Why Doctors Quit.

Today, Charles Krauthammer has an excellent column on the electronic medical record. He has not been in practice for many years but he is obviously talking to other physicians. It is a subject much discussed in medical circles these days.

It’s one thing to say we need to improve quality. But what does that really mean? Defining healthcare quality can be a challenging task, but there are frameworks out there that help us better understand the concept of healthcare quality. One of these was put forth by the Institute of Medicine in their landmark report, Crossing the Quality Chasm. The report describes six domains that encompass quality. According to them, high-quality care is:

1) Safe: Avoids injuries to patients from care intended to help them
2) Equitable: Doesn’t vary because of personal characteristics
3) Patient-centered: Is respectful of and responsive to individual patient preferences, needs and values
4) Timely: Reduces waits and potentially harmful delays
5) Efficient: Avoids waste of equipment, supplies, ideas and energy
6) Effective: Services are based on scientific knowledge to all who could benefit, and it accomplishes what it sets out to accomplish

In 1994, I moved to New Hampshire and obtained a Master’s Degree in “Evaluative Clinical Sciences” to learn how to measure, and hopefully improve, medical quality. I had been working around this for years, serving on the Medicare Peer Review Organization for California and serving in several positions in organized medicine.

I spent a few years trying to work with the system, with a medical school for example, and finally gave up. A friend of mine had set up a medical group for managed care called CAPPCare, which was to be a Preferred Provider Organization when California set up “managed care.” It is now a meaningless hospital adjunct. In 1995, he told me, “Mike you are two years too early. Nobody cares about quality.” Two years later, we had lunch again and he laughed and said “You are still too years too early.”

We are now in the third year of Obamacare and its troubled implementation. One feature of Obamacare is a mandate to adopt the “Electronic Health Record.” Naturally, the term used is not “Medicine” or “Medical.”

I hear this everywhere. Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, “The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”

You may have zero sympathy for doctors, but think about the extraordinary loss to society — and maybe to you, one day — of driving away 40 years of irreplaceable clinical experience.

The comments to the article in the Washington Post are about what one would expect from that readership. What are the results of this mandate ?

One thing that everyone agrees on is that advances in technology can contribute greatly to our attempts to improve quality and value in the healthcare system. And this is where electronic health records (EHRs) come into the picture. The EHR is the instrument at the center of most organizations’ plans to drive lower cost, better care. In fact, huge amounts of money have been invested in these EHRs, and organizations are understandably concerned about what their return on investment will be.

The adoption of the EHRs in clinical systems should help drive the quality agenda. But it’s important to recognize that EHRs alone may not be sufficient to deliver data intelligence, to really deliver data to clinicians in a meaningful way that will help them improve value.

I was an enthusiast about the electronic medical record when I was in practice and was a member of the national association, The American Medical Informatics Association.

There is a program called “10 x 10,” Which seems to focus on distance treatment by the use of video and remote care can make great use of such techniques. Native Alaskan village clinics can use “telemedicine” to improve care.

Previously, data sent from a rural clinic traveled from its location to a ground station, to a satellite orbiting beyond the earth, and then to a ground station on the receiving end before reaching it’s destination.

Data that timed out during that process had to start again. Sending an image could take several tries, upwards of 20 or 30 minutes.

Now, information travels by fiber optic cable or microwave tower. For many YKHC clinics, that means it travels from the clinic to Bethel out of Bethel by fiber optic.

The same image that once took half an hour can be sent in a matter of seconds.

This is where EHR can make major contributions.

The EHR that Krauthammer writes about, however, is a burden with very little to recommend it.

“EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity.

This hardly stays the long arm of the health-care police, however. As of Jan.?1, 2015, if you haven’t gone electronic, your Medicare payments will be cut, by 1 percent this year, rising to 3 percent (potentially 5 percent) in subsequent years.

Here is where the compulsory nature of government mandates comes into play.

One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.

At faculty meetings I hear stories of clumsy interfaces that, for example, require a diagnosis be entered before any data can be recorded. That is not how medicine works. After the patient is worked up, the erroneous diagnosis cannot be deleted. That is foolish and may be dangerous.

As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

What it is doing is driving me out of teaching students and it is driving many older doctors to drop out of government medicine altogether.

Using an advanced analytics application to analyze our data, we discovered that 10 care processes accounted for 53.2% of our organization’s variable cost. This knowledge helped us prioritize our improvement efforts. We knew exactly which care processes—such as asthma care, appendectomy and more—gave us the greatest opportunity for reducing variability and waste.

Here is the real incentive. Like all discussion of “quality” by government or payer organizations, it is all about cost. I have no objection to cost reduction where reasonable, but technology is a major cost driver and young doctors are losing the institutional memory of older ways of doing things. I know my students, or at least those I will not be teaching, may lose what I might have been able to impart.

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