Saturday, August 29, 2015

Politics, Technology, and Democracy: The Case of the Electronic Medical Record

I am not an Electronic Medical Record guru. I am a pediatrician. Some people can be both, and we will rely on them for progress in the future. But just because I am not an EMR guru doesn't mean that I should simply receive the EMR as delivered. After all, I am an end user, living and working where the rubber hits the road, caring for patients. (To be fair, I actually see patients only a half day a week at this end stage of my career, so I have time to do things like writing a blog.)

When I was a Harvard undergraduate, I audited a course given by Louis Hartz in American government. He loved to lecture, and loved the overflowing small lecture hall that attested to his enthusiasm and eloquence. I thought he was a treasure, so even though I didn't take the course, it was a good 11 AM time, only a few blocks away from my 10 AM class, and what was Harvard if not a smorgasbord for intellectual pursuits? [Besides which, I recently read on my Heidi Priebe Facebook page, that an Extroverted Intuitive Thinking Perceptive (ENTP) type like me is typified by auditing courses in college. (ENTPs also try to ask embarrassing questions and playing Devil's Advocate, she says, but I didn't do that. Harvard was too intimidating for that. Ok, I did it once in David Riesman's class, but I'm still embarrassed about that to this day.)]

But I digress. Hartz addressed himself directly and cogently to the issue of democracy and governance. Should a populace surrender its authority to technocratic elites (this term actually came later) who are better skilled and better informed to run a government? Not at all, said Hartz. View the populace as passengers on a ship and the governing elite as the captain and crew. It is up to the passengers to determine the destination; it is up to the captain and crew to get them there. The hazard of not having the passengers in charge is that the elite's decisions might serve their own interests primarily.

On the other hand, the technical elite needs to be proactive as well as the passengers. An informed elite can help guide a populace away from xenophobic or Luddite tendencies, for instance, and to sketch a more positive future. In addition, innovation comes from what is possible. Generally a technical innovation appears and then someone else figures out what to do with it. The Ipod was invented when a Japanese team showed Steve Jobs the mini hard disk they had invented; it was Jobs' imagination that translated the new technical possibility to a useful product. We in practice need to hear about the innovations just as Jobs did.

So, I look at the use of EMRs through the Hartzian lens. I might not be an EMR guru, but I know a lot more about treating patients in my specialty of pediatric primary care than most everyone who is an EMR guru. I know better than they do what I need. But, if the gurus have something to say to us users, I'm all ears and eyes.

What is the EMR's equivalent of the elite's having its own ends in mind? It might be the accumulation of clinical data. The technical elite is obsessed with processing data for research. If they could record all the treatments for a clinical condition and trace outcomes through the EMR, wouldn't that be a terrific guide to practice? There have been some successes with this in in-patient care, as my colleague Chris Longhurst at Stanford has pioneered. But in outpatient care we haven't heard of anything yet, and I would predict that the hopes of the researchers will be found to be far overblown when compared to reality. Don't forget, what they are forecasting is lots and lots more work for themselves and their acolytes, and that has to sway their unconscious minds.

A problem here is that there is a conflict: to get all this data, the EMR needs to codify the conditions and the treatments; narrative doesn't help, you need checked boxes. But to get checked boxes, you need a lot of grunt work in coding and checking. Who does all that data entry? The primary care end user, that's who. So we are roped into extreme effort, that according to so many of my colleagues takes hours a day of extra work, all on the speculation that it might somehow be translated into usable research data. The practicing doctors never signed up for this, they were signed up for this. The elite chose it and enforced it. (I'm not mentioning the new coding tool that is being enforced as part of this effort, called ICD 10, which once again has the practicing doctors spending extreme amounts of time and money in becoming ever more specific in checking the boxes – there is a different code for right ear infection vs. left ear infection, for instance, and it's up to the practicing doc to check the right box. Excruciating. And, it is projected that many docs will have to take out lines of credit to tide them over a period of non-collection while the insurance companies and Medicare adjust. Unbelievable. Who signed up for this?)

And meanwhile, what do these EMRs look like to us, the end user? My colleagues, especially the estimable Herschel Lessin, have observed that EMRs look decades out of date – decades! To my mind, the presentation of the patient chart that appears on the screen is not much different from DOS 2.0. It is basically a linear rather than graphical interface. There are lots of lists. What is clear is this: the presentation of the chart is not what I would prescribe for my purposes. It was done to me, not of me, not by me, not for me. The developers wanted those boxes checked. Hartz's elite has dictated the terms.

What would I prescribe for an EMR if asked? Here's my answer:

I have always run an office with the idea that when the clinician comes into the exam room, the table should be set for him or her. Just as you would want in eating a meal, everything you would want should be right there on the table, easy to see and grab. In the days of paper charts, this meant that all labs should be attached to the chart, all order sheets should be readily available and pre-formatted, all handouts already given to the patient and others available to the clinician if wanted, etc. And I always insisted that the idea of all the table setting should be to make it easy for the clinician to do the right thing at the right time.
How would that translate to the EMR? Don't think linear, think pattern; don't think DOS, think Windows. Don't think of lists, think dinner table.
How would I set the table for a well child exam? I would sit at the computer screen and have five or six little windows on the screen, each active so that I could click on it and enlarge it if I wanted, but sharp enough so that I could see it just in its unenlarged window.
One window would be the growth chart -- I could glance at that and see height and weight and know it looked good right from the start. If there were a problem, the window would have a red border to indicate to me that I should look at this closely, and maybe look at it first.
A second window would be the immunizations -- ditto to the comments above for growth chart, and the needed vaccines for this visit would be flashing red. Other comments would also be there as needed - we know what these might be.
A third window would be the narrative from the last visit, with a highlight of what I or the last person to see the child wanted to be checked on the next visit. Enlarging this window would bring up that note, and also give me the capacity with one click to see the narrative from the visit before that, etc.
A fourth window would be something like a problem list, but it would be concerns of the parents in the past, listed by date, and concerns of the clinician in the past, also listed by date.
A fifth window would be today's questionnaires filled out by the patient, with access in this window to questionnaires in the past.
In other words, the EMR would be working for me, I wouldn't be working for the EMR. The patient with me would be served primarily, the research interests would not be the prime consideration. My logic would be imbedded in the computer, the computer's logic would not imbed itself in me.

The unhappy recent history of primary care medicine is that we have been left in the shadows. I have documented elsewhere that recent surge of High Deductible Health Plans has put the interests of both working class patients and primary care physicians – the least powerful interests in the health care industry – last. The development of EMRs is just another instance, I'm afraid, of the same political imbalance.

Many will say to this point that it's not political, but in the immortal words of Bill Murray in Ghostbusters, “It's technical.” Me, I doubt it. Politics is life, and often unconsciously, the more powerful always put their interests first, often with the belief that if only others knew what they knew, they would agree. Me, I doubt it.

What will be the solution? American economic thought has always placed reliance on competition to make progress. The problem is, however, that as health systems get bigger, they ally with an EMR product, increasingly the Epic product, and while it is powerful, Epic is “by engineers, for engineers.” And most importantly for development and innovation, Epic is an anti-competitive enterprise.

Ideally, Epic would be a framework for all parts of a medical network, and the individual components would be subject to competition. That would mean that a pediatric practice that was a member of a network would be able to choose for itself either the embedded Epic pediatric product, or another competitive pediatric product that would fit into the overall Epic system seamlessly. That would be real competition; that would lead to progress. But as Paul Levy has just pointed out, anti-competitive behavior is what we are seeing instead. The problem is that Epic loves being a monopolist. Epic does not play well with others.

Well, this was a long blog entry – sorry! But the overall picture of practice is of rapid corporatization. If we are preserve the most essential components of medical practice as we have known it, a close connection of doctor to patient, the practicing doctors will need to rise up and lead. There are current courses available in medical leadership. Docs need to take those courses and take them to heart.

And they could do worse than to read Louis Hartz, The Liberal Tradition in America.

Budd Shenkin

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