Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Empowered by the digital revolution, the U.S. government claimed that turning American medical charts into electronic records would make health care better, safer and cheaper. Ten years and $36 billion later, the system is an unholy mess. KHN partnered with Fortune magazine to investigate this botched operation.
The resulting story, “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong” (March 18), proved clicky on social media. Even Seema Verma, administrator of the Centers for Medicare & Medicaid Services, who was interviewed for the feature, tweeted it out.
The below article shares the findings of a joint investigation by @FortuneMagazine & @KHNews on the impact of a messy EHR system. Take a moment to read through to better understand EHRs w/in our #healthcare system, & the direct impact it could have on you: https://t.co/pKkHGLr3u4
— Administrator Seema Verma (@SeemaCMS) March 18, 2019
1,000 Missed Details?
Your recent investigation into the problems with electronic medical records was interesting and consistent with my experience when our medical group (UW-Madison) purchased EPIC Systems for our clinics and hospital. One thing not mentioned in your report was this: In most technology advancements, job loss occurs. With the EMR, a whole new labor force developed beyond the software people needed to install and maintain the system. They are called “Scribes.” Does it make sense that with the modern EMR we have actually had to add jobs to achieve efficiency?
— Dr. Gregory L. Sheehy, Madison, Wis.
This is a very thorough article but, tellingly, there are no EHR screenshots demonstrating how thoroughly wacked the average EHR UI is.
— David Mann (@manndmd) March 19, 2019
— Dr. David Mann, Parker, Colo.
My criticism of your “Death By 1,000 Clicks” article is generally not about what it says but what it doesn’t say and its tone. The article emphasizes the undeniable fact that EHRs cause new sources of medical error that can damage patients. It devotes a lot of ink to documenting cases in dramatic terms. With hundreds of vendors and thousands of hospitals, the quality of EHR software and how it is implemented is highly variable. Among the major weaknesses of some EHRs are awkward user interfaces that can lead to errors.
However, the article fails to note the ways EHRs can, if properly used, help prevent errors. It briefly mentions that around 60% of physicians using EHRs feel they improve care quality. But it fails to discuss new, exciting technologies to improve EHR usability, data-sharing and patient access to their digital records (patient-facing APIs, SMART FHIR apps). Studies suggest that EHRs even improve physician-patient communications.
A substantial part of the tremendous increase in physician documentation is not caused by EHRs but by the need to obtain more data on why expensive tests and procedures are being ordered in an attempt to rein in out-of-control health care costs and to support new “value-based” reimbursement of care. Clearly, EHRs could be better designed to help with these burdensome new requirements and work is ongoing to do that, but the article gives the impression that EHRs are the sole cause of physician burnout. Simply not true.
Yes, the health care system has huge issues with patient safety, but it had them before EHRs and there is no evidence I am aware of that they have, all together, made the problem worse. Unlike paper records, digital health care records can and actually are being shared. The data they contain is becoming the platform for innovation to fix EHRs, engage patients and help address many of the other structural problems in our massively complex, error-prone and expensive U.S. health care system.
— Dr. Mark L. Braunstein, Atlanta
Editor’s note: Dr. Braunstein developed one of the first electronic medical record systems in the early 1970s. His latest book is “Health Informatics on FHIR: How HL7’s New API is Transforming Healthcare.”
In depth article except for the concentration on MDs exclusively! #nurses are in the #EHR 24/7. Check out our article (Staggers, Elias,Alexander, Makar)on nurses’ EHR pain points. Lack of #usability is an issue for all disciplines when it comes to EHRs# #nurses4HIT
— Dr. Ellen Makar RN (@Makarel5) March 21, 2019
— Ellen Makar, Washington, D.C.
Your “Death By 1000 Clicks” article paints a bleak picture of the state of electronic health records (EHRs) in the U.S. There is little doubt that the introduction of EHRs has added a clerical burden to physicians, and information sharing has not materialized at the expected rate. However, based on my own research in the area of eHealth adoption and implementation, I disagree with the authors’ conclusions.
The article relies heavily on individual stories but does not address the overall rate of error. The stories are horrifying, and the suffering of the individuals affected should not be diminished. But it matters if they represent a 5% or 0.005% error rate. It also matters what the error rate is compared with pre-EHR implementation. In the organizations I have observed and data I have seen, the evidence clearly suggests that the EHR error rate is lower. The article also ignores the possibilities created by EHRs for clinical decision-making by gathering millions of treatment records. We are just starting to use the data collected to support evidence-based care, but that capability is another counterpoint to the arguments in the article.
The article suggests that the problems reflect (yet another) failure of the federal government. However, research evidence does not bear this out. EHR deployment and information sharing have been challenges in virtually every nation, regardless of the level of government involvement. The government will always be involved because health care is a public good, but the challenge is not because it is a government operation; it is because it is incredibly complex.
The struggle has never been just about technology — it is about the need to move from highly individualized, disconnected processes to much more structured and connected processes. These processes are fraught with difficulties making progress seem slow. But branding them a failure because they have not yet fully evolved is inaccurate in the face of the benefits they have demonstrated, and unhelpful because it perpetuates a view of how they should be managed that may undermine their progress.
— Deborah Compeau, senior associate dean of faculty affairs and research at the Washington State University Carson College of Business, Pullman, Wash.
Actually we have a lot to show for it, little of which is positive. Like many policy dictates, once started there is no assessment of effect & corrective action. We should be in the 6th iteration by now #EHR #healthpolicy #burnout #ptcare
— David May (@DavidMayMD) March 19, 2019
— Dr. David May, Dallas
Your electronic health records coverage was fairly comprehensive. But you neglected to highlight that the Obama administration incentive was both a carrot and a stick. You correctly described the amount of money promised if a physician practice implemented an EHR but neglected to mention that the cost of that implementation often equaled or exceeded the government subsidy. Furthermore, if a practice did not comply with the implementation within five years, they would be subject to a fine of their Medicare billing, which increased every year. If the fine had not been present, few physicians or institutions would have changed.
My 19-person orthopedic practice had had a limited EHR for record keeping for more than a decade. Simple functions that you take for granted in your word-processing program, like being able to undo a mistakenly checked template, do not exist and you have to go back through the entire note to delete erroneous entries. We are not Luddites, but technologically savvy individuals. EHRs were not adopted by the medical community because they did not and still do not work efficiently.
Additionally, you noted that the proprietary nature of EHRs is because of the desire of doctors and health systems to maintain patient control. Wrong. Patients do not choose doctors based on their EHRs. You have put the saddle on the wrong horse. EHRs are motivated to keep their systems individual because they do not want doctors and their institutions to change to a better EHR. When we went with our current EHR, our accounts receivable went from under 30 days to over double that amount, and the individual doctors exhausted themselves learning and setting up the system after they had put in full days taking care of people. A new system would have little in common with our current one and learning a new system is not a headache that we wish to take on, unless there was a clear advantage. EHR companies would have little motivation to agreeing to industry standards that would make the systems have more in common for fear that their customers indeed might change.
— Dr. F. Ray Nickel, Ventura, Calif.
Why Knee Braces Can Cost An Arm And A Leg
I am an internist. Most primary care offices do not mark up durable medical equipment by 200% to 400%, as your story suggests (“Price Of A Brace Brings Soccer Player To His Knees,” March 26). My office is required by contract to purchase such devices through our vendor for medical supplies and they price-gouge us. I know what we have to charge our patients to avoid losing money and tell them what we have to charge versus what they can buy it for online or at the pharmacy, and they decide. Sometimes to treat an acute injury, having the ability to dispense and be sure they receive the proper item that fits correctly trumps the extra cost. I applaud your story calling out clinics that do extreme markups but do not appreciate the blame being placed on the medical profession. One more little stab in our death by a thousand cuts.
— Dr. Janis Howatt, Portland, Ore.
Same happened to me but with a $150 wrist brace that was $40 online. The @Swedish clinic that prescribed it never returned my calls and the supplier said tough luck, the return period is up (I wasn't billed until weeks after that return window closed). Great system.
— Josh "Thanks Zags" Belzman (@JoshEdits) March 26, 2019
— Josh Belzman, Seattle
I am an orthopedic surgeon and a strong proponent of greater transparency and cost accountability in medicine. Do not forget that cost does not equal value. The price for durable medical equipment (DME), like a brace, includes all the overhead — the cost of acquisition, storage and dispensing — to provide that brace in a responsible manner. A trained tech assures the proper size and educates on the correct application and wear. These services are not available online or at a drugstore, and the employee’s salary and benefits must be paid. In the spirit of a balanced comment, a minor MCL sprain can and probably should be treated with a simpler brace with a much lower cost.
Insurance copays for DMEs can range from 15% to 85%, not a routine 20% anymore. This segues to my main point: medical billing. The U.S. health insurance system is shifting more of the cost to the patient in ever-increasing copays and deductibles while extorting higher and higher discounts from physicians, who then increase their chargemaster to offset the discounts. If the physician attempts to waive the copay or sell the DME directly (rather than go through insurance), he can face civil or criminal penalties.
The entire system is also designed to use cost shifting from commercial insurance to offset lower reimbursement from government payers like Medicaid, Medicare, the Indian Health Service and Tricare. In many cases, Medicaid reimbursement is not high enough to cover the bare overhead of a practice. This is driving more physicians into employed positions with hospitals and health care systems, which results in much higher health care costs overall as well as less access to care.
I am in favor of more transparent billing (which this soccer-playing patient admits he received but did not read). Where the emphasis should be is in more transparent contracting and reimbursement by insurances, simpler insurance coverage for enrollees, clearer explanation of benefits and more transparent billing from hospitals.
— Dr. William Ritchie, Albuquerque, N.M.
A Texas tweeter tossed out general praise for the “Bill of the Month” feature, a crowdsourced investigative partnership between KHN and NPR.
— Tanya Tussing (@tanyatussing) March 22, 2019
— Tanya Tussing, Austin, Texas
Damage Done By Cheating Scandal
Honestly, this is probably my biggest concern about the admission scandal, because it could hurt students across a wide swath of the higher ed landscape. Students With Disabilities Call College Admissions Cheating ‘Big Slap In The Face’ https://t.co/j0k3SvTdor via @khnews
— Palmer Muntz 🖇 (@PHMuntz) March 20, 2019
— Palmer Muntz, Vancouver, Wash.
People with learning disabilities are already put at a disadvantage that they can only partially overcome with the special testing accommodations they can qualify for. However, testing accommodations are difficult to qualify for, and many students who make use of that arrangement are accused of cheating. This whole scandal (“Students With Disabilities Call College Admissions Cheating ‘Big Slap In The Face,’” March 14) is not only an insult to the community of those facing mental health issues, it will make it even harder for those with legitimate learning disabilities to receive the arrangements they need to take the standardized tests required for acceptance into many colleges. This is yet another example of how mental health issues are not taken seriously, though they should be, since they impact millions of people, especially students.
— Srija Ponna, San Jose, Calif.
New flash: disabled people largely would rather not be. Scandals like this erode our credibility, furthering the “entitled” misconception. #TOBT
Students with disabilities call college admissions cheating “big slap in the face” – Kaiser Health News https://t.co/a1KRQ2Zb4y
— Rizzo Cromer (@TrainOrBTrained) March 15, 2019
— Rizzo Cromer, Reno, Nev.
Mental Health Care For All?
If we are going to move to a “Medicare-for-all” system, the public should understand that Medicare currently covers only psychologists and social workers for mental health treatment. Medicare does not cover the other master’s-level therapists (marriage and family therapists, or MFTs, and LPCs, or licensed professional counselors). I’m an MFT in Washington, and this means that Washington’s number of insurance-reimbursable psychotherapists would be cut by more than half (from about 20,000 to about 9,000). I’m willing to bet that most other states would experience similar cuts. I encourage everyone to contact their local representatives and senators about HR 945 or S 286, which are currently in committee and will expand Medicare coverage to include other master’s-level therapists.
— Jim York, Everett, Wash.