Dr. Computer

In a perfectly titled Op-ed, “The computer will see you now,” Dr. Anne Armstrong-Coben, a pediatrician and assistant professor of pediatrics at Columbia, shared the reality of adopting electronic medical records. She highlighted the greatest thing we’ll sacrifice…

The loss of humanness of medicine and the private and personal relationships built between patients and their doctors.

The Computer Will See You Now

For 20 years, I practiced pediatric medicine with a “paper chart.” I would sit with my young patients and their families, chart in my lap, making eye contact and listening to their stories. I could take patients’ histories in the order they wanted to tell them or as I wanted to ask. I could draw pictures of birthmarks, rashes or injuries. I loved how patients could participate in their own charts — illustrating their cognitive development as they went from showing me how they could draw a line at age 2 and a circle at 3 to proudly writing their names at 5.

Now that I’ve been using a computer to keep patient records — a practice that I once looked forward to — my participation with patients too often consists of keeping them away from the keyboard while I’m working, for fear they’ll push a button that implodes all that I have just documented.

We have all heard about the wonderful ways in which electronic medical records are supposed to transform our broken health care system... The benefits may be real, but we should not sacrifice too much for them.

But, the problem isn’t just with pediatricians, she cautioned. JFS has shared the problems encountered by doctors and nurses in neonatal intensive care units and other acute care settings, despite their every effort to make them work, documented in the medical literature. And as cardiologist, Dr. Westby G. Fisher, M.D., explained, the focus for doctors becomes clicking and responding to hundreds of little boxes and prompts. As Dr. Armstrong-Coben went on to write:

Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up…

In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care. In the past, I could pick up a chart and flip through it easily. Looking at a note, I could picture the visit and recall the story. Now a chart is a generic outline, screens filled with clicked boxes. Room is provided for text, but in the computer’s font, important points often get lost. I have half-joked with residents that they could type “child has no head” in the middle of a computer record — and it might be missed.

A box clicked unintentionally is as detrimental as an order written illegibly — maybe worse because it looks official. It takes more effort and thought to write a prescription than to pull up a menu of medications and click a box. I have seen how choosing the wrong box can lead to the wrong drug being prescribed.

So before we embrace the inevitable, there should be more discussion and study of electronic records, or at a minimum acknowledgment of the downside…

As she noted, the personal relationships built between a doctor and patient is integral to improved health outcomes and that’s not built with a keyboard and computer screen.

Another physician, Dr. Lou Lukas, M.D. from Allentown, Pennsylvania, who has worked with electronic records for more than a decade, as well as been an administrator trying to share records between offices, also wrote a cautionary letter to the New York Times business section this week:

Medical Record-Keeping

… While the records may sound simple, they are preposterously complicated, with thousands of data points per chart. Some information, of course, is valuable to providers across the continuum of health care, but other information should never leave the office. It is important to know about medications, allergies, test results, etc. But do you want every health care professional — or billing clerk or receptionist — to know, for example, that you got a sexually transmitted disease from your husband?... Before we embark on vastly expanding electronic records, let’s decide how to use them well.

In all examinations of the purported benefits of electronic medical records, the undeniable fact arises: they aren’t about caring for people, but about profits. They have yet to show that they improve actual outcomes for patients or reduce medical errors (let alone healthcare costs), while they have been shown to impose new risks for many patients. And they certainly aren’t really about streamlining care for caregivers or enhancing patient privacy.

Electronic medical records do, however, make it easier for third parties to track billing claims and pay-for-performance measures (steering medical care towards the tests, medications and procedures that will make or save money for third-party payers, rather than what a doctor feels is best for an individual patient), and enhance surveillance of the population to identify people for interventions and to monitor their compliance with third-party guidances. There’s the real reason that all health information technology (HIT) legislation mandates “interoperability” — it’s the key to third-party oversight of the patient care and of people.

Speaking of which, this past week, the coalition of HIT vendors, pharmacies and pharmacy benefit managers, insurers and other stakeholders in electronic medical records met last Monday in San Francisco to unveil their plan to address the growing problem of security breaches. This Health Information Trust Alliance (HITRUST — covered here) had been charged with creating the guidelines for the security and regulation of nationalized HIT and establishing the broad network for the exchange of electronic medical records. As PC World reported, the coalition released the first IT security framework specifically for medical “data loss prevention” this week. Calling it the “Common Security Framework” (CSF), the cost for each healthcare provider will start at $1,875 and the costs will be higher for large organizations.

Protection from the loss of data, while of most concern to stakeholders, is just one aspect of concern with electronic medical records. The financial and human costs involved, and protecting the privacy and accessibility of those records are of concern for most patients and doctors. But the ready sharing of electronic records (HIE, health information exchange) is a mandated part of nationalized HIT. And the federal Health Insurance Portability and Accountability Act, as we know, offers consumers little privacy protection or protection from misuse of their records.

The new federal mandate calls for nationalized integrated electronic medical records, which means all information— from doctor and hospital records, diagnostic tests, lab results, prescription drug records, etc. — is automatically populated into the federal database and shared among a wide birth of interested parties, with no ability of consumers to opt-out or give their consent. This new legislation also allows the government and any stakeholder to sell our private health information.

New Mexico has been a state most vigorously pushing electronic medical records, under initiatives led by Governor Bill Richardson. Its Senate just passed the Electronic Medical Records Act (SB278), which requires that all electronic medical records used by any state agency must “use software or hardware that complies with federal interoperability laws or rules.” To unsuspecting residents, the significance of “interoperability,” probably went unrealized. Instead, they heard unsubstantiated claims that electronic medical records reduce errors and control costs.

The Governor told media, this bill also protects the privacy of their electronic medical records. “We expect this legislation will encourage providers to use electronic records because they know their patients’ information is confidential,” said Health Secretary Dr. Alfredo Vigil.

Reality says otherwise. The privacy protection came in the form of a provision that disclosure of private information would be restricted unless patients give their consent, “it is required for emergency treatment, it is necessary for the operation of the record locator service and the health information exchange, or otherwise permitted by state or federal law.”

Healthcare professionals already know, but a lot of consumers may not, that federal law, under HIPAA, already gives a vast array of third parties ready access to their medical records. The public may mistakenly believe that the consent provision in the bill is a new “opt-in” feature and that it gives them a way to keep their records private and out of government databases. But, in reality, in order to receive medical care and have medical bills paid by insurers, patients already have to sign a HIPAA form — and give their “consent.”

Reading the actual legislation, the bill calls for the retention and accessibility of electronic medical records; requires an audit log of everyone who’s accessed records and a system for consumers to obtain copies of their audit logs for a fee; provides for both in-state and out-of-state disclosure of all medical records; removes any liability from health institutions or health information exchanges (used by the department of health) for any harm caused by an individual’s exclusion of information; and excludes insurers from the privacy provisions in the bill. Most of these provisions will require additional government resources to regulate and oversee the database, “for start-up costs, maintenance, training and ongoing technical support for users statewide.” But this bill includes no estimate of how much it will cost taxpayers or doctors to implement its provisions, and it includes no appropriations.

Dr. Armstrong-Coben’s comment that “the computer may see you now” was an important reminder that a computer is now sitting between our doctors and us. But she neglected to remind us who is behind that computer screen.