So over the past week, while I’ve been working on edits to my dissertation and prepping for a job interview on the other coast, I’ve been thinking a lot about the great responses you guys gave to my first post here. Before I go off in another direction, I want to reply to some of them.
Health care is a complex system. And American health care is a distinct beast from British or French or Canadian health care. We must approach it with some humility, and study the way pieces fit with each other and operate in their environments before we start changing things. There’s a reason the ACA works the way it does — stepwise efforts and pilot programs are a much more sane approach than massive delivery overhaul. The same goes for EHR.
Here’s one of the most important things to remember too: It’s not just that it’s a complex system in the way it’s used in each location. It’s also the second most decentralized industry in the country, second only to the floral industry. For much of healthcare’s history, it’s been a cottage industry. The introduction of major government oversight, in the forms of Medicare and Medicaid, and the emergence of HMOs that paved the way for the corporatization and bureaucratization of medicine have done a lot to change the landscape. But much of medicine is still practiced in those small private practices. It’s that kind of a complex system.
EHR also presents some unique difficulties. The main one is a hold-up problem. I have written about this before. Insurers and patients benefit, as Leah points out, and the situation for doctors is a bit messier. I happen to believe that they benefit in the long-run from increased efficiency and a lighter workflow burden (administrative tasks consume massive amounts of physicians’ time and are among the chief things they complain about when discussing low job satisfaction) but are punished in the short-run because the onus of learning the new system and adapting workflow is placed solely on them, and they are much, much too busy to put up with it. I am sympathetic to their resistance. It is a clear case for a subsidy program, although this has already been tried with limited success, perhaps because physicians don’t really want extra money to spend extra time learning a new system; they value that extra time far too much.
This is such a great point: “the onus of learning the new system and adapting workflow is placed solely on them, and they are much, much too busy to put up with it.” Also, let’s not forget that physicians are a valuable resource when it comes down to it. You don’t want to keep waiting all those hours to see your doctor, right? Then we shouldn’t have systems that keep physicians doing administrative tasks and keep them away from clinical tasks.
Here’s the way I look at it. Imagine this scenario:
Someone comes to you and says, “You need to change the way you do your job. We’re pretty sure it’s a good idea to do this change, and we think it will benefit someone - maybe you, but actually maybe some other groups - but we can’t absolutely guarantee it.”
You say, “Well, ok. I can see the way I do my job could stand for some improvement, but the routines I have set up? I’m quick. Maybe it’s old-fashioned, but I feel I can do my work efficiently and effectively.”
The person says, “That’s nice. But times are changing. We need to change those parts. It’ll take about two years for you to feel proficient again. You’ll probably see benefit in these other areas! But just maybe not in the efficiency areas. You might not ever be that quick again.”
How would you feel? I will hazard a guess. You’d probably feel, I dunno, not okay. Screw changing times! What is this? A punishment?
This is obviously an extreme - and extremely negative - example of how EHR implementation can be presented. But I’m not making it up. There are physicians who have been through it and still feel this way.
Of course, there are really positive examples of EHR implementation, of physicians who absolutely LOVE IT. Who feel 100 times more efficient after than before. I’ve interviewed those people. There are entire systems that are renowned for their fully successful implementations and their almost impossibly happy clinicians.
At the same time, there are also people who feel they’ve gotten lost in a maze of clerical duties, in tasks that take them away from patient care. They feel they can’t enter data in a way that properly reflects their patient visits. They feel overloaded with tasks they never had to perform before, tasks they see as administrative, tasks they feel leave them little time to perform clinical duties. They feel that what made them quick can never be regained, and they don’t feel the benefit has been worth it, because of system design or because the benefit is neither to them or to the patients but to administration. So why change? Why go through the pain and misery when the system they have serves them well enough? These are important questions to answer.
The doctors who love it are male, female, younger, older, white, black, Asian, and work in primary care, OB/GYN, neurology, rheumatology. The same goes for those who don’t love it. It’s not just about the technology or the money, as healthpolitics points out, although both of those are important factors. Time is an incredibly precious resource. Other important issues are how people interpret patient care, and concerns regarding professional identity, division of labor, and authority.
One big problem I think needs to be addressed - and that I plan to write on separately - is how distanced we as patients have become from physicians. As angry as we are at insurers, there’s a lot of blame and finger pointing at doctors. This isn’t to say there aren’t doctors who don’t deserve every ounce of the anger we send their way, or that the healthcare industry hasn’t made its share of missteps. Rather that after spending 18 months in ambulatory care practices, I discovered a newfound respect for just how hard many physicians work and how much they care. Transitioning to EHR is a difficult endeavor in an already tough job. I’d like to find a solution that is as much pro-patient as it is supportive of the physicians who will bear the brunt of the change. To me, that’s the only way we will be successful. Supported, happier, more effective doctors will be better equipped to take care of their patients. Whether they do so in managed care, large medical networks, or small, pay-for-service practices - doesn’t that sound like a healthier system than the beleaguered, finger-pointing, vitriolic one we have now?
One thing that isn’t mentioned in Leah’s post is hospitals. I think facilities actually lose when EHR is implemented because in the status quo they routinely replicate scans and procedures done at other facilities at significant profit. Streamlining the system means less procedures, hence the benefit to patients and insurers, but the big losers here are hospitals, which already operate at fairly low profit margins.
As I mentioned, I spent my research time in ambulatory care, so I have yet to gain expertise in EHRs in hospitals. I hope to in the future, but until then I leave this area to someone who has more knowledge. While related and connected, they are different beasts. So please, keep this info coming - I find it fascinating.
I look forward to hearing much more from this blog.
Thanks! Please, keep responding. This is such a critical dialog.
(Source: leahreich, via )
