Who’s writing those orders? Are computers replacing your doctor?

In a valuable article today, Dr. Westby G. Fisher, M.D., FACC, a board certified internist, cardiologist, and cardiac electrophysiologist in Evanston, Illinois, illustrates the concerns of doctors about electronic medical records and their computer-generated drug orders and patient management.

“If the patient has diabetes, a ‘hypoglycemic protocol’ order set is automatically generated by the pharmacy,” explains Dr. Fisher. “No doctor order is required, but the treating physician's name is attached automatically to the orders.” He gave an example of a patient he cared for this weekend and the 30 drugs generated for this one patient in what he calls “cook-book medicine” under electronic medical records. He questions if this save lives. And, what’s the cost of automated orders without a doctor’s involvement? As he asks:

How many errors occur on the basis of misinterpretations of these automatic orders? ("Oops, I forgot to ask if she was pregnant.") Where is the evidence-based studies demonstrating the utility of this automated approach to patient care? Could this be why EMR's have not been found to save money to our health care system? Are we losing cost savings to our system by removing physician judgment?

He suggests that perhaps more doctors aren’t asking the tough questions because “it’s far easier to cover your butt with automatically-generated orders that the patient has to pay for in the interest of assuring their own ‘safety.’” His full article, “Polypharmacy Gone Wild,” describes the glucose blood sugar cut-offs that mandate a different form of glucose be given.

This timely post comes as doctors are questioning patient care guidelines and performance measures being mandated through EMRs that treat numbers and set increasing lower targets — yet lower doesn't necessarily mean better as has been seen, for example, in aggressive control of blood sugar levels, in light of the excess deaths demonstrated in the ACCORD trial and the failure to lower heart attacks or deaths in the ADVANCE trial — and the cost-benefit ratio of electronic medical records being pushed by the U.S. Department of Health and Human Services.

What you may not have heard is that the official results of both of these large randomized controlled clinical trials were just published in the New England Journal of Medicine [available free to the public].

The ADVANCE trial had been conducted at 215 medical centers across 20 countries on 11,140 adults with type 2 diabetes to evaluate intensive pharmacological control of blood glucose levels to achieve a glycated hemoglobin value of 6.5% or less. After 5 years of follow-up, the more intense management had no effects on major macrovascular events or death from cardiovascular disease or deaths from any cause. Severe hypoglycemic incidences were more common in the intensive-control group as compared with standard clinical care (2.7% versus 1.5%).

The ACCORD trial had been conducted at 77 medical centers across the United States and Canada on 10,251 adults with type 2 diabetes with either established cardiovascular disease or risk factors. This trial evaluated intensive pharmacological control of blood glucose levels to achieve glycated hemoglobin levels below 6% as compared with standard clinical care. This is the trial that was halted in February after 3.5 years of follow-up, due to increased deaths in the more intensive treatment group compared with the control group (257 versus 203). The just-published study reported that the aggressive treatment also didn’t reduce major cardiovascular events (heart attacks, strokes, cardiovascular-related deaths) and that hypoglycemia requiring intervention was also higher in the treatment group as compared with standard clinical care (16.2% versus 2.4%).

The problematic research and efficacy behind screening and treating health risk factors (indices, such as blood sugar, cholesterol, blood pressure and BMI), and the use of false surrogate endpoints rather than actual health outcomes, is being fiercely debated among medical professionals and has been extensively covered at JFS. Regardless of where you stand, the bottom line is that a vested third party is deciding what ideal numbers everyone must have and how they must be managed. Not doctors, using their clinical judgment of what may be appropriate and most beneficial for each individual patient and his/her desires. And these third party-determined pharmacological guidelines are incorporated into performance measures and electronic medical record surveillance programs.

Meanwhile this past week, the Department of Health and Human Resources’ Health Information Technology office issued a cross-agency directive to speed the adoption of electronic medical records nationwide as part of the 2004 Executive Order calling for the establishment of a federal health database. As was reported by CQ HealthBeat, the directive lays out comprehensive guidelines for federal agencies to link private and public sectors over the next five years.

As the American Medical Association’s AMNews reported a few weeks ago, while the federal government wants most Americans on the federal electronic medical record database system — which would include clinical notes and allow the sharing of patients’ lab and diagnostic results, computerizes doctor orders, and prescription drug information — by 2014, little progress has been made.

“The high cost of EMRs, combined with a small return on investment, is a main reason why physicians have been slow to adopt systems,” according to Jonah Frolich, senior program officer at the California HealthCare Foundation. While some of the billing functions of EMRs benefit doctors, he said, “most of the return on investment accrues to health plans.” [And who's lobbying most intently for EMRs?]

As AMNews reporter Dave Hansen wrote:

The average cost of an EMR system is $20,000. Slightly more than a quarter of practices with 11 or more physicians — a situation that describes only 8% of doctors — used comprehensive EMRs in 2006, according to an October 2007 Centers for Disease Control and Prevention report based the National Ambulatory Medical Care Survey.

Only 7.1% of individual doctors with solo practices — which account for about half of all doctors — use these comprehensive EMR systems and 9.7% of doctors with a partner, according to the report.

Dr. Fisher’s article today provides further insights into why doctors are not embracing these electronic medical record systems. It’s not just about costs, but patient care. Maybe, more doctors are questioning the efficacy of 30 drugs being prescribed to their patients by a centralized computer and they see what may be in store for all of us once we’re in the system.