EMRs May Be An Answer:
What Was the Question?

By

Leonard Zwelling

         The term EMR may be rather new. I hadn’t heard it a lot
until I got to DC. The electronic medical record was one of the many
“innovations” being hawked by the Democrats on Capitol Hill and particularly
within the Executive Branch as a major solver of the problems at which health
reform was aimed: decreasing costs, increasing access and improving quality.
This “EMR” terminology was new for many, but the concept was not new to me at all. After all, I had officed
next to Dr. Mitch Morris former Chief Information Officer at MD Anderson for
many years.

         Mitch for those of you who don’t remember him was a very
young, somewhat brash, exceedingly bright gynecologic oncologist who came at
this problem as would be expected. He was a physician who thought that the power of computers could be harnessed to improve record keeping, better decision
assistance, warehouse of data, be used for population based research and become a
doorway to matching patients with available clinical trials. Mitch was way
ahead of his time for he was not a code writer and thus could not create such a
system but saw himself as the keeper of the idea, the indentifier of a viable
product and an installer of a true computerized system to document patient care
and assist physician decision making.

         As is almost always the case when doctors have to lean on
non-doctors for technology or administrative support, it is not too long before
the vision of the docs and the vision of technical experts clash and the docs
lose. I saw this in Washington, Holcombe and Legacy. Once the money guys and
the lawyers and technical experts get involved the docs are quickly shoved
aside and at best tolerated. This was one of the reasons I went to business
school because I did not want to have to sit across the table from an MBA at a
meeting who would be able to dismiss me as being insufficiently trained to
understand a contract budget.

         Unfortunately, MD Anderson has been in the EMR desert since
this time over 20 years ago, and still does not have an EMR. Anderson does have
a system that the physicians seem to like, but it would not qualify as an EMR
under government standards and this will affect reimbursement rates soon
enough. EPIC is the future for Anderson.

         This same sort of thing happened at Legacy. The organization
had an EMR of sorts but it was fairly primitive and run completely out of
Chicago and given to the whims of a centralized authority that could never
understand what the docs were doing in the clinics.

         I see the same thing happening here at Hermann where I am an
inpatient and have felt the lash of the EMR when orders are not written
perfectly and the centralized pharmacy can delete orders and take a long time
to get a drug to the in-patient floor.

         So what could an EMR have done? What do they really do? Is
this what we need them to do?

         Obviously an EMR is a legal document that chronicles the
care received by a patient. In that it is not really any different than a
classical paper chart except rather than having a doctor write a note, he or
she must click through interminable screens just to record data and then drop
some orders.

         Does it decrease costs? I never understood this claim while
I was in DC, and I still do not. Costs are driven by the aging population, the
overuse of technology, the rising costs of national medical care, the
greediness of the insurers, the doctors, and the pharmaceutical industry. And
finally the incredibly poor national approach we have to end-of-life care. That
approach would be described as none at all.

         I don’t see how the EMR alters this.

         Could the EMR alter access? Only if it allowed doctors to
work more efficiently, improve scheduling, doing the work of coders and billers
so as to supplant people workers with machines. That could happen, but not yet.
Most doctors I see laboring under an EMR have found their work loads increased.

Finally,
would the widespread use of interactive (each can talk to all others) EMRs improve
quality?  Perhaps. If an erroneous
medical order was prevented when a doctor wrote for a drug to which the patient
was allergic, that would help. If researchers could use well-structured
clinical data from thousands of patient records to do comparative effectiveness research to identify
those questions, still unanswered, but the answer to which might change
practice greatly. Sure. I would love to be able to sift through the 50 years of
data in the Anderson data banks to find out how best to treat primary prostate
cancer. When I proposed this to the Division Heads in 2009, when $1.1B of
stimulus money had been set aside for comparative effectiveness, I was met with
a resounding—“meh.” Why? Because if either radiotherapy or surgery were found
to be inferior, one group would be really unhppy. As a close friend said to me
then, “don’t ask a question to which no one wants to know the answer.”

So
that leaves us with the question, what the heck are EMRs good for anyway?

They
are very good for the folks that have created them and install and maintain
them. They are making a fortune as the government insists on meaningful use of
computerized technology if full reimbursement is to be received by health care
providers.

They
are pretty good for the geeky in every medical school class who can now use
their high school days playing computer games to carve out a job of a CIO.

If
an EMR is truly integrated so that patient care automatically drives pharmacy
orders, billing, data gathering and comparative effectiveness research, that
would be ideal, but that is highly variable as far as I can tell.

What
the EMR as currently changed most definitely is that it has done has turned doctors into
clerks, ward clerks into data managers, and the patient into an afterthought to
be dealt with once the record is updated.

As
a patient, I think this sucks and were I still a doctor, I know it would suck.
So here’s an idea. Let’s return to square one and decide what an EMR is
supposed to do. If it is supposed to be the tool to allow physicians more
thought time and patients more and better care, I am for it. From what I have
seen over the past few years and especially the last week, we aren’t even
close.

When I drag my IV pole around the ward for my “exercise rounds”  what I see is nurses, docs and clerks in front of computer terminals and no
one with the patients.

The EMR needs a ton of work, but that work ought to be driven by the needs of the patients and the doctors. 

Leonard Zwelling