Disagreement on Benefits of Computerized Health Records

Robert Pear, writing in the 6/7/2010 New York Times ("Doctors and Hospitals Say Goals on Computerized Records Are Unrealistic") quotes several sources to support his thesis that the Federal Government has promulgated inappropriate expectations and time-lines for implementation of billions of dollars ($34 billion) in subsidies for the purchase of health care computer systems by doctors and hospitals.

Although medical literature is divided on whether computerization benefits medical care outcome quality, it seems that medical and hospital administrators, who have no direct patient care ongoing experience and may be interested in the financial benefits of the subsidy, tend to praise the concept of computerization, though not the Obama administration's expectation and timelines.  For my part, I have never seen a computer that can quickly and inexpensively find a breast or testicular lump, or detect a swollen lymph node in the neck, or read a drug-seeking patient's body language. On the other hand, physicians who spend their time entering data into computer keypads probably won't have the time or incentive to carefully check for those breast, testicular and lymph node lumps and will probably find their patient flow statistics enhanced by giving the narcotic-seeking patients the drugs they want rather than deal with the complexities of care that these patient require.

The real benefits of the subsidy may be China, whose industries churn out huge numbers of (?virus infected?) computers which will be bought by American health care providers and brought into doctors' offices and health care facilities where they will store highly sensitive personal data. As someone whose personal medical data was stolen from a health care facility, I wonder if we really know what we are getting into?

It's The Money, Stupid!

John Roach, the late academic political scientist, said it succinctly: no-one can compromise on matters of principle. We fought the American Civil War, incurring massive losses of life, because neither side could compromise its principles. Some pro-life partisans are in prison for life, because they followed their principles and murdered physicians who performed abortions.

It's not matters of principle which shapes the health care reform debate, it's political money.

Do politicians have commitments to principle? When there is a hot contentious issue with enormous public interest, such as health care reform, politicians can play one side against the other and cash in through political contributions and other financial support. There is no issue of principle: there is only the issue of price. The more contentious the issue, the longer the process, the more money key politicians can garner for their coffers. It's not a party matter, it's money. It's not constituent interest, it's money. It's not principles, it's money. It's not ethics, it's money. It's not doing the right thing for the public, it's money in the treasuries of well-positioned political figures.

$127 million in lobbying by the health sector, which was well-represented in Senator Kennedy's closed office meetings, in the first quarter of 2009 is no small change. Senator Baucus brought in $3 million in the 5-year period ending in 2008 and according to the Kaiser Health News (click the blog title for the link) big contributors included major pharmaceutical manufacturers, insurers and a major pharmaceutical executive.

As you watch the political maneuvering, remember, it's not health care that key people in Congress worry about, it's their economic status and political bankroll. The issue isn't "where's the beef," its "where's the money"?

A Superficial "Take" On Electronic Health Records

Steve Lohr's June 19, 2008 New York Times opinion piece, "Most Doctors Aren't Using Electronic Health Records" cites a government report published in The New England Journal of Medicine ". . . that doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care" and sadly notes that ". . . yet fewer than one in five of the nation's doctors has started using such records."

I checked the June 12 and June 19, 2008 print version of the NEJM and, noting that the article did not appear in print, concluded that the NEJM print edition uses its costly print resources more carefully than its virtual edition.

In this era of "show us the evidence" the first question Lohr should have asked is "what evidence proves that electronic health records reduce illness, reduce complications of illness, extend life and have a positive effect on outcome? The second question, with respect to the doctors' opinions, is "so what?"

Doctors' opinions reflect personal, colleagues and employers' bias. Opinions are interesting, but they are not hard evidence. Before we waste additional billions on technology which may not affect outcome positively and may affect outcome negatively, we need hard evidence. (See my blog "Clinical Competence or Electronic Medical Records" dated Sunday, May 11, 2008.)

One physician, who is implementing electronic records for a large medical group, recently told me that his job guarantees lifetime employment. Interesting observation - but how does that help patients? Another told me that he has less time for eye contact, communication and examining patients because he spends at least four minutes per visit preparing the computer record. And all of this without proof of outcome benefit.

Before we spend additional billions, buying technology which has not been proved to improve health care outcome, and before we fill the coffers of hardware and software companies and a new healthcare bureauracracy which never deals directly with patients, let's stop and ask for hard evidence of value.

The electronic health record is a tool not salvation. Before we waste additional resources, let's ask whether this technology meets the requirements of Occam's razor.

Clinical Competence or Electronic Medical Records?

It may seem unfair to ask: "do you favor clinical competence over electronic medical records"? But today, the United States doesn't have enough dollars to pay for health care for its entire population. Use of billions of dollars of scarce resources to pay for electronic medical records systems will divert money from training competent clinicians in evidence-based medicine and may have a detrimental effect on health care.

Pysician, nurse, and nurse practitioner training programs stress the mantra: show us the evidence for the diagnosis you make and the treatment you prescribe. Unfortunately, health systems administrators, insurers, politicians and others who control the flow of health care dollars are not required to show solid evidence supporting their rush to electronic medical records. The information technology industry claims superiority for its products. Politicians, bureaucrats and administrators wax enthusiastic about their chance to spend billions of dollars on technology which does not yet demonstrate patient health outcome superiority as compared to traditional paper records and systems. The issue isn't whether a computer generates a pretty report for a mid-level administrator; it is whether the patient lives or dies or suffers severe medically unnecessary complications or pain.

Citing two studies of handheld electronic medical record systems, a 2006 Canadian abstract did not find conclusive evidence of a net benefit from the use of the handheld medical record system. It did report an increase in the number of wrong or redundant diagnoses (http://www.biomedcentral.com/1472-6947/6/26/abstract downloaded 5/11/2008).

Crosson and others reported the effects of electronic medical records on diabetes care in an NIH funded study (http://www.annfammed.org/cgi/content/full/5/3/209 downloaded 5.11.2008). Statistical analyses demonstrated no evidence of an improvement in ultimate outcome. Surprisingly ". . . . patients with diabetes in practices that did not have an EMR were significantly more likely to have received care that met the guidelines for processes of care, treatment, and intermediate outcomes".

There is literature claiming that electronic medical records systems show a good return on investment (http://www.medicalnewstoday.com/articles/76786.php downloaded 5/11/2008). Where are comparable studies demonstrating that the money spent for such expensive systems show a net benefit to patient outcomes. Where is the answer to the mantra: show us the evidence?