Over the last years, while interviewing state Medicaid directors and local health officials, we’ve heard that the use of electronic health records has the potential to be a great cost saver for governments. They let doctors from different departments or different hospitals easily work together with the same records with far less costly human intervention. Though there's a lot of potential here, the vision for what can be ultimately accomplished falls short in the implementation.
We’ve heard many doctors -- both journalistic sources and personal contacts -- complain about the negative effects of this technology. Among the issues most obvious to patients are delays from frozen screens and missing digital records. During our own experience with doctors at New York City hospitals, health-care providers told us repeatedly to carry our own medical records in old-fashioned manila folders in case the digital transfer didn’t materialize. When hospitals merge, the problems just get worse.
The painful technological transformation of medicine is elegantly portrayed by Robert Wachter in Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age. We foraged in the well-documented, persuasive book and then chatted with the doctor in order to better understand his ideas.
As he told us: “I don’t think policymakers have done a good enough job of assessing how their policies are impacting front-line clinicians and patients. No one is smart enough to figure out all the speed bumps that will occur. There are always unintended consequences.”
Wachter doesn’t deny the power of technology to improve health care. But he's also unsparing in his description of the massive implementation bumps that came from the rapid influx of about $30 billion from the 2009 federal stimulus program. Over five years, the adoption of electronic health records by hospitals and doctors’ offices has grown from about 10 percent to 70 percent.
Wachter, a professor and interim chairman of the Department of Medicine at the University of California, San Francisco, cites several barriers to integrating technology and health care, including:
new practices that are overlaid over old ones, systems designed by technology specialists who don’t consult with the people who will be using them, insufficient training, dwindling human interaction and routine errors in simple data entry. As Wachter explains: “The physician’s note has become bloated and unreadable. Doctors cut and paste yesterday’s notes into today’s notes. That creates the possibility of fiction -- cutting something that was going into today’s note that is no longer going on.”
In addition, he said, electronic records downgrade the importance of a narrative in place of checkboxes filled out to satisfy billers and create quality measures.
“It’s created a workflow that has doctors clicking on boxes to make external players happy."
The book will resonate with public managers who face many of the same problems when technology is designed by people who don’t understand the complexities of how their work will operate in practice. For example, the federal government put in place an elaborate incentives program to make health-care providers use electronic records in a meaningful way, but the second phase of it was largely unachievable, according to Wachter, because it depended on more sophisticated technology than currently exists. For example, the federal government wants to encourage electronic communication of information when patients are discharged from hospitals. But for discharged patients who are admitted to nursing homes, the hospitals often can’t achieve this goal. None of the stimulus money went to nursing homes, and so many lack the electronic capacity to receive and utilize this information.
Then there's the impact that technology systems have on human relationships.
Wachter entered a largely paper-based medical profession in the mid-1980s and eloquently describes the changes in how doctors spend their time. Gone are the days when young doctors had to congregate in chest reading rooms to tap the wisdom of seasoned radiologists.
“It flabbergasted me that once we had computers, doctors stopped hanging out in the floor and talking with each other,” he said.
He cites a 2013 survey in which 85 percent of office-based doctors said they were spending more time on documentation and two-thirds were seeing fewer patients.
So, should we tear down the computers and go back to paper-driven systems? Of course not.
“At the end of this journey, I actually see that this is going to work out,” he said.
We agree with Wachter’s optimism. The potential of technology -- in health care and elsewhere -- is rarely fulfilled until its users and its creators find themselves working together. The key to this is for the two groups to communicate with one another and for high-tech contractors to reach out to (and listen to) their customers.