Full disclosure: I am not a rabid fan of dogs. None rank among my best friends. Perhaps my antipathy stems from a memorable childhood event, when I was chased down the street where I lived by a neighbor’s large and not-so-friendly hound. He seemed to be twice my size, and this explains why I may still hold the record for the fastest 50 yards ever run by a 5-year-old child wearing soggy winter boots and heavy snow pants. Nowadays, many of my canine interactions involve dogs that seem to delight in obstructing my running path or just for the fun of it, will growl, leap upward at my chest or occasionally nip at my shins. I must be a marked man!
My views notwithstanding, in a weak moment, I’ll admit that some dogs are not only truly cute but clever, too. Witness how they avidly fetch sticks, balls and other objects thrown high into the air or onto the surface of water. Kneeling on command, rolling over when asked to do so, they are dedicated companions. In fact, a scientific statement issued by the American Heart Association suggests that dog ownership may have a causal role in reducing cardiovascular disease risk.1
Dogs’ keen olfactory sense has been used by law enforcement agencies to track human scents and detect incendiary devices. Yet as the recently retired, pet-loving, late night television host David Letterman and many dog lovers readily admit, teaching an old dog a new trick can be mighty challenging. After all, they seem happiest when their daily routines stay unchanged. Fetch ball thrown high into the air, jump up, catch and return to owner. Repeat 18 times or until a runner distracts you, whichever comes first.
Humans share this innate behavior pattern with our canine cousins. We generally prefer stability in our daily patterns, whether it’s how we take our coffee, get our daily news or choose our late-night snacks. By the way, who moved my cheese?2
Our Changing Roles
Change can be stressful, and changes in the workplace can be especially trying. For centuries, how medicine was practiced was strictly determined by the practitioners themselves. Doctors set policy and established guidelines. They were in charge of the profession. They were trained to give orders to others and had a hard time being told what to do. The slow, but steady, erosion of the doctor’s role as policy maker became a precipitous decline in the past decade.
Consider a few recent developments that have indelibly altered our medical practice. First has been the sudden emergence of a handful of powerful players in the field of electronic health records (EHRs), whose bloated software programs create enormous patient charts, resembling an auditor’s spreadsheets. Example: A nurse colleague recently demonstrated how it will now take her 11 mouse clicks to complete an order for a pneumococcal vaccine to be administered to a patient.
Second, clinicians have been astonished by the ascendant role of Medicare’s oxymoronic Meaningful Use parameters in determining what constitutes a useful clinical note. Although some requirements make sense and enhance the quality of care being rendered, others merely encourage more meaningless mouse clicking in an effort to achieve pointless targets.
Third, no doubt, will be the introduction in October of the bewilderingly confusing ICD-10 disease classification codes, which should have been coined, The Guide for the Perplexed, after the text written by the 12th century Jewish philosopher, Maimonides. Not surprisingly, this pedestrian system is woefully dated, having been developed nearly 30 years ago. Example: The seropositive status of patients with rheumatoid arthritis (RA) is determined solely by the presence of rheumatoid factor, because the cyclic citrullinated peptides hadn’t yet been described.
Fourth, and perhaps of greatest concern, medical care is being dispensed more and more by mega medical groups and hospital corporations. The steady decline of the solo and small group practice has reached a point of no return. The mantra has been that in order to survive as a clinician, one must belong to a huge organization with deep pockets and large and ever-expanding networks of referring doctors. How else could a practitioner negotiate with health insurers and regulators or be able to afford to install and maintain the costly information technology (IT) systems mandated by Medicare or survive an audit?
The Corporatization of Medicine
These changes have resulted in the science of medicine being replaced by the business of medicine (see Rheuminations, April 2015). Witness the intense business-speak used to advertise an upcoming medical symposium on healthcare hosted by the venerable New England Journal of Medicine: A new world. Competition. Consolidation. Integration. To drive improvement in quality and affordability, U.S. healthcare needs marketplaces driven by competition around real value for the health care consumer.3
A new world, indeed! Patients are now consumers or customers, medical specialties have become product lines or franchises and doctors are providers. Unwittingly, physicians are being transformed into readily interchangeable data-entry workers whose main task is to mouse click all the required buttons to get to the final screen where they can finally sign the record and move on to deal with the next customer. Our practices are beginning to look and sound more like call centers than centers of medical expertise. The precious and declining few minutes that constitute a visit nowadays are being further decimated by the need to engage in data entry or to correct the data entry work of others, because some of our colleagues have found ways to simply ignore the whole process.
Although we may believe otherwise, a careful look at how the EHR industry came to dominate our practices was not a stealth operation. Instead, it was a series of shrewd tactical decisions and complacency on the part of regulators that has led to the current debacle.
The story begins in 2009, when the intertwined relationships between the EHR industry, government regulators, hospital systems and doctors became even more entangled with the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH). Because of the alluring financial incentives it created, this Act spurred the adoption of EHRs by hundreds of thousands of doctors.4 Although the goals of the Act seem worthy, there appears to be a major flaw in its objectives. In the years leading up to its passage, many meetings were held at the White House for the key players in the EHR industry, representatives of the information technology departments of several major healthcare systems and administrators from the Department of Health and Human Services. Their goal was to formulate the basic rules that would be used to create a massive, national electronic records interchange.
No doubt for clinicians, a key—if not the most important provision—would have been the requirement that medical records be readily transferable from one doctor to another across all health systems. When doctors think of medical records, this is likely their primary definition of a well-functioning EHR. It was assumed that barriers would vanish, allowing physicians everywhere to share the up-to-date records of mutual patients. No longer would there be a need for wasteful reams of paper to be manually copied, faxed, scanned and finally deposited into the record as a patient moved from one system to another. In essence, this stipulation would have acknowledged a very critical point, which is, the patient rather than the healthcare system owned their medical records.
Not only was this lofty goal not achieved, but the target for establishing standardized interoperable patient records has been kicked down the road for at least another decade. In political speak, this means likely never to occur. As John Halamka, MD, the chief information officer of the Beth Israel Deaconess Hospital in Boston, succinctly says, “You know, there are forest people, and there are tree people. Standards folks are, by necessity, bark people. They’ll spend a day debating the relative merits of an ampersand or a semicolon.”5
Not much point for us to be barking at the moon.
There may have been some legitimate technical reasons for this lack of consensus. However, because cost-effective care is the catchphrase that constantly rings in our ears, the inability of the government to mandate these changes, especially as it was doling out $35 billion in incentive grants, is surprising. Truly shared records reduces the likelihood of a medication error, a huge source of medical injury, and ready access to lab test results and imaging studies eliminates the high cost of redundant and unnecessary tests.
An Epochal Event
Unlikely as it may seem, this stalemate was the favored choice of the EHR providers. They prefer the lack of universal transferability of records or inoperability, because this allows each of them to create their own electronic version of “gated communities,” where providers can interact only with others who work within the same proprietary record system. For the largest providers, this strengthens their sales pitch. It may be a key reason why one provider, Epic, based outside of Madison, Wis., has already garnered over 40% of the entire EHR market. Once Epic was awarded the contract to create the EHR for the Kaiser Permanente Health Plan of California, a torrent of customers followed.
Recognizing the benefit of being able to reside in the similar gated community as the Kaiser medical records, one by one, some of the largest hospital systems in California followed suit. These included four of the five University of California hospitals, Cedars-Sinai Hospital in Los Angeles and Stanford University Medical Center in Palo Alto. Other major systems followed, including Johns Hopkins in Baltimore, the Mayo Clinic in Rochester, Minn., Northwestern University in Evanston, Ill., and recently, my employer, Partners Healthcare in Boston. Like our canine friends who learn to play within the confines of electronic fences, large hospital systems are learning this trick, too.
As someone who has used an electronic record since 1989, I find the training required for these new systems can still be daunting. I recently experienced all of this first hand, as my hospital converted its easy-to-use, internally developed electronic record system, LMR, to the Epic system. Fourteen thousand employees were required to travel to offsite locations in the Boston area at odd hours to complete the requisite 20 hours of training.
There were several jarring discoveries. Despite the various claims, the key purpose for these records is to capture each and every event or transaction that takes place in a visit. These software programs are essentially giant, powerful vacuum cleaners that suction up all possible medical charges. No crumbs are left behind, hence those 11 clicks to order and bill for that pneumonia vaccine.
The chart interface is both bland and busy; a feat the late Steve Jobs would have mocked and likely corrected. Jobs cared deeply about the user interface. This is what made him such a genius. Instead, we are provided with screen setups that ought to be avoided by migraineurs and anyone who comes to work in a sleep-deprived state.
Another major selling point is that these programs are structured so that each patient visit will collate all the requisite data to achieve the designation of meaningful use. There are even warning buttons reminding you of what still needs to be done to achieve this chart nirvana. A host of templates are available for doctors to create notes and—dare I say—even upcode their visit. Although providing a shortcut, which may not be entirely legal, templates also discourage reflective thinking and stifle the creative analysis of the patient’s condition. Its widespread use endangers the art of the medical note (see Rheuminations, May 2012).
All of these new changes are quite demoralizing, especially when one considers that the likelihood of seeing any significant improvements in these systems over the next few years is practically nil. First, there are no great incentives for these developers to improve their products.
Consider the fact that these EHR systems cost hundreds of millions of dollars to implement. Partners took a $1.2 billion charge for theirs.6 There will be little appetite and no money left to install another program. Healthcare systems will be stuck with their purchases.
Second, the ability for Silicon Valley startups to offer innovative modifications to these systems will be limited because most EHR data are stored in proprietary server networks and not somewhere on the cloud. Access is closely guarded. Finally, the sheer scope of moving massive patient networks from one EHR platform to another poses daunting logistical challenges to the institutions and their staff that should be experienced only once in a lifetime.
Lessons from BlackBerry & Microsoft
It has been stated that disruptive innovation most likely occurs when dominant companies become too large and complacent. Witness Apple’s meteoric rise from near bankruptcy to becoming the largest capitalized company on the planet, zooming past its bloated rivals, Microsoft, IBM and BlackBerry. How did it succeed? By giving the customers what they wanted. When asked why BlackBerry, a once high-flying smartphone company, has gone to the dogs, David Yach, its former chief technology officer, said that he learned in retrospect that beauty mattered, fun mattered. “That was so antithetical to BlackBerry. It was aimed at efficiency, security and all the practical things people in the biz world want.”7
So can we be saved by an innovator who understands that EHR systems should be helpful, not horrible, encourage creative thinking, not stifle it and keep the user thoughtfully engaged, not terribly discouraged?
As we approach launch day, in their hourly e-mails, our IT bosses constantly sing the praises of our new EHR. They foresee a brave new world of data acquisition. However, unlike Pavlov’s dogs, I am not salivating at this prospect.
Simon M. Helfgott, MD, is associate professor of medicine in the Division of Rheumatology, Immunology and Allergy at Harvard Medical School in Boston.
- Levine GN, Allen K, Braun LT, et al. Pet ownership and cardiovascular risk. Circulation. 2013 Jun 11;127(23):2353–2363.
- Johnson S. (1998) Who Moved My Cheese? New York: GP Putnam and Sons.
- Innovations in healthcare leadership: The new healthcare marketplace. NEJM Group.
- Health IT legislation and regulations. HealthIT.gov.
- Wachter R. (2015) The Digital Doctor: Hope, hype, and harm at the dawn of medicine’s computer age. New York: McGraw-Hill.
- Weisman R, McCluskey PD. Athenahealth, BIDMC to craft records system. Boston Globe. 2015 Feb 3.
- Austen I. Behind the downfall at BlackBerry. The New York Times. 2015 May 24.