination of several important settings, including treatment of ductal carcinoma in situ and of prostate cancer, and of discussions on how to maintain a healthy diet and exercise balance, illustrate the issues in play.
Franz Kafka, meet Joseph Heller
A byproduct of EHRs has been the loss of patient privacy and the security of personal health data, with little transparency or accountability. We discuss a number of vast scale transactions, involving many millions of EHR records and in some instances, billions of dollars, among industry, the government, insurers and advertisers. Data analytics companies apply advanced techniques to sift through these huge quantities of very detailed medical records, genetic information, and personal information on behalf of their clients. Promises of data anonymization can be and frequently are readily broken. Finally, we truly live an age of acute cyber vulnerability and require much more data protection, given the numerous, prominent and diverse recent instances of large scale data breaches and theft.
Legal Recourse: Slim and None
Prominent health law experts agree that patients have very limited recourse to protect themselves against violations of privacy.
We clarify the usage of the terms electronic medical record (EMR) and electronic health record (EHR), what the HITECH Act, Affordable Care Act, and Meaningful Use are and how they relate, and where Epic Systems fits into the big picture.
Worse than Russian Roulette
We quantify the likelihood of interoperability between two different EHR systems – it is small.
Life Begins at 60
Even if we achieve full interoperability among major hospital systems, the extent of a patient’s complete medical history that exists within the hospital’s electronic record may be (and typically is) minimal.
The recent drop in the number of independent primary-care physicians is striking, with 35% independent in 2014, down from 62% in 2008. We describe why this has come about, and what might be lost, particularly continuity of care with a single provider, along with associated consequences. This has accelerated patient interest in alternative solutions such as concierge care.
Throw Dr. Kildare from the Train
In the last few years, I have seen a pronounced increase in the number of retirements and planned retirements among local physicians from both the academic and private community. In large part, this is in response to a profound recent change in the balance of power and authority within nearly all hospitals from a medical-centric to an administrative and business-centric environment, accompanied by a remarkable migration towards incessant bureaucracy, and by a hard push to meet `productivity goals` that are little more than a volume measurement to pursue Meaningful Use dollars. The severe, often unseemly collateral damage here is that many esteemed colleagues are being treated as commodities or clerks by the hospital staff.
Commoditization: The Rise of the Clones
It appears that physicians have been reduced to generic commodities in the business model of the Affordable Care Act, e.g., independent of competency level or experience. Along similar lines, it is implicitly presumed that there is no consequence to a patient’s medical care if one switches insurers, and as a result, switches treating physicians on a yearly basis. I argue that this model will most likely lead to greater long-term system costs, in part due to the loss of continuity of care from a familiar doctor.
Turnover – Replacement Parts not Equal
When I was young, medicine was considered to be the top career choice by many, and a significant percentage of our smartest and most driven students became doctors. Who will replace these physicians upon their (often accelerated) retirement? At present, the job of doctor is still generally well regarded, but the profession no longer seems to attract nearly as many star students, particularly compared to finance, consulting or entrepreneurial ventures. Recent data confirm a compelling shift.
EHRs – less Love and more Money
The depth of doctors’ dissatisfaction with EHRs is confirmed by many recent studies. Secondly, we examine a potent 2014 research report by RAND that includes an analysis of the role of EHRs in health care, including a comparison of the VA’s VistA and Epic EHRs. RAND concludes that EHRs’ principal successes to date relate to billing, not to medical care, and that short-term rewards and procedures are increasingly favored over long-term benefits and prevention.
The State of EHR Interconnectivity is `Not Shortly`
We discuss the current and near-term future status of full interconnectivity of EHRs, plus some of critical behind the scenes issues that frame the debate and the politics.
Two histories from EHR experiences in the United Kingdom provide important cautionary tales for the U.S., given parallelism along several essential lines. First is the recent failure of the nationwide NHS IT program to connect patients’ records electronically, Connecting for Health, which was “urgently” dismantled in 2011 at a cost $20 billion following years of well-publicized problems. Second is a the history of how the Cambridge University Hospitals NHS Foundation Trust went from being world-renowned centres of excellence and among the safest hospitals in all Britain to a failing enterprise that was placed on “special measures” in a matter of 8 months in 2014-5. An executive report very recently published by the U.K.’s Care Quality Commission detailed, with many specifics, that this drop was to a large extent due to problems the Trust had in implementing its new Epic Systems EHR.
We propose several suggestions to potentially help to resolve some of the identified conflicts and concerns, with a view to the long-term. These address patient histories, patient privacy, treatment of physicians, and regulation of EHRs, and more broadly, systemic reform.
We discuss who is winning and who is losing in our rapidly changing health care ecosystem. Unchecked, I foresee an acceleration towards two-tier medicine, which probably was not the preferred outcome of recent reforms. There still is time, if we act decisively within the near future, to significantly change yet preserve the system while creating much better long-term outcomes for patients and doctors.