Free Market Electronic Medical Records

Let me share with you the opening paragraph on electronic medical records in a recent NY Times article:

Dr. David J. Brailer, the federal official who is trying to prod the nation's health care system into the computer age, has delivered a warning to the health care industry: take steps soon to make it happen or the government will probably impose a solution.

Now, I think one can file physicians in the group "self-interested individuals." I would be tempted to think that if you had to force them to adopt something that is supposedly in their best interest, maybe it is not worth doing. But that is not the government's way. And everyone is lining up demanding that we move forward with this. But there are three reasons it is worth taking a step back.

First - cost. Physicians are often chided collectively for their business-savvy, or lack thereof. But they are just smart enough and self-interested enough to, at least intuitively, understand that if marginal costs exceed marginal benefit, it is not worth pursuing the margin. So if not them, then who? It is patients who supposedly benefit from EMRs, and they should pay the cost one way or another. But they don't actually do the paying for their care, so that leaves the two big payors - insurance companies and governement. We know that insurance companies are self-interested - so if EMRs reduce patient care costs, why wouldn't the insurers be jumping at the chance to increase their fees to doctors who adopt EMR systems? As far as I know, they are not. (I see this fact and say "why?" Politicians see this fact and say, "why don't I just make you.")

So that leaves the government. But state governors are seeing a crisis in Medicaid, and federal politicans are slowly starting to wake up to Medicare's fiscal crisis. Are they going to fund it? Surely not. That just leaves one other party - taxpayers. (note: this is not to imply that Medicare/Medicaid are not tax-funded - I'm just talking about their current budgets.) Certainly that's possible, but it's worth asking - if all these other intersted parties are dragging their feet, maybe there's a reason.

Secondly, the issue of medical error rates. Everyone assumes that EMRs will drastically cut medical errors, and pretty much pay for themselves. They act like the only errors are bad orders and prescriptions due to poor physician penmenship. But you can't ignore a very big cause of medical errors - wrong decisions by the physician. Now EMRs may have some fancy ways of picking up drug-drug interactions, but they will be silent about doctors putting patients on the wrong drugs. And EMRs bring new errors themselves - data entry. Now I'm not saying that medical errors will increase with EMRs, or even that they won't decrease. But the decrease may not be as drastic as some claim, and it is prudent to be conservative in estimating before dropping many a dime on these systems.

Last - well just read this:

Congress has been doing its own prodding on the matter, with another bill introduced this week. Trying to pick up the pace, Dr. Brailer, in meetings with health care and technology executives here at their industry's big annual convention, has told them to come up with a single set of technical standards for electronic health records. (emphasis added)

It's ridiculous to think that 1 million physicians across this country, caring for 250 million people, can come up with one, and only one, set of standards and regulations to usher in a project that will cost tens of billions of dollars. Even assuming that this were possible, it's a horrible idea. The best EMRs will result from simultaneous systems running in parallel across the country, with trial and error finding out what works and what doesn't. It's ludicrous, and downright dangerous, to believe that physicians as a collective have the knowledge to know in foresight what wil constitute the best set of standards for everyone's EMR.

I don't want this to sound like I am against EMRs. I am not. I think they can be valuable and worth the investment - but only if done correctly and for the right reasons. If they come into being for political reasons, collectively funded, and centrally conceived, regulated, and managed, we will look back and wonder why such a good idea turned out so mediocre.

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Re: Comments by Medical

Re: Comments by Medical Software Guy

I couldn't agree more. One aspect of the software (any software) is what may be defined as "testing". It would appear to me that most civilian application software (Microsoft included) is rushed into/onto the market (often in Beta form) with little or no testing. The end user is thus forced to do the developers testing.

I am a retired Chief Engineer, Engineering Manager, Systems Engineer, and Systems Integrator for Military Weapons Systems (including software) and, prior to my retirement, worked for many years for a major aerospace/aircraft manufacturer. I have worked for many years "responding to government requirements" and it is both a losing position while being very expensive. While systems integration/requirements testing was a major budget vital line item in any any weapon system procurement project it was almost always inadequate in scope.

Electronic Medical Records software is no different than most civilian software in the fact that the requirements are often not fully analyzed, testing is not defined up front during design, and design is not 'frozen' before implementation starts. At that point the designer is playing catch-up and is for ever behind the eight ball while the 'tester' is lost.

EMR software will be no different from other failed government software projects (I.E. IRS, FBI, and Veterans Affairs)unless the requirements are properly defined (and 'frozen') and I'm not sure the bureaucrats in Washington have the wherewithall to accomplish this job.

I used to work for a

I used to work for a software company that made medical record software for hospitals. The stuff isn't cheap. Tens to hundreds of thousands of dollars per hospital. Further, in the case of our product, it was very hospital-centric and had lots of features that probably are of no use to a doctor's office. It probably lacked many features that would be useful in a doctor's office, too.

Developing a version for the office would have been a major investment, but would have the advantage of a market hundreds of times the size of the hospital market. With a little work, the software might be adaptable to dentists, optricians, maybe even vets. Still, we are talking about a market that numbers no more than a million or so total customers. A small market for an expensive product means there isn't much of a market at all.

But buying this kind of software isn't just a one-time expense that can be amortized over many years. Medicare and friends like to make changes that can take effect as often as every quarter. Every 3 months, we updated the content of program, as new diagnosis and procedure codes take effect, as new Medicare pricing takes effect, and as new rulings (either regulations published in the Federal Register or decrees from the courts) change the way the people who work with medical records have to do their jobs. Imagine having to update your copy of Quicken every 3 months because GAAP rules are always in flux. Oh wait, maybe that already happens...

Anyway, the effort of keeping the software updated can be more daunting than the initial sticker price. Then there's the inherent bugginess of the software. Think about it: the software changes at least once a year and as often as every quarter. That's not much time for a proper testing cycle. Even for the times when only the basic data is changed, as opposed how the data is used, you still have little time to determine if the data is correct. One time, I was trying to work through the pricing calculations Medicare published in the Federal Register, and got very different results from what their examples indicated. Was the example in error, or were the published formulas in error? If this sounds similar to the IRS not knowing what the tax laws are, I'm sure that's just a coincidence. ;)

To sum it up: the doctors are looking at expensive software that requires constant care and feeding and is of dubious reliability. Is it any wonder that few doctors have taken the plunge?

Actually I didn't forget.

Actually I didn't forget. That is usually the one and only objection people can come up with against EMR. I wanted to steer clear because I wanted a little something new.

But it surely is a concern.

I think you forgot to

I think you forgot to mention the fear of EMR and the ability of hackers to access private information. Granted network security and encryption continues to improve it is still a scary issue.