(1) The Paper Mentality: Computer automation of existing paper-based medical records and billing systems perpetuated the very dysfunctional and inefficient health care processes that preceded the EMR. As one of the early physicians to use an EMR told me early in my healthcare career, "This EMR just makes it faster and easier to be even more inefficient." In the early days of EMRs-- 1990s-- there was a missed opportunity to apply software and computerization to dramatically improve efficiency and quality of care, but instead, early software developers chose to simply computerize the familiar paper-based processes. To a large degree, today's EMR implementations are still stuck in this paradigm.
(2) Defensive Medicine: In the 1980s, the Rise of the Lawyers and malpractice litigation in healthcare also gave rise to defensive, paranoid medicine, especially among specialists. As a result, this paranoia began to emerge in the medical record. The information that was documented in the EMR became less about effective handoff and communication about patient care and more about protecting the physician from litigation-- and understandably so. Clinical notes, in particular, grew longer and longer. The software design of EMRs followed; EMRs became expensive word processors and transcription/dictation systems.
(3) Billing Complexity & Compliance: Once again, beginning in the late 1980s, the complexity of insurance plans, including Medicare and Medicaid, began to increase exponentially. Depending on which study you believe, at least 30% of healthcare overhead in the US can be attributed to our arcane billing and insurance processing. The requirements for clinical documentation to justify and comply with billing requirements also increased exponentially. And, once again, the software design of EMRs followed suit. E&M coding is just one of many examples.
If we could build an EMR from scratch today, the design and functionality would be motivated by:
(1) Clinician efficiency and throughput
(2) Quality of care for individual patients
(3) Quality of care for populations of similar patients
(4) The economic sustainability and affordability of care
Every click of the mouse, every function of the software, would tie back to one or more of these design motives. Billing compliance would emerge as a natural consequence, as would protection against litigation.
This article, below, is loaded with the metrics that clearly describes the high and unfortunate impact of current EMRs on the lives of primary care physicians. The article originally appeared in a newsletter by HealthFinch, an innovative software technology company, dedicated to making the lives of primary care physicians more efficient, more effective, and more fulfilling. My dear friend, Dr. Lyle Berkowitz, is the Chief Medical Officer and driving force behind HealthFinch.