It was only a short while ago when a visit to the doctor was a face-to-face conversation. The doctor would ask questions. He was interested in what I said. He listened to my responses and we discussed what to do. It was a positive interaction.
In the last year or two, there’s been a shift. Much of my time with doctors has been spent watching them type. In one case, the doctor tapped away on his laptop, occasionally looking up to ask questions before returning to the main focus of his attention: his computer. In another case, the doctor intermittently tapped on an iPad while we spoke. In a third instance, the doctor had a conversation with me and then apologized that he would be spending the next half of our session typing up the results of our conversation. All this typing was required, he said, if he was ever going to be reimbursed for his services. It was getting in the way of being a doctor.
Surely, I said, computerized medical records generate benefits. They are easily retrievable. They can be transferred from one practice to another and accessible to the many different service providers—hospitals, laboratories, specialists, radiology and so on—that might be involved in any one patient.
“In theory, perhaps,” he replied. “But in practice, it’s a horrible and costly bureaucracy that is being imposed on doctors. I spend less time with patients, and more time filling out multiple boxes on forms that don’t fit the way I work. Often I am filling out the same information over and over again. A lot of it is checking boxes, rather than understanding what this patient really needs.”
What about retrieving information? Isn’t that easier?
“Again, in theory, retrieval should be easy and quick,” he said, “But you can’t flip through these records the way you do with a paper file and easily find what you want. The other day, for instance, I inherited a new patient along with her electronic records. Her previous care-givers had checked forty-five boxes of problems. There’s no way that I can deal with a patient with forty-five problems. She and I talked for some time and eventually we figured out that she had six real health problems: then we could begin to discuss what to do. And then I had to input that discussion into the computer. The electronic record didn’t save time. It made everything take longer.”
But at least now you can get the records electronically?
“Sometimes,” he said. “But each network has its own system and often the systems are incompatible. The systems don’t talk to each other. So transferring records from one system to another becomes another nightmare.”
But why do you type while the patient is there?
“Filling out these forms and checking all the boxes takes me a lot of time,” he said, “If I don’t do it now, I will spend half the night trying to remember the discussion and typing up the results of the day’s visits. The outcome is that I have less time to spend with patients. Instead of making the system better, it’s making everything more costly.”
What we are seeing here is the implementation of Obamacare—the Affordable Care Act—which has provided reimbursement incentives and an electronic medical records deadline for those who adopt electronic medical records (EMR). However, for those who don’t meet the electronic medical records deadline for implementation, the government has laid out a series of penalties. The message to doctors is clear: implement electronic records or pay a price.
“The government already is wasting billions on the medical EMR,” my doctor told me. “They are committed to giving each health care system $17,000 per doctor who is successfully using electronic medical records to help them cover their software investment. This money goes to the health care system and not the docs. So it’s basically a very lucrative pass through to the software people for generating an inadequate and burdensome system.”
Survey: most doctors lose money with electronic records
My doctor is not alone in seeing problems with the way that electronic medical records are being implemented.
A recent survey published in Health Affairs by Julia Adler-Milstein, Carol Green and David W. Bates, estimates that doctors who install electronic medical records systems should expect an initial loss of around $44,000 on their investment. Almost two-thirds of the practices using electronic records would lose money even with government subsidies, the researchers said.
Having electronic records is in principle a good idea, but only if one imagines implementation as quick and intuitive so that it’s easier for doctors to input and retrieve information rather than from scribbling notes on paper. Reformers imagine some kind of well-tuned iPhone or iPad with lots of cool gadgets and apps that make life easier.
But in practice, implementation of electronic health records today is anything but quick and intuitive or easy to use. It’s mostly like old-style form-filling software that is an aggravating pain to use. It takes forever, involves continuous repetition, is counter-intuitive to use and offers few benefits in return. Along with upfront costs, doctors said they have to work longer hours because of the software. Smaller offices, those with five doctors or fewer, struggled the most.
The study shows that 27 percent of practices are projected to gain by seeing more patients or getting more claims approved by insurers, though there is no indication what happened to the quality of care in such accelerated throughput.
Implementing electronic records is expensive and difficult
Another review of the experience with electronic records is entitled, “Physicians Use Of Electronic Medical Records: Barriers And Solutions.” Here Robert H. Miller and Ida Sim also conclude that achieving quality improvement through electronic medical use is neither low-cost nor easy.
Despite the theoretical potential for quality improvement from computerized records, they found that few physician practices use electronic records. Miller and Sim argue that “the path to quality improvement and financial benefits lies in getting the greatest number of physicians to use the electronic medical records [EMR] (and not paper) for as many of their daily tasks as possible. The key obstacle in this path to quality is the extra time it takes physicians to learn to use the EMR effectively for their daily tasks.”
Miller and Sim report:
“Interviewees reported that most physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increased time costs resulted in longer workdays or fewer patients seen, or both, during that initial period… Even highly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options, and navigational aids… Although vendors are slowly improving EMR usability, most vendor interviewees doubted that any “silver bullet” technology (for example, voice recognition, tablet computers, or mobile computing) will dramatically simplify EMR usage. Designing easy-to-use software for knowledge workers is a challenge that spans the software industry beyond health care.”
Miller and Sim suggest policy interventions to overcome these barriers, including providing work/practice support systems, improving electronic clinical data exchange, and providing financial incentives for quality improvement.
This thinking is fanciful. Paying people to work unintelligently doesn’t work and ultimately will be ineffective. What is needed are systems that actually help doctors do their work.
The world didn’t need incentives or support systems to get people to adopt iPhones or iPads. We embraced the iPhones and iPads because they are easy to use and they made our lives better.
When the software embedded in electronic records isn’t adapted to the doctor’s needs and the way they work, hopes of major productivity gains through policy fixes like incentives or training are doomed.
The politics of electronic health records
As the penalties of Obamacare start to be imposed, the predictable politics will kick in. Critics of the Obamacare will trumpet the (correct) conclusion that electronic medical records as now being implemented are likely to increase costs, and will argue (incorrectly) that the idea of pushing for medical records is a bad one.
Proponents will argue (correctly) that electronic records have the potential to save costs, and argue (incorrectly) that soldiering on with the current flawed systems can succeed with more incentives and training.
Both sides are correct and incorrect. We know from long experience in other sectors that dumping big, clunky, computer systems on to the work of skilled professionals doesn’t save costs. It increases them. Providing incentives for the professionals to use hard-to-use computer systems is a losing game. What is needed is easy-to-use software that fits the way doctors work and makes their working lives easier and better.
Beyond politics or health care: Agile
In essence, we are not dealing here with a health care problem. We are dealing with a management problem. There is a long experience over many decades in dealing with it. It’s called Agile.
The traditional 20th Century management approach to doing anything, whether software development or anything else, was a standard sequence of specifications, planning, implementation, and delivery.
With large complex systems involving professional work, the approach runs into major problems. The end result isn’t just that the projects don’t finish on time. A large proportion of such schemes never finish at all. Rising costs and user resistance to implementation ends up in the project being scuttled.
How the Air Force wasted several billion dollars
A recent illustration comes from the Air Force which recently canceled a six-year-old software modernization effort that had consumed $1.3 billion and produced nothing of value. Note, that’s $1.3 billion, not $1.3 million. And it’s not that the project produced less benefit than expected. It produced absolutely no benefits at all. The whole project has been canned.
The fiasco is described in the New York Times in an article by Randall Stross which notes that the Air Force’s effort began the project in 2006. The project had been “restructured” a number of times. When the Air Force realized that it would cost still another $1 billion just to achieve one-quarter of the capabilities originally planned that wouldn’t meet even minimal requirements—and that even then the system would not be ready before 2020—it gave up on the project entirely.
The need for Agile
Traditional hierarchical methods of management are ill-adapted to software development where systems are involved in constant change, during design and construction (as the true needs of the system become better understood) and during deployment (when end users start to exercise the system). Most of the costs of such systems come over the whole life of the system, not during the initial design phase.
As an interesting book by Alan W. Brown, Enterprise Software Delivery (Addison Wesley, 2012), points out the consequent shift from software development to software delivery, combining constant innovation and control.
The health sector needs to learn how to cope with the complexity of software delivery. Brown notes how Agile thinking, such as Scrum, has transformed the management of software by reconciling the requirements of innovation and control. It involves:
- Horizontal collaboration and transparency
- A focus on quality and constant testing
- Loosely coupled highly cohesive architecture that is designed to evolve
- A focus on delivering working software
- Individual and team flexibility
The key: transform the management culture
As Brown points out, the biggest challenge in enterprise software delivery lies not in these software practices themselves, but rather in the overall management culture. If the organization remains in a vertical, hierarchical mode, with an approach of “here’s the system—implement it”, none of the advantages of computerization will accrue. In fact, costs will increase.
The problem is that hierarchical bureaucracy is still pervasive in the health sector. Producing easy-to-use software or the agility to make continuous adjustments from experience lies beyond the performance envelope of this type of management.
A radically different kind of management is needed. It needs to begin, not with a goal of “introducing electronic medical records”, but rather with the goal of “improving the working lives of doctors through better technology”.
Instead of producing outputs in the form of electronic records, the goal needs to be generating positive outcomes for doctors. Once outcomes for doctors are positive, the need for incentives vanishes: doctors will want to improve their working lives. There will be stampede to use the new technology.
But this entails a revolution in management thinking. Instead of seeing electronic records as merely a shift in technology from paper to IT, it involves a transformation in the way the health sector thinks about and manages work. It means new goals, new roles for managers, new ways of coordinating work, new values and new ways of communicating.
Fortunately, there is a vast experience in thousands of organizations around the world for over a decade to show the way. It’s still the best kept secret in the management world.
We need to stop torturing doctors with systems that make work more difficult and generate systems that are better—better for doctors, better for patients and better for the health system overall. And for that to happen, we need a different kind of management.
Other sectors have learned to stop wasting billion dollars through failing to embrace Agile. When will the health sector learn?
A different way of thinking about organizations
The health sector needs to recognize that it can’t solve the problems of health within the health sector alone. The difficulties of implementing electronic medical records are part of a broader societal problem involving how we think about organizations.
Unless we see the pervasive problem of hierarchical bureaucracy infecting every aspect of society, not just health, the army of the management experts, the MBA graduates, the efficiency experts, the management consulting firms and the politicians will conspire to re-introduce and reinforce the hierarchical bureaucracy, yet again, with new language, but sadly similar results.
There are many organizations that are being run in the Agile mode—producing outcomes not outputs, with managers acting as enablers, with work being done by self-organizing teams, with values of transparency and continuous improvement and horizontal communications . In the private sector, they are hugely profitable. They present models for the health sector. The health sector needs to join with this broader movement to reform organizations across every sector of the economy.
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