New JAMA Study Shows that Electronic Health Records Do Not Reduce Administrative Costs

By Lambert Strether of Corrente.

I thought of working words like “debacle,” “scam,” or “bezzle” into the headline, but today is my day to be kind (and the entire topic really demands that I pull on my yellow waders and write another “Credentialism and Corruption” post, which I might do at a later time). However, the headlines give a sense of what a bombshell this study should be for the EHR industry. On the spectrum from reluctant admissions all the way through to The Bezzle:

  1. Electronic health records don’t cut administrative costs Harvard Gazette (February 20, 2018).
  2. Electronic Health Records Don’t Reduce Administrative Costs Harvard Business School (February 20, 2018).
  3. EHRs fall short in reducing administrative costs Health Data Management (February 21, 2018).
  4. Why health IT experts think Apple will succeed where Google failed with medical records Health IT and CIO Review
  5. An Introduction to Medicalchain: Blockchain for Electronic Health Records CryptoSlate. (This is from February 8, but I couldn’t resist.)

The complete study (an “Original Investigation”) is here at the Journal of the American Medical Association. Unfortunately, the study is paywalled, and the study material that JAMA exposes muffles the bombshell. From the abtract, the methodology:

Design, Setting, and Participants This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system’s total cost of processing an insurance claim.

(The Harvard Gazette calls the “process map” methology “state of the art.”). And the results:

Main Outcomes and Measures Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures.

Results Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures.

I don’t understand why the JAMA abstract merely lists the dollar costs of EHRs, rather than comparing them to non-EHR systems; however, the study authors have been happy to do that for us in the press. The Harvard Gazette:

“We found no evidence that adoption of these expensive electronic health record systems reduced billing costs related to physician services,” said Kevin Schulman of the Duke Clinical Research Institute, the Duke University School of Medicine, and Harvard Business School, one of the study’s authors.

From Health Data Management:

“We keep hearing about electronic health records and how they are supposed to improve the efficiency of hospital administration,” says study co-author Barak Richman of the Duke University School of Law and the Duke-Margolis Center for Health Policy. “We found that, as a general percentage of revenue, the amount expended on billing and administrative costs is just as high as it was before EHRs were adopted. Some people thought that EHRs were going to be the solution—and, they’re not.”

And fom Modern Healthcare:

Administrative costs made up as much as a quarter of professional revenue for some patient encounters, according to the study, which focused on a single academic medical center. Researchers attribute much of the high cost to varying contracts between the hospital and health plans and payer as well as varying price schedules.

“After investing more than $30 billion in health IT, we haven’t improved the administrative efficiency,” said Dr. Kevin Schulman, one of the study authors and the associate director of the Duke Clinical Research Institute. “That was one of the big promises of digitizing records.

(Ka-ching. Thanks, Obama!) And in an editorial accompanying the article, JAMA does explode the bombshell:

As high as these figures are, they likely underestimate the true financial burden of billing for physicians in most health systems. For one, the hospital and physicians of [the academic system in the study] share a single billing organization, an unusual efficiency for an industry in which hospitals and phyicians are typically separate business entities. In addition, billing costs in this study did not include costs within clinical department for credentialing [nota bene –lambert] and other billing-related functions or charge integrity costs (ie, the costs associated with ensuring that all health care delivery charges are accounted for and properly acrruved to each patient or discharge). While annual operating costs of the EHR were included in this estimate of billing costs, the capital costs of the EHR were not. When the full costs of EHR installation and implementation were fully amortized an attributed to billing, the calculated costs of billing increased by another 44% to 68%. As the authors point out, the appropriate allocation of EHR costs clearly requires further refinement.

(“Further refinement.” Dry. Very dry.)

In this brief post, I won’t review the many reasons why EHRs have always been a bad idea (except for those profiting from installing them, of course; see NC in 2014, 2014, 2014, 2015, and 2015). Rather, I’ll allow a doctor to explain how EHRs cause practitioners burn out. The New England Journal of Medicine:

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care.

“We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

You would expect the results of destroying the morale of doctors to be bad for patients, and so it is:

Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.

What to do? One obvious answer is to stop building EHRs and roll back the systems that are in place.[1] Why not use paper? Roy Poses writes in Health Care Renewal:

I now make a prediction for the future that, once again, seems obvious to me:

Today’s EHRs, especially the sections for narrative clinician documentation, will be downgraded from their “template madness” time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper. Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s’ as at, but paper nonetheless. Data extraction of these notes for financial purposes will be done, once again, by coders.

But this solution might well be fit within a larger, systemic solution. Because why are EHRs so hard? Because — drumroll please — a multiple payer system is hard to program for. Modern Health:

“Adoption of certified EHR systems by hospitals appears to have been unable to cope with the complexity of multiple payer contracts,” the study authors wrote.

(That “certified” is important; CMS’s Medicare and Medicaid EHR Incentive Programs actually require providers to sign attestations that their systems are conformant.)

And the Harvard Gazette:

“To a large degree, the significant administrative costs measured in this study are the consequences of heterogeneous payment requirements across the multiple payers and health plans contracting with the academic health center,” said another study author, Barak Richman of the Duke University School of Law and the Duke-Margolis Center for Health Policy. “We need to understand better how complexity is driving these enormous costs within the system, costs that do not add value to patients, employers, or providers.”

Thus, as so often happens, what is framed as a technical problem is in fact a problem in political economy. In software, complexity is the enemy of quality, and in this case the complexity is created by the multiple payer system that the EHRs are trying to model. Dare I dream that JAMA is finally coming round to single payer?


[1] An analogy between EHRs and electronic voting suggests itself. Why on earth are we trying to turn local election officials into IT specialists, when we could adopt a simple, rugged, and proven system like hand-marked paper ballots, hand-counted in public?

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Alex V

    Opinion on EHRs in a single payer system from the commentariat? I livee in Sweden with single payer and can’t say I’ve personally encountered any downsides, although I’m sure they exist. I can, for example, read all my medical journal entries from all medical visits whenever I want to, online. That of course has security risks, but haven’t heard of breaches. Yet.

    1. Altandmain

      You cannot compare a universal healthcare system to the for profit system and frankly, mess, that is the American healthcare system.

      The issue is that the way that the electronic health system works, it is clearly designed to try to maximize revenue and not improve patient outcomes.

      1. Malcolm MacLeod, MD

        Altandmain: You are completely correct. I’ve been preaching single payer
        Medicare for All for years and years, but nothing changes. Profit, and lots
        of it, has become the primary motivation. Sad.

          1. sgt_doom

            Thanks for this great article, Mr. Strether!

            I once briefly worked for a medical records outfit (before they offshored all our jobs) which was once of the sleaziest places I have ever worked, admittedly in the midst of a private equity/MBO “pump and dump” but got caught off guard badly on the dump side!

            The people in management were sociopaths, the workers not much better, and this outfit brought in a “Hostile Workplace Specialist” (someone to advise the senior executives on how best to create a hostile workplace to encourage the few remaining workers to leave, instead of just laying them off outright!!!) – – definitely typical criminal corporation one finds today in America.

    2. oh

      I hope you realize that hospitals in the USA applied for and received millions of $$$$ from the govt. during the Obama administration and put it to use – to maximize and monitor billings to the detriment of doctors and patients. Doctors are forced to enter data into a profit centric system that is quite unwieldy and one where data is not shared been hospitals or caregivers.

      Systems in other countries help the patients, doctors and hospitals to retrieve records to help treat patients.

  2. Bobby Gladd

    “…a simple, rugged, and proven system like hand-marked paper ballots, hand-counted in public?”

    Well, tallying up among one of “n” candidates or “yes/no” on a ballot initiative is simple relative to managing the 3.500 to 4,000 variables comprising the database “under the hood” in the typical ambulatory EMR.

    WAIT! I know! Blockchain to the Rescue!

    The problem is the economic imperative, not digital tech per se.

    Single Payer.

  3. allan

    “What to do? One obvious answer is to stop building EHRs and roll back the systems that are in place.”

    No, no ,no, no, no. Like Mallory contemplating Everest, they will do it because it’s there.
    In a recent Five Year Plan at a nearby U, two of the five most expensive projects were
    eight-figure “investments” in IT, including digging the EHR hole wider and deeper.
    Resistance is futile.

  4. rd

    Uhhh…I thought the purpose of EHRs was to improve patient care by having the patient’s medical history in an available, accessble form as the patients bounces from doctor to facility to another doctor. This would be so that care can be given using a fairly complete picture of the patient instead of just treating a toe that is disconnected from a body and a mind. This should result in lower overall medical costs by reducing complications and errors that are the cause of a lot of unexpected medical costs, but have little to do with administrative costs.

    It never crossed my mind that EHRs were supposed to reduce administration costs, since every medical entity has at least one, if not more than one, administrative branches associated dedicated to billing, insurance, collections ,denying care etc. To cut administrative costs, it would be necessary to reduce the number of entities attempting to collect money or prevent payments.

    1. Disturbed Voter

      Saving money or providing increased benefits … for who? That is the unasked question. It matters who “who” is.

    2. Summer

      They are thinking of saving processing time as in cutting workers – money that won’t have to be paid.

      You thought they were concerned with better record accuracy in order to provide quality care for patients.
      That would be too much like right.

    3. Harold

      When you change doctors they never read your charts, paper or electronic. They just insist you go back to square one and take all the tests and/ go through the whole protocol all over again. That has been our experience.

    4. Yves Smith

      We’ve run many cross posts from Health Care Renewal on what a disaster EHRs are. They are all about billing. And not only that, there is considerable evidence they degrade care. One study identified them as the biggest risk to patients in hospital systems.

    5. Lambert Strether Post author

      > Uhhh…I thought the purpose of EHRs was to improve patient care… It never crossed my mind that EHRs were supposed to reduce administration cost

      New in town?

      * * *

      I wrote:

      One point that I don’t see made very often: Medical coding is currently used to figure out how to bill for health care services. This is, however, an insane perversion of the coding taxonomies, which were originally designed to classify health care delivery as such, not billing for health care. (If you don’t see a distinction here, you may be a neoliberal.) If we could re-engineer medical coding[4] by using its taxonomies for the purpose for which they were originally designed, we might learn a lot about how to deliver health care, besides saving a large number of skilled and well-paying jobs.

      I believe we’ve got some medical coders in the readership; please correct me if I am wrong.

      1. oh

        Hospitals with EHRs are forcing doctors to enter data (on their own time in many cases) and are bypassing coders, thus fattening their bulging wallets. I know doctors who complain about having to enter data into these systems.

  5. ramore

    This Duke study is studying the wrong thing. The principle behind EHR needs to be – enter information once at the time of origin and the information flows to where it is needed. That it has an administrative role, i.e., getting paid, is a secondary use. That the administrative side is cumbersome is a “feature” from the payer side rather than a bug.

    The savings on an integrated electronic system is that an emergency physician or specialist knows what your primary care physician knows and vice versa. A physician not traditionally in your care process, e.g. you’re traveling or a new physician in a different specialty, can know what his/her predecessors know.

    An electronic system checks for drug to drug interactions or dosage problems that occur within a paper system. These savings are huge from my experience.

    What ACA did not address was the payer system and the ability for payers to figure out ways to game the system. It tried to control this by mandating the service offerings but that is the front-end. It needed to address the back-end as well.

    One can tell the problem isn’t solved until one starts to see health insurers leave their fancy buildings in high rent neighborhoods and locate within low cost locations and facilities.

    1. Yves Smith

      With all due respect, you don’t know what you are talking about. EHRs were never designed to improve patient care. They are extremely cumbersome for doctors to use, require them to page through tons of checklists and make it difficult to provide and access observational notes.

      1. Oregoncharles

        ramore: “The principle behind EHR needs to be” – emphasis NEEDS. I’m not sure you disagree; they’re describing the way it SHOULD work. You’re saying it doesn’t work that way.

        1. Yves Smith

          There has been too much invested in EHRs for anyone to throw them all out and start over. That is how radical the changes need to be. Hence talk about what needs to be isn’t operative. MBAs are now running health care, not doctors, and provisions in the ACA that basically make it close to impossible for doctors who takes insurance to operate as a solo practitioner or even in a small practice guarantee that. We’ve been writing about the corporatization of medicine for at least three years.

      2. Chris

        With all due respect, Yves, your perspective may be correct in a U.S. context, but among countries that are not the U.S. (aka “the rest of the world”) there are many which have a single payer or predominant payer system, where billing is either irrelevant or an afterthought. In those countries, ramore’s comments about the purpose of an EHR are valid.

        In Scandinavia, for example, health systems see no value in offerings from US EHR vendors, and get local IT firms to build what they need.

    2. Lambert Strether Post author

      > The principle behind EHR needs to be – enter information once at the time of origin and the information flows to where it is needed.

      Your idea seems to be that information entry is frictionless, even if the EHR UI/UX were not such that doctor’s were looking screens all the time, instead of at the patient.

      It’s not. “Enter information once” turns doctors into file clerks. Not, perhaps, the best use of their skills.

      1. Disturbed Voter

        Example …

        My doctor has the nurse/tech meet with me first, to take, and record, all the routine information. Then the doctor comes in for the one-on-one … and makes whatever orders need to be made, including recommending the next visit. Then I see the admin on the way out (similar to the one I saw on the way in) who then actually schedules the next appointment or the lab (if it can’t be taken by the tech/nurse when I first arrived for the current appointment). My doctor just got out of med school, and I think she is optimizing her expert time. Of course, the goal for her is to spend as little time as possible with each patient, so that as many patients can be seen in a work day as possible. It would be uneconomical for her to spend all day chatting with the hypochondriacs or seniors.

  6. Lee

    I’m not sure this is salient but I’ve opted for a single large scale provider, Stanford, for primary and specialist care firstly because they are the only cutting edge provider for my orphan disease and secondly, everyone I see has ready access to my complex medical history. And last but perhaps not least, all my docs happen to be skillful, good humored, and witty young women. Am I being politically incorrect? If so, I don’t care.

    A more or less concurring voice from Dr. Novella at Science Based Medicine

    Electronic medical records

    Electronic medical records (EMRs) were supposed to improve the practice of medicine, increase efficiency, improved outcomes, reduce errors, and decrease costs. The actual benefits have been modest, however. A recent analysis finds that EMRs are just barely cost effective, with a benefit-cost ratio of 1.23 and a payback period of >6 years. However, this analysis does not include the price of data breaches, which is estimated at over $50 billion since 2009…..

    It is not clear where the disconnect is, but in my experience (being involved in implementing EMRs at my own institution) the problem is in communicating between IT experts and medical experts. IT experts don’t understand what health care providers need, and the providers don’t necessarily understand what an EMR can and should do. Key individuals with dual expertise are needed to bridge the gap.

    Further, the quality of available EMR applications just lags behind more popular applications. With the EMR I currently use there seems to have been zero investment in designing the user interface. This leads to unnecessary mouse clicks, increased cognitive work, decreased efficiency, and increased errors.

  7. Jack

    From the article here and previous ones I have read on both NC and elsewhere, I think using “EHR” is a misnomer. Clearly, the problem is not with the recording of a patients history, diagnosis, testing, and treatment in a n electronic format. It is shoehorning the recording of information into a billing system, which seems to be the primary purpose of all these EHR attempts. I have used the VA for medical treatment for years and they have an EHR system that works well. I can go online, view and print, every single visit, prescription, test, procedure, and treatment I have ever had. When I see a new physician (my primary care doc recently changed) everything about me is at her fingertips. Heck, I don’t have to even see the doc sometimes. Just secure message the VA, the nurse reviews, the doc prescribes or schedules a test, all without ever having set foot in the door of the clinic or hospital. But that system is NOT a billing system. That is what these systems mentioned here should be called.

    1. Arizona Slim

      The VA system is called VISTA. And I’ve heard that it’s open source and could be used outside the VA.

    2. Lambert Strether Post author

      I have heard good things about Vista — written, IIRC, in the MUMPS language — but “you go to war with the EHRs you have.” The next time I write on this, I’ll have to find out of CMS certifies VISTA; somehow I doubt that it does, that would be too sane.

    3. Chris

      In a sense, VA is a single payer healthcare system that sits embedded within the U.S. That’s why VISTA can focus on being just an EHR, without the billing.

      And it’s a pretty effective EHR. When Katrina hit, VA’s New Orleans patients had their VISTA records (including medication details) back online in around 36 hours.

      1. mcwoot

        Maybe my post wasn’t clear, but your link echoes my point that portability is a clear, natural patient benefit of EMR in concept. It is the poor design and execution of these legacy systems that limit or prevent such portability. I expect this is because these systems were designed as billing tools first and foremost. But as described in the link, the benefits are such that the concept of EMR shouldn’t be discounted just because the current examples are crappily executed.

        1. Lambert Strether Post author

          Your post was perfectly clear.

          You wrote:

          a significant benefit of EMR is portability

          Had you meant to write:

          a possible benefit of EMR is portability

          Presumably you would have done so. It’s the difference between

          I have a pony


          I want a pony.

          This is not hard.

          1. mcwoot

            I’m not being intentionally obtuse, but I feel that response is a little harsh. As a patient and consumer of healthcare, portability is extremely important to me, and a digital records system seems to be the best way to achieve that. So from the patient perspective it is a benefit of EMR (vis a vis paper records scattered across everywhere the patient has ever lived). Unfortunately the current execution models aren’t designed to deliver. But I would expect a better solution on that front would be an EMR system designed properly, rather than a return to paper records.

          2. mcwoot

            Maybe it’s better to say it a different way – digitized records are portable in a way that is impossible for a suitcase of paper files. So from the patient’s perspective the benefit of an electronic records system is the ability to have portability of records. Again, it’s unfortunate that current execution is not designed to support this.

            1. Roxan

              Recently, I went to see a specialist at a major hospital. They gave me a 5 page printout about the ‘cure’ they were proposing, which was pasted together, randomly, and all about the wrong drug! No one bothered to read it or notice that it didn’t make sense. Things have continued in that manner. It’s too difficult even to get records from one dept to another, never mind from one institution to another.
              Also, used to know someone who did ER coding. They made her do 300 charts a day, plus two more hours at home. All were sent online. A terrible job!

      2. Chris

        The VISTA records from New Orleans were portable, Yves.
        The problem you identify is a consequence of choices by most U.S. EHR vendors, providers and insurers to prefer siloed systems rather than standardised, interoperable alternatives. Those choices are almost certainly driven by commercial considerations (protecting market share, locking in customers, charging for records transfers, hiding errors).

        And try not to conflate EHRs with billing systems.

  8. Beans

    The EHR is at least in part a jobs program, much like the TSA. But unlike the TSA, which has made travelling much more of a challenge to the passengers, the EHR has remade the way physicians shape their clinical thought process. In the past, a doctor was trained to think based on the creation of a SOAP note – (Subjective, Objective, Assessment, Plan) – this model put all the facts and observations on the table BEFORE a plan of treatment was made. The format of writing a SOAP note had a direct impact on how physicians thought through diagnosis and treatment. The mental training of conforming to a SOAP note had far more benefits than drawbacks, IMO, and gave physicians a frame of reference that shaped their thinking over the course of their career.
    The EHR I have used does not model the SOAP process. Instead I am walked through a mirade of screens that I have to click as “reviewed” (including Ebola screening) that can misdirect my train of thought from what is presenting to making sure that I am clicking all the right boxes so that I can ultimately close the chart. Added to the distraction are the meaningful use checkoffs that I am strongly encouraged (and audited to determine my compliance with the encouragement) so that my institution can obtain an incentive payment.

    1. m

      After the patient with Ebola in TX, EHRs now have a mandatory bunch of check boxes on admit related to travel. With the numerous shootings we now have a few drop boxes to check related to guns in the home.

      The systems out there are so expensive that once a hospital invests in the overpriced junk they are stuck. U of AZ had just purchased EPIC, went broke, got bought out by Banner Health & now must change to Cerner. Crazy!

      Perhaps, by being forced to use these drop & check boxes some future AI MD can replace the human MD based on algorithms, rather than individualized health care.

      But what do I know I just am an end user of this garbage. The politicians got nice donations and EPIC & Cerner went to the bank by having regulations forcing MDs & hospitals by the stuff to be CMS (Medicare/Medicaid) compliant.

  9. PlutoniumKun

    Not quite on topic I know, but on the general subject of the digitisation of public services, a few weeks ago I was having a conversation with a long time public sector union activist. She was saying that she gets constant complaints from members about the disruptive impact of new IT systems. I asked if the Union ever fought against IT upgrades. ‘Hell no’ she laughed ‘In 20 years of doing this job I’ve never yet seen one that didn’t end up requiring even more workers to do the same job!’

  10. The Rev Kev

    “Because why are EHRs so hard? Because — drumroll please — a multiple payer system is hard to program for.”

    Well there’s your answer right away. America should switch to single-payer health straight away and there would that problem gone.

  11. Merlin

    As a patient I have mixed feelings about EHRs.

    When I changed my primary care physician a few years ago I was surprised that the new doctor spent the greater part of my initial appointment entering data on her computer, turning her head every so often to look at me. It not only seemed to me a great waste of time for a highly paid professional but I thought doctors could sometimes get useful diagnostic clues from a patient’s physical appearance. On the plus side, it appears to be really trivial for the doctor to fire off a prescription to my drug plan or local pharmacy.

    My other experience with EHRs was at my ophthalmologist’s office. About five years ago I noticed that computers started appearing in all the exam rooms. Curious, I asked about them and the doctor told me that it was something they were being forced to do and it was costing the practice $150,000. For a couple of years the computers remained unused. I assumed they were having trouble getting used to the software or maybe the transition from paper records was just too daunting.

    In any case, my old doctor has retired and his successor seems to be taking full advantage of their EHR system. He is treating me for glaucoma and I have quarterly checkups so I have a huge amount of data (my old paper chart was already a couple inches thick). The doctor zips through my file like a virtuoso, pulling up past measurements of intraocular pressure, reviewing visual field tests, comparing retinal images, etc. It seems to me that viewing all this information would be a lot more difficult with paper records.

  12. Anonymous II

    I guess I am so astounded by the premise of this whole series of articles that I will require clarification. I am not questioning the worthiness of this discussion but my mind is reeling.

    So is the premise that the idea of electronic Health Records is a bad idea or that the current implementation of electronic records has gone off the rails? Because adhering to the idea of paper records has to be compared to some latter day remnant of. . . I’ll stop. Perhaps the folks at the AMA have never filled out a paper claim form?

    Let me draw a picture of that arduous task. Get out your typewriter . . . no, please we can’t go there. Get out your pen . . . no, that’s worse yet as whiteout is still messy. The next best thing, so we can adhere to the paper format, is to have a programmer come into the office (or the office manager can arrange to have off the shelf software installed) so a desktop computer or laptop can be the biller’s assistant. Ok, so set up software in the office desktop so an ‘electronic’ (digital) proxy or facsimile of the claim form appears on the desktop screen and the biller can enter and tab through the 56 different boxes that make up the form. Then have a printer loaded with paper copies of claim forms and then the printer will print off the form which will be mailed off to the payer.

    At this point, a serious question arises: since all of the data is digital, why must we download that to a paper form to submit? Because again, and I will not yield on this, pen to paper is not an option for record keeping in any kind of practice that kept its doors open after the likes of Marcus Welby retired. Many practices and facilities most likely do have software mentioned above. But again, why, when the information is in a digital format would anyone reduce and partially inhibit the usefulness of that format and drag it down to snail mail or courier and paper envelopes? Why? My brain is aching.

    Remember when we used to write letters back and forth to one another? Then computers came along and you composed those chummy missives in Word and mailed them off.
    Oh wait.
    I only did that once or twice.

    So is the problem that the implementation of EHR is run amok of bad software development?

    Well blow me down. Because I thought Microsoft had brought us into the land of . . .

    Again, I’ll stop.

    So it’s the software issue right? It’s poorly designed and written, full of bugs, not user friendly, destroys the creativity of the user, hobbles work flows, has built in arcane defaults that can’t be over-ridden, has numerous updates that unhinge a lot more situations than what are fixed, has a support staff that writes you responses to say you should check your spam except the spam filter didn’t stop their non-existent email, relies on protocols that were simplistically and severely limited in 1987, does not comply with many design features of well-established platforms, and to top it all of the software manufacturers are managed by a group of godless, insulting, arrogant SOB’s who still believe their piece of shit software is a gift worthy of enshrinement in all of the temples of the land. So that’s the problem!

    1. Anonymous II

      By the way, electronic medical billing direct to insurance companies has been around since about 1994?
      Is this conversation in today’s post about billing or electronic health records?
      Because they’re two completely different topics in so many ways.
      Still in all,
      my comparison to Dr. Welby is apt
      I had the wonderful experience, in 2007, when I did not have a car, and had to take a 45 minute bus ride, of traveling to the hospital where I had been treated to have them haul out a CD of my tests, so I could be the courier and run it back to my doctor’s office.

      I truly believe the AMA is 50 years behind the times.

      Of course I could have ridden my buck wagon to the hospital and back to the provider’s office
      Ah for the good old days

    2. Lambert Strether Post author

      Do consider reading the studies and the links. You will find many of your questions answered there, and you will save yourself a good deal of time writing, and the commentariat a good deal of time reading. You write:

      I will not yield on this, pen to paper is not an option for record keeping

      Nobody’s asking you to “yield.” The answer is right in the post, from Roy Poses, M.D., who has been working this vineyard for years:

      Today’s EHRs, especially the sections for narrative clinician documentation, will be downgraded from their “template madness” time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper. Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s’ as at, but paper nonetheless. Data extraction of these notes for financial purposes will be done, once again, by coders.

      Shorter: You’ve heard of scanners?

  13. Dr. P

    Anonymous II, if you really think that your crosstown bus experience from 2007 no longer occurs, think again.

    Back in 2004, George W. Bush articulated his vision for the government-mandated EMR revolution. Here is part of the vision, quoted from the White House Archives:

    “The President called for the completion and adoption of standards that will allow medical information to be stored and shared electronically while assuring privacy and security. The necessary work is already well underway and much of it has already been completed. In the last several years, the Department of Health and Human Services (HHS) has been collaborating with the private sector and other Federal agencies to identify and endorse voluntary standards that are necessary for health information to be shared safely and securely among health care providers. Federal agencies are accelerating their use of these standards.”

    An admirable goal that has yet to be achieved. Hospitals at which I practice are absolutely unable to exchange information, other than by fax. They are in silos. The doctors in their offices around town? A myriad of EMRs are represented, none of which communicate with each other, nor do they communicate with the enterprise EMRs at the hospitals. Amazed patients ask me all the time, “isn’t all this in my records?” The answer is yes, but since EMRs do not talk to each other, the best way to exchange records is to print them from one EMR and fax them over to the consulting doctor’s office to be scanned into another EMR. The situation would be laughable if I didn’t live it every day. I STILL have patients bring copies of records to the office, and have a stack of CDs on my desk right now from various hospitals. The problem is our government took what I have often called a “bottom up” approach to EMR adoption, rather than a “top down” approach. There was absolutely no attention at all paid to President Bush’s original vision as quoted above: EMRs were not required to exchange information. CMS is just beginning to require EMRs to exchange rudimentary information, but if the software doesn’t work right, guess who gets penalized? The doctor, not the software company.

  14. MedicalQuack

    Oh yes EHRs are money makers for the insurers. It wasn’t always that way, as it was a good idea to have medical records organized in a program to access all pertinent information about your care, I know I wrote one in the early days, integrated it with billing software and brought in the lab results. The bill software still had to function and billing still needed to be done but the EHR records populated a lot of data that didn’t have to be typed in, so it made it easier and faster to bill, basically all the information you used to get when the doctors gave you a copy of the SuperBill.

    Enter the insurance business, and this is where it all began to get real complicated. In came the templates of text for doctors to enter that had all the correct wording that would lead to the appropriate code and then we had SMOMED text to coding, and it went on from there. So you would see your md and the record had 4 pages of a one minute visit. It was not was it was supposed to be, no longer in the doctors words. Then came the analytics and that’s what the insurers wanted to start scoring doctors from their input…I could go on and on, but it turned into a monster of data algorithms and not the simple program used to create records, bill and store information. Once the payers got involved in what they wanted from an EHR, it all went into complex perceptual creation of madness.

    Recently I wrote about the prescription coupons that connect to EHRs, so they get the doctor to send off an electronic coupon to the pharmacy and that’s another story in itself so it enriches the PBMs so they can be assured of capturing every DIR fee that they can. Drug stores pay those fees and Publix warehouse auditors about had a cow recently asking what is this $25 million dollar charge we pay, it’s the DIR fees of having the privilege of filling your prescription and being in the network, so be aware next of your doctor offering you an e-coupon for your script through your EHR. The EHR has been given tentacles to almost every profit center in the business and this is just one example, and if the doctors don’t put the correct records in and get the right code in there, it comes after them, as they are scored to death on their EHR performance.

    Again, wasn’t a bad plan to begin with but once the government got involved with the incentives, the whole game changed.

  15. Barbara Kurth

    I worked at Duke Medical Center as a Research Practice Manager (I was a PhD research scientist for many years prior to working at Duke) just as EPIC was being introduced to Duke. It was a nightmare for anyone needing to input and trouble shoot no matter how much people protested otherwise. Duke decided to “be the first” to use EPIC for research as well as clinical practice so you may be able to imagine what billing was like for that. I managed to stick it out for about 3 years then retired before I became a screaming me me. Actually i probably retired after becoming a screaming me me.

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