Computerizing Health Records: Will It Really Cut Medical Costs?

By SCOTT HAIG – Thu Mar 5, 12:15 pm ET
If the cheerleaders - including the one in the Oval Office - are right, computerized medical records will save us all: save jobs, save money, reduce errors, and transform health care as we know it. In a January speech, President Obama evoked the promise of new technology: This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests," he said, and he has proposed investing $50 billion over the next five years to help make it happen.
Any doctor will tell you the advantages of having lots of patient data on computers: it helps us avoid redundant tests, gather huge amounts of data for research, screen automatically for drug interactions, all with no problems with our famously illegible handwriting. I would be happy if every patient could hand me a digital file of everything about him; it could really save time on first visits. But against our government's push to get all patients' records computerized we must keep in mind there will be a cost to this - far beyond the billions to be spent setting it up. Many of us in medicine are concerned that the greatest cost will be in the quality of medicine that we practice. (Read "The Year in Medicine 2008: From A to Z")
American doctors have not been enemies of the digital revolution. Looking up lab results and x-rays on our computer screens beat out carbon copies and sheet film in an instant. We like e-mail; we shop, take tests and read our journals on line. But the romance, for most of us, began to sour with Computerized Physician Order Entry [CPOE]: entering patients' hospital orders on the computer. This is when we first confronted the downside to uploading our every medical judgment.
The majority of us are forced to use computerized orders or risk losing our hospital privileges. But most of us have found that CPOE is a lot harder than writing out orders on paper, takes far more time and in too many ways is just not as good. We're never quite sure that what we've typed is going to be seen by a real, live, analog nurse, that it isn't just going to disappear. (It does.) We can't order certain things with those buttons and pull-down menus that we could in writing - things like "patient may wear her own flannel nightgown and underwear" or "please, please get the x-ray I ordered for yesterday", or "prop up patient's legs with pillows like this" followed by a little stick-figure drawing. (See pictures from an X-Ray studio.)
After CPOE grief and the obvious but very important "what if it breaks?" issue, our immediate concern with putting all that medical data on a nationwide computer network is privacy. Who gets to look? How do you limit access to information and respect privacy when managing a disease, like diabetes or AIDS, that affects many organ systems and so involves many different kinds of doctors and services. Doctor-patient confidentiality seems quite likely to be one of the sacrifices Americans will be required to make to get this project going.
Health care is a labyrinth of insurers, doctors, hospitals, clinics, pharmacies, all using different computer systems; are we really going to create a single comprehensive system that gives everyone access to all the information they need? Or find a way to get the multiple systems already out there to talk to each other? It would be a task to make Reagan's Star Wars plan seem quite manageable. But that is only the beginning; really hard is going to be getting this multi-billion dollar juggernaut to actually save us money. (Read "Faith and Healing: A Forum".)
Not surprisingly, nationwide adoption of Electronic Medical Records is being pushed hardest by those who would profit financially from it. The slightly embarrassing financial reality of EMR is that large, mechanized medical operations like hospitals, clinics and big multi-doctor practices stand to make quite a bit of money by adopting them - given our current convoluted system of paying for health care. Two clear factors make EMR a money-winner: improved billing and internal cost control.
Medical billing, for both hospitals and doctors, is accomplished via a system of codes, which is already so complicated that there are special schools for it, granting degrees not just in coding but in special branches of coding. Coding boils down to assigning specific numbers to every problem (diagnosis codes) and other numbers to every treatment (treatment codes). Though the lists, in my field of orthopedics anyway, are woefully inadequate to capture how we actually think about or treat patients, they are still ponderous and complex. From common cold to brain tumor, open heart surgery to handing over an Ace bandage, there is a code that every doctor, hospital, therapist and supplier must use if they want insurance to pay them. (Read "Medical Records Go Digital".)
It isn't hard to see how a digital chart is a ticket to increased revenues. Instant communication from the health information side - with all the tests, diagnoses and treatments - to the billing side that pays for it all, makes billing faster and easier. Why give away that Ace bandage for free? This at least is efficient. But communication the other way, from billing to medical, will take place too. And this is more ominous. The doctor should tell the biller what he found and did. But that EMR program can easily be a very clever, covert way for the biller to tell the doctor what to say he found and did. We don't simply write whatever we want in an electronic chart: we must select from predetermined choices. And these choices offer an open invitation to hyped-up diagnosis and inflated bills.
When, for instance, does a urinary tract (bladder) infection become a pyelonephritis (infection involving kidneys and ureters)? There's no clear-cut answer. But when the computer reminds the doctor, every time he clicks on the "urinary tract infection" button, that the hospital gets many thousands more for the more serious condition, it's just as easy to click on the "pyelonephritis" button and make your administrators happy.
Or consider that nearly every patient who has a big hip or knee operation will run a fever for a while afterward. No one really knows why. But let the computer pick up the temperature elevation and make me address a pull down menu that includes "fever of unknown origin" and I have to add a diagnosis to the patient's chart that often means a bigger payment - though the only treatments for this fever are being given anyway.
Or go to the doctor with a sore knee and for some reason he is examining your ears. It might be that you have a very thorough doctor who is ruling out a rare ear-knee syndrome. More likely, the EMR program he bought is reminding him that notes on the chart about just few more body parts will kick your visit up into a higher-paying code.
The EMR makes money in ways like this, using cleverly designed "thought bins" that are put into the program by profit-maximizing, code-savvy administrators. EMR can inject more higher-paying codes into our patient contact and squeeze that much more money out of it - quite innocently too. It is, after all, a computer forcing these choices.
EMR, financially, is the mouth and esophagus of a hungrier billing animal. And not just in hospital practice. Private medical practices, whose incomes have been driven down over the years by decreasing insurance reimbursements, are hiring computerized record/billing companies in droves. Their promise? To create electronic medical records that comply completely with coding requirements. This way the practice can bill more and improve its bottom line, even after paying the billing company for its services, which run 6 to 10 percent of gross. The insurers got computers so the doctors are getting them too. It's an arms race - though, unfortunately one in which good patient care is watching from the sidelines. (Read "The e-Health Revolution".)
If hospitals and big clinics think they can make more money with EMR, why then does everyone from the President on down believe that computerized medicine will help contain costs rather than inflate them? Is it simply that better medicine should be cheaper in the long run and having all that information available should make for better medicine?
Though this tends to be the message, all too often the mechanism is much simpler. Computerized medicine means both more information - and less medicine. Less therapy, less surgery and less testing too. That's how it saves money. A variety of promising terms describe it - terms like targeted treatment, algorithmic patient-care, fiscally responsible medicine and evidence-based practice - but for doctors treating patients, one word describes how computerized records save money. Denial.
EMR has the potential to greatly increase insurance company denials of the tests and treatments that doctors order. In the old days, the tests we ordered were done first - though bills for them might not get paid. Now when findings aren't bad enough to "justify" expensive tests or treatments, (according to sources chosen by - you guessed it - insurance companies) the computer tells everyone, immediately, "you're going to eat this." Might this eliminate unnecessary testing and save money? Sure. But who determines what is necessary? Who should a patient trust to make her medical decisions? Can the government or an insurance company be as good an advocate as her doctor?
Doctors live with denials, some of them dangerous. I've ordered MRI's on hospitalized patients that somehow never got done, physical therapy and medication never delivered, because of "unmet requirements" picked up when codes are scanned. When the white blood count isn't high enough to "justify" the hospitalization for IV antibiotics, the physician whose judgment says "this patient is sick and belongs in the hospital" is told his services as well as the hospitalization will not be paid for. When a doctor is convinced a test or treatment is needed, (and his patient doesn't have the money to pay for it) he has just two choices: wait for the patient to get sick enough to "justify" what he wants, or join the game - and lie about how sick he is. It's just a matter of clicking a different item on a pull down menu.
Finally, the political debate also revolves around using information technology to figure out which treatments are most effective. This seems eminently sensible: might certain heart patients, for example, do just as well with clot-busting drugs as with more expensive angioplasty procedures? The drug route could save about $7000 a patient Crunching huge amounts of data from a wide cross section of patients could help us do better research than we are doing now. But what will happen when the new computerized research turns up a treatment that works a little better but costs much more? Will they tell us? What happens to the patient whose particular circumstances argue for a different treatment than the computers and the bureaucrats recommend?
There are countless ways to control costs; some of them, like liability reform, won't easily fly through a Democratic Congress. We held our breath as Mr. Obama drew a line in the sand in front of Big Agra and the teachers union last week, hoping against hope he would continue it across the trial lawyers. But the doctors I know wince whenever electronic medical records are held up as some kind of silver bullet.
Before we had them on every countertop, computers held such promise for us in medicine: doctors and patients live in a world of painful, pressing questions, the answers might be in there. Or so we thought. Twenty nine years from the night I first sat in a hospital in front of a computer screen the questions persist. And I still don't see the profit-maximizing, cost-controlling physician with his nationwide computer treating patients any better than the great physicians I've known have. With pen and paper, personal commitment to each patient and judgment born of practical experience. None of which I have found in a machine.

For More Information:
http://news.yahoo.com/s/time/20090305/hl_time/08599188300200