Letter From the Editor

Bruce D. Cheson, MD

Last week was the day when, every 6 months, the first few patients in my clinic are the same. They also share several features: all have an indolent NHL and are currently in remission; none had ridden a bicycle seriously until the first Lymphoma Research Ride, and all have now ridden in each of the 5. Always the first to appear is a physician, usually cheerful and mild mannered. At his most recent visit, he was uncharacteristically animated and upset. He had just read a story in the New York Times, March 5, 2012, based on a study from the National Center for Health Statistics published in a journal called Health Affairs. The authors, after surveying 1,100 physicians, came to conclusions contradicting a RAND Corporation estimate that electronic medical records (EMR) would save health care spending in the United States $80 billion a year. Indeed, they estimated that EMR might actually increase that number. The study found that doctors using computers to track tests ordered significantly more imaging studies than those who did not. But, it wasn’t the article itself that was particularly unnerving to my patient, but the 229 blog entries that followed.

Not being a blog reader (in step with my rebellion against social networking), I nonetheless later retrieved the Times article (paper copy), and located the comments that followed online. In general—these people really have too much time on their hands (which might be better spent learning grammar and spelling!). Nevertheless, the comments could be organized into a few basic topics with various viewpoints: 1. Will EMR save money? In the short-term, probably not. Will it ever in the long-term? It would require a full re-engineering of a health care facility, which is time-consuming, but probably worth it. Clearly more training will be needed to improve the usefulness of EMR. It will only benefit the companies that make the software. 2. Does it make finding data easier? Is it useful in an emergency? Perhaps if you happen to be in the facility where your EMR was entered. 3. Were doctors who ordered more tests better doctors, or are they just out to make more money that way? Whoever suggested the latter ignored the concept of prior approval and the fact that doctors cannot receive money for the tests they order. 4. Some commenters resented that their doctor spends 40–75% of the time looking at the computer, whereas others thought that such use indicates a better doctor with advanced skills. My patient related that his practice had spent a million dollars on a new EMR system, and had purchased laptops for each of the physicians to use for data entry. Yet, he found himself spending most of his time staring at the keyboard and monitor, and less time interfacing directly with the patient. 5. The article that generated the responses was pretty dreadful, or it was quite useful. 6. Technology is causing health care costs to soar, or it is the abuse of that technology, eg, overtesting/treating in the last few months of life, that is causing them to escalate. 7. Some comments were from doctors who loved EMR—charts were better organized, and data were easier to find and less often duplicated; others hated it and felt it detracted from the patient interaction. 8. There was general agreement that EMR added a substantial amount of time to the day. Some physicians noted that they were actually compelled to see 2–3 fewer patients a day as a result. So, instead of making more money, it was either costing them money or they were making the same but having to put in more hours with no additional reimbursement. 9. EMR saves trees. However, records still had to be FAX’d because every practice uses a different system that doesn’t interface with other systems. Indeed, in our hospital, the in-patient EMR does not communicate with our outpatient EMR. 10. An academic physician opined that EMR added further to the decline in young physician examining skills. Just checking off boxes to order tests, he stated, was no substitute for the laying on of hands. 11. The continued build-up of past notes was likened to Where’s Waldo, where you have to hunt to find what is really important. 12. Those who wanted a central records system argued with those who didn’t want just anyone having access to their health records. 13. EMR should not focus on cost-saving, but on life-saving. 14. Academicians don’t have a clue as to the use of such technology, and the study should have been restricted to community doctors. 15. Were these findings really cause and effect? Were the increased tests ordered necessary, and did they improve patient care? 16. It is all O’Bama’s fault!

Does EMR save me time? Yes and no—every note written by a fellow or my nurse practitioner has to be carefully edited, and corrected for grammar, spelling, and too many unintelligible abbreviations. They rarely seem to update the patient age or HPI—the patient is here for the 6th cycle, not the 5th! But, I love not having to schlep down to radiology to view an image (if they could even find it in the file room).

How can we resolve the issues? I think that many problems would vanish through the Cloud. There would be no need for redundant systems, and data would be readily retrievable from anywhere. In my clinic, the computers are strategically placed to face opposite the patient. I always make a point of turning around to make eye contact. There is actually a course given to our house officers regarding the use/abuse of the EMR in patient interactions.

Grumble as we may, EMR is here to stay. But that should not be at the expense of the doctor/patient relationship.

Until next month . . .

Bruce D. Cheson, MD