Why doesn’t America have electronic medical records?

Ezra Klein poses the question:

I’ve never read a compelling explanation of why the nation’s doctors and hospitals haven’t broadly adopted electronic medical records.  It’s not as if they’re allergic to technology.  At this point, cardiovascular care employs every strategy but astral projection to keep our in rhythm.  It’s not as if it wouldn’t be cheaper and easier for them.  The man hours and costs from keeping track of files, printing out labels, finding lost manila folders, and getting sued because the nurse misread the doctor’s handwriting are enormous.  Theoretically, insurers should be pushing on this, but they seem behind the curve, too.  And it’s not as if there aren’t tested programs in use — not only does Europe do electronic records well, but the VA does them beautifully, and they’ve released their primary program, ViSTA, as open source, for free use by anybody.

I can think of four reasons. 

1. Most of the benefits are reaped by the patient, and in the long run.  Today’s suppliers don’t realize these benefits in the form of profits.

2. The United States has relatively weak data protection laws.  Many people don’t want outsiders to know their medical history, and information compilers fear lawsuits if the information leaks out or is hacked.

3. No single provider has an incentive to move first in this game.  Why computerize if no one else has?

4. I haven’t computerized my office (is Alex laughing?), I worry more about surviving until the next day.

The comments over at Ezra’s are excellent.  And if you think that electronic records are the source of vast productivity gains, just have Medicare mandate such a change.  Readers?

Addendum: Here is Arnold Kling.


It's a public good. A lot of people would marginally gain from the public records, but no individual actor would benefit enough to fork over the cash for the IT needed for such a move. Clearly, either the hospital would need to see the cost-benefit advantage of such a move, or the health plans (including Medicare) would need to provide an incentive that would make it advantageous to the hospitals.

But as you alluded to a CMS mandate, this does seem like a situation where the government could intervene with a sharply directed mandate to provide a shortcut passed the market's slow-moving shift to EMRs.

Finally, something I actually know something about.

1. The United States has relatively weak data protection laws With the advent of HIPAA, that is no longer true.

2. Data capture is a significant problem. Input devices are slow, clumsy, and/or expensive. People still prefer pen and paper.

3. Interoperability standards are still evolving. This is a significant problem in compiling a unified medical record for a single patient across many providers.

4. As has been hinted, the biggest driver will be regulatory compliance - often at the state level, not necessarily the federal level.

That Europse does electronic records well is a bit of an overstatement. Here in Denmark the struggle to make electronic records is way over budget and is still long in the making and I believe (via www.adamsmith.org) that a similar thing is going on in England.

I always thought that a lot of the problem was the difficulty of getting everybody to use compatible systems. The VA can make it work because they can dictate to every one of their facilities what software to use. My company has toyed with the idea of giving clinicians laptops and using electronic charting, but we would still be turning our digital record into a fax, so that the facilities where we see patients could have a paper copy. In a large university hospital I have seen at least three electronic records systems in use, none of which could communicate with the others.

It doesn't seem like the "doctors use the latest technology, so why not electronic records" is a good argument, since learning the latest procedures and such gives them a competitive advantage, whereas e-medical records mostly serve to give them no such benefit, at a large fixed cost plus lowered productivity in the middle of a learning curve which will probably never end. There's an article on NextGen about an anecdotal issue that plagues older doctors with regards to digital records.

I work in the IT and medical industry. I've worked on EMR systems in the past and have some knowledge of how it works, how it's sold, etc.

There are a lot of problems that arise when developing software for the medical field. When you develop software, you are taking business rules and processes and translating them into a pattern that can be interpreted digitally. The problem with the medical field is that (due to government regulation) these rules are constantly in a state of flux. That's federal rules: state laws and regulations add another layer of complexity.

Creating a simple patient charting system is easy. It's the details that cause all of the problems (billing, scheduling, etc, etc).

The medical industry is so complicated (again, due to regulations) that software engineers that are willing to invest time and money in development have difficulty connecting with individuals who are experts in the field and knowledgable enough to translate the rules into something that a normal person can understand. Most of these 'experts' are already highly paid consultants and speakers. One individual may be an expert in Medicare billing rules for wheelchairs, while another individual may be an expert in enteral nutrition. Each sub-industry has it's own quirks and oddities: bringing it all together is a monumental undertaking. What may be true today may no longer be true tomorrow if a beaurocrat changes his mind.

That helps to explain the private sector: but what about the government?

Expecting the government to mandate some sort of nation-wide software will only end up in further inefficiencies. I've seen government software projects (in particular was the software used to calculate loan qualifications in New Orleans after Hurricane Katrina hit). They aren't pretty, let me tell you. It is extremely rare that a well-suited, talented company receives a government contract to write software. There's so much cronyism in that industry that the mere thought of a government-mandated centeral EMR database makes my tear my hair in despair.

This just sums up some of the issues that I have personally seen in the industry. I could go on for hours on this subject.

Patient mobility definitely goes on the other side of the equation, and ability to electronically transfer files in the case of an emergency arising on vacation, etc, would be a definite benefit. The cost/benefit equation probably also changes when you look at the truly massive recordkeeping that a large hospital or insurance company does.

Like most situations where person A derives a benefit from person B incurring a large hassle, I would expect the progress of electronic recordkeeping to be slow and gradual.

Finally a topic I know about. Most doctors are small business operators and EMR represents a big capital expense and ongoing cost as well. Since payments are fixed by insurance and Medicare, EMR represent an actual monetary loss to the doctor with no way to pay for the cost, even in the long term. I don't think EMR increase productivity since most established doctors are already as busy as they can be.A lot of the patient care notes cannot be done by EMR and must be hand written or dictated/typed into the patient chart. There is no OS or software standard across the country that all have agreed upon for EMR, so communicating between sites becomes a problem. The benefit for EMR is eventually the patient and the insurance companies, for different reasons, and the doctor loses money with EMR.

My health care provider/insurer is fully electronic. Every room has a computer that’s used to pull my file, write notes, access test results, etc. Everything always seems to go smoothly and longest I’ve ever spent in the waiting room is 5 minutes. I can access my own personal medical records online if I wish. The nurse/doctor types in my symptoms to the computer, and gets back a list of potential causes. Ultimately the Doctor makes the diagnosis, but the computer helps make sure he doesn't miss an important possibility. Further, my doctor (or a nurse) will reply to questions by email†¦ usually within a few hours (which often saves a visit).

My wife gave birth at this health provider’s facility and it was a wonderful experience. We stayed in the same room the entire time (30 hour labor!). We had a private room complete with bathroom, birthing tub and a chair that converted into a bed for me to sleep in. The room was well stocked with supplies, which meant time was not wasted running back and forth to the supply closet. Since there was a computer in our room, no need for nurses to run back and forth looking up information. Our baby was examined in the same room he was born in (he never left our sight). We dealt with a single nurse during each 12 hour shift. When shifts were changed, the nurses handed off our case while in the room with us. That way, if the departing nurse forgot to explain a detail, I would know. Of course, all the details were right there on the computer next to the bed anyway. At departure, there was no need to talk to a receptionist, because the nurse was able to check us out right from our room.

My provider is the low-cost managed plan offered by my company’s health benefits program. I’m a mid-level manager at an investor-owned utility, so it’s not as though I’m on some fancy-pants executive plan.

Maybe I’ve just been lucky, but I’ve never had any problems with the many insurance providers and health care providers I’ve used during my lifetime. In my experience, Managed care is great. It’s a real shame that it was so horribly demonized in the 90’s.

What do plastic surgeons do? Since they're in the private market, it'd be interesting to see how they've handled it.

Kaiser Permanente is going electronic at all their locations. They have already done so here in Central California. But they have an incentive to do it, since they are an insurer that provides almost all their care internal to the firm, and can do lots of helpful database queries internally to optimize care based on that data. Most other health care insurers probably do not have the same incentives to switch as Kaiser does.

So, this is all well and nice, but YMMV, depending on vendor, project, execution, hell, even how the contracts are structured (who's responsible for maintenance, will the state or the contractor be running things, . It's not for no damn good reason that Texas canceled the deal with Accenture to handle the CHIP program. Accenture dropped the ball big time -- instead of building and running the service even at the level of quality the state had been providing, they succumbed to the capitalist impulse to cut costs to increase profits too drastically, and the resulting degradation of service cost them the contract and the state lots of time and money to rehabilitate the program. Partially.

These matters are not simply economics, or improvement of service, or politics, or any of many other issues. They are a convolution of all of the issues.

pinus: HL7 is an annoying standard, but it's a standard, it exists, it works, and most medical systems can read and write it.

A problem with it is that there is a really wide variety of medical information that can be written, and so the standard is really, really, really large in an attempt to satisfy the many kinds of data that could be interchanged, and that leads to some confusion.

But, ultimately, it's not the obstacle. If there was a lot of money in the business of connecting healthcare systems, people iron out the kinks in HL7. The field languishes because the healthcare industry isn't really interested in finding good EHR products and buying them, not because the technology isn't there.

I've noticed a reluctance on the part of the legal community too.

lawyers are, in a sense, there own bosses. Baby boomer, computer inept lawyers have no authority over them pushing for change.

Now hospitals are different, with Hospital administrators calling the shots. But most hospital administrators try to avoid confrontation with doctors.

I want to offer up my “Top Ten Reasons Why Electronic Medical Records are Here to Stay.†

1. EMRs are in just about every presidential candidates briefing book on health care. (’cept maybe Fred Thompson)
2. Medicare, Medicaid and federal employees want them. (the feds can’t get enough of this stuff)
3. Private health plans want them. (finally getting on board!)
4. The technology industry wants them. (big, big bucks to be made here from deep, deep pockets)
5. Walmart wants them. (new Wally Mart clinics supply-chain management tool)
6. Newt Gingrich wants them. (big neo-con transformational to-do item thingie)
7. India wants them. (lots of data-entry workers to employ)
8. China wants them. (needs one unbelievably ginormous system)
9. Consumers think they want them. (like iPods!)
10. Doctors don’t want them. (usually a good motivator for the rest of us)

Given these most excellent reasons, how can we miss?

On Europe: I second Peter's comment on Denmark, which has an excellent NHS-type medical system. I lived for 30 years in France, another every good health system on a public insurance model, and the EMR was very backward - it's being pushed by the billing system for primary care (pay cash, send in form, get reimbursed on standard scale; increasingly now the form is replaced at the pharmacy by a chipped card, Google "carte Vitale".)
In Spain (NHS type) EMR works for the local clinic but the university hospital runs on paper and lost my wife's records twice.
The British NHS IT programme seems to be in trouble because it's so ambitious - a scheme for the entire population of 60 million, and every type of care.
The US certainly has a lot to learn from Europe on the basic design of health care, but it's not so obvious for EMR.

There are some hopeful but misguided souls out there. My hospital is trying to force physicians to convert to EMR just as they forced us to look at X-rays on-line. Reading X-rays takes me 3 to 5 minutes ( compared to 60 to 90 seconds with film ) ...........you all will be waiting during this time. Much of the time the image doesn't come through , is lost, and must be re-done. Now they want me to do all of my work on computer..........the computer mostly spits out canned text which is not exact, and the document takes longer to prepare ( you are still waiting during this time ).
My advice after 25 years of medical practice is to speak out loudly against EMR.........it takes longer, it's not as accurate as a written or dictated note, IT IS NOT SECURE, and will not have any effect on medical mistakes except perhaps make them easier to hide. Example..." I didn't type that order....someone must have used my name and password " The corporations who own hospitals and the third party payors, as well as the people who sell these gadgets stand to gain..not you!
They will be sure to change the software or the "required" format every few years just as the music industry changed from vinyl to 8-track tapes, to cassettes to CD's to MP3's so everyone will need to buy their new required software or gadget.
Take a book and a sleeping bag with you to the emergency room........we won't be able to get to you because we are busy typing.
For any lawn care workers or landscapers out there, what if you were required to mow only with an approved digital/laser guided titanium blade mower with a maximum speed limit of 1.5 MPH. These mowers will retail for $12,500.00. A crude analogy.The mower won't turn unless you stop, do a laser scan of the grass in front of you, and re-program the mower. In this way you won't accidentally mow over the owners rose bush, probably something you have never done anyway.
And let's not mention the spyware the corporations are currently installing along with these EMR terminals. Tell your congressman NO NO NO NO NO to electronic medical records, else I'll wave at you as you wait in the lobby.

ER physician in Texas

Hi, I am trying to find hospital records for when I was born at St. Joseph's Hospital in Syracuse, New York on 10/08/1968 at 11:21 a.m. but was told that because the records are so old they were destroyed. ANy ideas? I would appreciate your help.
Jennifer Freeman
Ft. Lauderdale, Florida

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