We trust computer technology to solve problems, save time and money, and improve our lives. It has. Why didn’t it work with electronic health records?
EHRs are costly, clunky, error prone failures we seem unable to fix. It’s as if we took off in a hastily designed rocket, realize we need to come back, but are stuck in orbit without a reentry plan.
The Obama administration set aside tens of billions in 2009 to forcibly drag doctors and hospitals out of the Stone Age of paper into the brave new world of bites and bits. It promised a Nirvana of heath care quality, efficiency and cost savings. Hundreds of billions more were spent by hospital systems, too, under government mandates. In retrospect much of that money was wasted.
We got lots of bits and bites, but no Nirvana. Instead, we got higher costs, more errors and no improvement in care, perhaps worse care. We forced doctors to spend three-quarters of their time staring at screens instead of looking at patients face to face. We got complex decisions trees that turned high-value professionals into clerks. What went wrong?
We asked the wrong question. It was therefore impossible to get the right answer.
Today, I am with my family catching a plane in Sydney, Australia. At check in there were 30 computer touch screens lined up to issue us boarding passes and luggage tags. We did it all ourselves without any airline staff assistance.
We punched in our names and flight numbers, answered questions about guns and flammables, printed out tickets and luggage tags and put them on our bags. Three hundred passengers spent at least 10 minutes each in this data entry and tagging task, perhaps 50 man hours of unassisted work was done by we passengers for this one flight.
There were five (not 30) human staff who looked at our tickets and passports, weighed and put the bags on belts and pointed toward the gates. Took about a minute. A few years ago there would have been 30 airline staff doing it all, and no touchscreens.
Assuming employees get $30 an hour, that’s $1,500 saved for each and every flight. With hundreds of flights from each airport that’s big money. Employees cost a lot ongoing. Touch screens work for years on one investment. We, passengers, were the happy, healthy — and unpaid — labor that made it possible. The airline’s question had been, “How can computers save money and employee time on passenger check-in?” It got the right answer by asking the right question.
In medicine, the customer is the patient, not the passenger. If we could get patients to check into the medical office, hospital or emergency room, go to a touch screen, populate the computer screens with their correct diagnosis, order their tests and imaging and prescribe their own treatments that would be peachy, but unlike passengers, patients can’t do that on their best days. There is almost nothing in medicine that can be done, ordered or documented by the patient/customer. Doctors and nurses do all that.
Before the EHR, I dictated hospital admission histories on a phone and a typist getting $30 an hour typed them. I do that on an EHR now and it’s slower. It takes me triple the time it used to. There is a complex template used, not much like the way I think about care.
Similarly, I used to hand write orders and give them to a clerk. It took but a few minutes. Entering it all by computer is complex. The EHR does not allow me to just write what I want. It offers drop downs, many suggestions, and reminders, and pages of choices to click and to select options, not to mention all the time taken to just get in and out of the triple layer of security built into every such program. That alone takes more time than handwritten orders used to take.
So in the hospital I have become a very highly paid clerk. It is as if Qantas required the pilot to do the data entry for billing and boarding of each passenger. Insane, you say? But that’s exactly what current EHRs do in medicine.
When a business buys computer systems it knows what it wants it to do. So do doctors. We want to know how to make it easier and cheaper to deliver better quality care. That is the right question. But the designers of our EHRs were not led by doctors and had other questions dictated by government and insurance goals. They wanted to mine physician medical knowledge for government health statistics and insurance billing purposes. No wonder we got the wrong answer.
There are doctor-designed EHRs that are agnostic to billing and statistical data mining. They work very well but are only used by private Concierge and Direct Patient Care practices that concern themselves only with patient care and not with data or insurance billing. Those doctors don’t run hospitals, but maybe they should.
Dr. Thomas W. LaGrelius serves as president and chairman of The American College of Private Physicians. LaGrelius owns a concierge practice and is paid directly by and works directly for his patients.