home email us! sindicaci;ón

Low Adoption of Electronic Medical Records: Hidden Reasons?

by Scott MacStravic

Adopting and particularly sharing EMRs have been major features of most expert suggestions for health care reform. Despite their availability for two decades, their adoption in the US is well behind most European countries, as well as China, Japan, Australia and Russia, at less than 20% compared to 50-90% and more elsewhere. Whatever the benefits of EMRs, to patients, payors, and the country as a whole, we are only slowly and somewhat reluctantly gaining them.

Among the reasons suggested for the slow adoption rate is the sorry state of third-party and consumer payments to providers, compared to the high costs of EMR adoption. A related charge is that our “cottage industry” providers do not seek improvements in quality and productivity for their sakes alone, but look first at what it will do for individual practitioners, personally, financially, and immediately. And most EMR benefits take a while to reach their full potential.

Small medical practices tend to be the slowest in adopting EMRs, probably because the cost of adoption, compared to the benefits, tend to be highest when there are few physicians to share them. Physicians have little or no education or training in the business of medicine, so are often unfamiliar even with the basic tenets of what makes for good business and profits, where dentists, for example, are well versed in such matters.

In addition to the internal advantages of EMRs to provider organizations, and to the patients they serve, there are supposed to be significant, potentially life-saving advantages to patients in making EMR data available to other providers. Enabling ERs, or providers not familiar with patients, for example, to access patient histories rather than repeat tests or make best guesses about diagnosis and treatment based on presenting signs and symptoms alone, is likely to save lives, improve quality, and save money.

Suggestions for increasing and speeding up adoption have included payors, including governments, offering incentives to reduce the financial burden of EMR systems, including higher payment levels ror providers that adopt and use them appropriately. Medical societies and schools could promote the use of EMRs, and include training in their use in medical schools and residency training. Malpractice insurance carriers could reduce premiums for physicians who have EMR systems. [B. Bysinger “Healthcare Crisis: EMR Non-Acceptance in the U.S.” Health Leaders News Features June 27, 2007 (www.healthleadersmedia.com)]

But there are other reasons for resisting the adoption and sharing of EMRs, not being addressed by suggestions for improving both. There are both marketing and legal disadvantages to having EMRs and sharing access to them. Medical records are one of the more significant “switching costs” that face patients who might consider changing physicians, or using a physician unfamiliar with their medical histories. If large numbers of competing providers had access to patients’ medical records, needing only the patients’ permission, their regular physician would lose this advantage and barrier to patients’ use of other providers.

For example, the American Medical Association has recently called for a probe of retail clinics owned by retail pharmacies and stores with pharmacy services. Among the many concerns expressed by physicians has been the lack of continuity of care when patients seek care at such clinics. If these clinics could easily and quickly access patients’ past histories by permitted access to EMRs, including EMRs that patients, themselves, may have on file with other providers, the continuity argument would become largely moot.

Given the marketing advantages already owned by retail clinics – prompt appointments, with any waits tempered by offering opportunities to do other shopping, rather than reading old magazines; low out-of-pocket costs, sometimes no cost when employers or insurers cover them in order to promote use of cheaper sources – eliminating most of the continuity disadvantage could take even more volume and revenue away from physician practices. If practices had operational and interoperative EMRs, could they resist sharing information with other providers when patients request it?

The legal liability disadvantage, which may be far greater than any potential premium reduction from malpractice insurers, lies with the threat that has always existed relative to accessible knowledge for providers. If they have access to the information, they can be sued if they fail to access it and apply it to any particular case, relative to either diagnosis or treatment.

Suggestions have made, for example, that it would be helpful if physicians cooperated actively in promoting patient compliance with taking medications and making recommended. Currently, employers, insurers, and pharmaceutical firms all engage in such promotion, and given the trust and reliance most patients put in their own personal physicians, they are powerful allies to have in such efforts. But if physicians have access to such knowledge, they might be sued for not using it to remind patients and achieve the level of compliance needed to control the chronic condition in question, or the level of cure of an acute condition that compliance would enable.

Any legal requirement, or the malpractice risk that would arise if lawyers could simply make a case for physicians and other providers being accountable for knowing what is contained in accessible EMRS, would tend to dissuade or at least cause concern among providers relative to their adoption. Providers would then be expected to access the entire patient record contained in EMRs, and be liable if they failed to respond to warnings, risks of interactions, allergies, etc. that were contained therein.

Even if accessing EMRs for every patient seen would only add a few minutes to each visit, it would mean reducing the number of visits per day a physician could manage within the hours each sets aside for the purpose. This would reduce the daily and annual revenue each physician could generate with the same investment of time. Given the growing desire of physicians to lead a normal life outside work, and enjoy a comfortable return on their major investments in becoming physicians, even a few minutes more per patient visit would probably be seen as too much. And having access to patient histories via shared EMRs might even increase malpractice liability compared to physicians that lack such access.

There are probably ways to overcome these disadvantages and risks of EMRs, or to counter them by advantages other than those already included in healthcare reform proposals. But until and unless the concerns of physicians are fully identified and addressed, including the marketing and legal risks cited here, it may be a long time before EMRs are adopted by even the majority of providers.

3 Comments »

  Matthias Muenzer, MD wrote @ June 30th, 2007 at 4:16 pm

Dear Scott:
with all due respect, you are not a physician and you have not used an EMR in daily life. I just finished implementing an EMR in my practice - as a hospital employed physician I did not have to buy the system, just start using it.
It slows me down, it drains your productivity, it makes simple tasks complicated and long, it takes clicks and click and clicks and more clicks. It does not give you the same quick overview of a patient that my paper chart gave me.
It is just a drain!
Very simple. No need for complicated arguments. Make the damn systems better and people will use them. Sounds simple, and it is simple.
Design systems so that physicians can adapt them to work exactly the way they want and then make them cheaper. Lower the abusive costs.
And I will be happy to help with suggestions if you want. But you may just continue to write important words in long articles instead of finding a company that produces a really great system.
Your Matthias Muenzer, MD ObGyn
muenzerus@gmail.com

  Richard Schoor MD FACS wrote @ July 1st, 2007 at 12:46 pm

I enjoyed your post and agreed with many of your points, except the following. EMRs have not been adapted widely for the following reasons. They are too expensive and less efficient for the actual, in-the-trenches-providers. Also, contrary to the “doctors are not good business men” argument, doctors will adopt EMRs when they see ROI. For large groups with multiple locations and providers, the ROI is obvious. For a small practice like mine that has one location and a bare-bones staff, an expensive EMR would never have ROI, despite what the vendors’ marketing pamphlets say.
And, I am an EMR supporter and use one in my office, only mine was custom built by me for me. Any case, I liked your post and dialogue is always good to have.
Dr Schoor

[…] Low Adoption of Electronic Medical Records: Hidden Reasons? by Scott MacStravic, World Health Care Blog June 29, 2007 at 2:14 pm · Filed under Electronic Medical Records Adopting and particularly sharing EMRs have been major features of most expert suggestions for health care reform. Despite their availability for two decades, their adoption in the US is well behind most European countries, as well as China, Japan, Australia and Russia, at less than 20% compared to 50-90% and more elsewhere. Whatever the benefits of EMRs, to patients, payors, and the country as a whole, we are only slowly and somewhat reluctantly gaining them. […]

Your comment

HTML-Tags:
<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <code> <em> <i> <strike> <strong>