I haven’t made it a secret in these posts that I’m a big fan of electronic health records (EHRs).  I think they improve patient care, and I think that paper medical charts will eventually go the way of the vinyl LP.  (For those of you born after 1980, I’m referring to an archaic music recording medium.  Yes, even more archaic than the CD.)

I’ve also written before about the very slow rate of adoption of EHRs by physicians.  Well, it turns out hospitals are no better.  A study in this week’s New England Journal of Medicine surveyed American hospitals for their use of EHRs.  The results were underwhelming.  Fewer than 2% of U.S. hospitals have electronic records in all clinical units.  Another 7.6% of hospitals have EHR in some units and not in others.

The barrier most frequently cited by hospitals for EHR adoption was, not surprisingly, the same barrier physicians cited: cost.  EHRs cost money, and in a marketplace which reimburses for quantity, not quality, who is going to make a major investment in better patient care?  Insurance companies pay a fixed price for each service provided, whether the outcome is fantastic or marginal, whether the patient is delighted or frustrated.  The financial incentive in such a market is to increase quantity as much as possible and to provide quality that is only good enough to avoid lawsuits.

Policy wonks and politicians (in both the current and previous administrations) hope to solve this problem by government subsidies for EHR adoption.  An article in yesterday’s Wall Street Journal cites a Congressional Budget Office estimate that over $20 billion will be spent by the federal government on health-information technology between 2011 and 2015.  EHR companies are naturally delighted as it will increase their revenue enormously.  Most physicians and hospitals won’t object either, since they will be handed a valuable tool at taxpayer expense.

I think patients (not to mention taxpayers) should be more skeptical.  First of all, the price of EHRs will skyrocket if they are subsidized.  (See the price of healthcare after Medicare was enacted.)  Second, there is little reason to believe that those who are handed a “free” EHR will use it as productively as those who invested their own resources to buy it.  After all, those who see the most value in it have already voted with their dollars; those who see the least value in it will require the largest subsidy to buy in.  So the cost will inevitably be greater than expected and the benefits to patients much less.

CDs replaced LPs because music fans were willing to pay a few more dollars for better music.  EHRs will inevitably replace paper charts.  But it will happen when patients (not insurance companies or government) are allowed to pay a little more for better care.

Learn more:

Wall Street Journal article: U.S. Hospitals Slow to Adopt E-Records

New England Journal of Medicine study: Use of Electronic Health Records in U.S. Hospitals

My previous post on EHRs: Only 4% of American Physicians Have Electronic Health Records

The New England Journal of Medicine and the Massachusetts Medical Society released a video this week of a panel discussion on U.S. health policy.  I thought it was a fascinating and intelligent discussion by representatives of all the stakeholders in the debate.  The discussion covers many topics critical to American healthcare, including the dwindling numbers of primary care physicians, adoption of electronic medical records, providing care to the tens of millions of uninsured, and the escalating costs of healthcare.

This is a handy primer on a topic that will become increasingly important in the next decade.

The video is about an hour long, and is open to non-subscribers.

Shattuck Lecture:  Health of the Nation – Coverage for All Americans

This week, a large national survey of physicians’ use of electronic health records (EHRs) was published in the New England Journal of Medicine.  The results generated a lot of attention in the general media.

The good news is that physicians with EHRs are largely very satisfied with them and believe that EHRs improve patient care.  The bad news is that nationally only 4% of doctors use EHRs.  The largest barrier cited as preventing physicians from adopting EHRs is the expense.

In any other industry, that would be unthinkable.  Imagine if a hotel came up with an easier way for guests to make a reservation.  If the new technology was very expensive, only those hotels with the most resources would be able to afford it initially.  But eventually the price of the new technology would drop and almost all hotels would use it.  Within a few years the older way of making reservations would be gone.  That’s why you can’t listen to an LP record anymore or find a public phone booth or send a telegram.  Better technology spreads like wildfire through a marketplace, regardless of how expensive it is initially.

So if EHRs are better for patients, why the slow adoption?  For that matter why haven’t CT scans dropped in price?  Or pacemakers or MRIs?  Most medical technology should be dirt cheap.  My son’s laptop is much more powerful than the desktop PC I had in high school and cost less.

The answer is that the insurance model corrupts the incentives that work in other marketplaces.  By fixing the price for care, insurance companies make it impossible for doctors to make more money by providing better care.  Doctors in the insurance model can only make more by seeing more patients.  In such a system there’s no reason to invest in an EHR, because the investment will not lead to increased revenue.

The same perverse incentives keep prices high.  Since the insurance company sets the price for a CT scan, there’s no incentive to drop the price for a CT to compete against other providers.  The incentive is to get as many patients through the scanner as possible.  So while Dell keeps making better computers cheaper, CT scan prices stay the same.

Now academicians and lobby groups are clamoring for insurance companies and government to pay doctors to adopt EHRs.  But insurance companies and government got us in this mess.  Having them subsidize EHRs misses the point, and would keep EHRs expensive forever, like CTs.

A few doctors dedicated to excellent care have already taken the financial risk to invest in an EHR.  Some of us have abandoned our relationship with insurance companies so that we can work for our patients.  Some patients who are also discriminating consumers have looked for such physicians and are willing to pay more to see them.  More doctors and patients, increasingly dissatisfied with the insurance model, will hear about us and follow our lead.  That’s the solution.

Learn more:

New York Times article:  Most Doctors Aren’t Using Electronic Health Records

New England Journal of Medicine article:  Electronic Health Records in Ambulatory Care — A National Survey of Physicians

Last month BusinessWeek had a fascinating article about cholesterol-lowering medications.  The article also teaches us how we should calculate a specific medication’s benefit and harm, and how pharmaceutical companies manipulate our opinions by reporting benefits in percentages but side effects in absolute numbers.  If you want an interesting lesson in evidence-based medicine, or just in cholesterol treatment, take the time to read it.  (My only major objection to the article is the headline, “Do Cholesterol Drugs Do Any Good?”  Of course they do, and the article doesn’t even argue that they don’t.  A more accurate headline would have been “How Much Good Do Cholesterol Drugs Do?”)

Here are the take-home points.

• Statins definitely prevent strokes and heart attacks in people at high risk for strokes and heart attacks.
• Statins also lower cholesterol, but no one knows if that’s how they prevent strokes and heart attacks, or if they prevent strokes and heart attacks through some other mechanism.
• The greater a patient’s risk for stroke and heart attacks, the greater the benefit she derives from a statin.
• Patients who have no heart disease and no risk factors for heart disease (these are non-smoking men under 45 or women under 55 without high blood pressure, diabetes, or first-degree relatives with heart disease) are at such low risk from heart disease (regardless of their cholesterol) that their benefit from taking a statin is likely to be very small, and only realized after taking a statin for many years.  At that point the side effects of a statin, even if mild and rare, may actually be more significant than the tiny benefits.

(Thanks to Harriet E. for pointing me to the BusinessWeek article.)

Tangential Miscellany:

At the risk of horrible immodesty, I just have to brag for a second about electronic medical records (EMR).  After my post a few weeks ago about the bad news about Zetia and Vytorin I wanted to review all of my patients who were taking the medications to make sure that they were on it for appropriate reasons.  With our EMR I was able to generate a list of every patient on Zetia or Vitorin in a few minutes.  Try that with paper charts.

This week’s New England Journal of Medicine publishes a health policy report about electronic health records (EHRs).  The article reviews the potential benefits of EHRs to patients and to physicians and laments that as of 2005 only about 23% of physicians used them.

The reasons for the slow adoption of EHRs provide an instructive illustration of deep problems in our healthcare marketplace.  EHRs are expensive, but they hold the promise of allowing better patient care, fewer medical errors, and eventual cost savings.  In the delivery of any other good or service a new technology that offers these benefits is adopted quickly and becomes ubiquitous.  That’s why pay phones and LP records have nearly vanished; they were replaced by cell phones and CDs.  Why then the stubborn persistence of paper charts?  The reason is the dysfunctional way in which most healthcare is bought.  The cost of the vast majority of care is paid not by patients, but by third parties, either private insurance companies or government entities.  These payers also set the price that can be charged for services.  Unfortunately, this applies not just for major unforeseen expenses, like catastrophic illnesses or hospitalizations, but also for routine and preventive care.  The effect is that there is no financial incentive for most physicians to increase the quality of the care they deliver, just the quantity.  If the price for the service is fixed, doctors can’t make more by taking better care of each patient; they can only make more by seeing more patients.  So why would doctors invest the time and the capital in an EHR that provides better care?  Any cost savings resulting from better health would benefit the insurance company, not the doctors.  Paper charts after all, are worse for patients, but don’t slow the doctor down.

It’s only when patients pay for their own care that the competition and balance present in all other marketplaces returns to healthcare.  When patients and physicians set the price, patients have a strong incentive to ensure that the care they pay for is excellent, and physicians have a strong incentive to invest in whatever technology will deliver quality care.  That’s why our office had an EHR from the day we opened in 2003.  While national physician groups were lobbying for government or insurance subsidies for EHR purchases, my partner and I simply bought one, confident that what was best for our patients would eventually be best for our practice.

It’s you, our patients, who make possible our EHR and our dedication to old-fashioned attentiveness powered by twenty-first century technology.  Thank you.

Tangential Miscellany:

A happy Father’s Day to all us dads!

Most of my patients know that I’m a big fan of technology.  From electronic medical records to viewing diagnostic images over the web, I love finding tools that help me take better care of patients.  A study in this week’s New England Journal of Medicine is an important cautionary tale that reminds us that new technologies should always be tested rigorously.

The study examined the use of a technology called computer-aided detection to assist radiologists in interpreting screening mammograms.  Computer-aided detection involves computer software that analyzes mammogram images and identifies suspicious abnormalities.  It was approved by the FDA in 1998 and has gained popularity since then.  The study was also covered in yesterday’s Los Angeles Times.

The study found that the technology actually decreased accuracy when compared to a radiologist reading the mammograms without computer assistance.  Computer assistance lead to an increase in potential abnormalities being identified that overwhelmingly turned out to be benign.  The number of women recalled for additional imaging increased by 32% and the number of biopsies increased by 20%, but the number of actual cancers detected did not increase.  So computer assistance only led to unnecessary procedures and didn’t assist in diagnosis.

So for now, we should leave mammogram interpretation to trained humans, and let computers do what they’re best at – connecting you to educational articles from your doctor!

Tangential Miscellany:

Drum roll, please.  The following are the winners of the Pedometer Project for March.

The winner with most steps was Sari A.  In her honor I’ll be donating platelets at Cedars-Sinai on April 12.

The winner for most improved walker in March was Victoria W.  In her honor I will volunteer at the Simms/Mann Clinic on April 18.

The winner for weight loss was Douglas C.  In his honor I will volunteer at the Simms/Mann Clinic on May 2.

My congratulations to all the participants!  The Project will continue through the end of April.

SureScripts is a company that allows physicians’ offices to send prescriptions to pharmacies electronically. It works with most electronic medical records (EMR) systems, including the EMR our office uses.

A recent article on eWeek.com reviewed SureScrips’ efforts to increase the number of physicians that are sending prescriptions electronically. There are many benefits of avoiding handwritten prescriptions. Legibility and avoiding errors due to poor handwriting is the most obvious benefit. Convenience is another. The article cites more.

Now, physicians using most EMRs can skip that paper-based step because prescriptions will be sent directly from the doctor’s office to the pharmacy. Pharmacies can also send refill requests back to the physician’s office for authorization.

Such connectivity will not just improve convenience, said Hutchinson, it will lead to enhanced care. For example, in February, SureScripts announced a plan to provide patients’ medication history to authorized physicians; this information can help doctors choose the best medication regimen.

Increasingly, doctors are realizing that quality care is based on reliable information, and that information can not be reliably stored or transmitted on paper.

In his State of the Union Address this week, the President specifically praised electronic medical records.

We will make wider use of electronic records and other health information technology, to help control costs and reduce dangerous medical errors.

Our office has had electronic medical records from the day we opened, three years ago. I believe that electronic records make possible improvements in patient care that are impossible with paper charts. Automatic checking for drug interactions and secure access from remote locations are just two examples. Our office has been such enthusiastic proponents of electronic records that the company that makes our medical records software, A4 Health Systems, published a case study of our practice.