America is at a critical point in bringing its healthcare system into the information age. Beginning with President Bush's advocacy of electronic medical records in 2004, and culminating with recent government HITECH incentives for physicians to adopt electronic medical records (EMR), health information technology has received increasing attention. EMR is also a part of the ongoing debate on health care reform. However, many mainstream physicians remain reluctant and concerned about using an EMR.
The Docs4PatientCare (D4PC) Mission Statement describes us as “an organization of concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship, promotes quality of care, supports affordable access to all Americans, and protects patients' freedom of choice.” As our health care system moves into the information age, all these issues will be profoundly affected. It is therefore appropriate and necessary that D4PC establishes a position regarding the use of EMR and related technologies.
Successful implementation of EMR will require cooperation among three disparate cultures: The physician community, the information technology community, and government. EMR has great potential as a vehicle for true health care reform – one that lowers costs, reduces medical errors, and improves quality of care and accessibility to care. But like any powerful technology, EMR can be used for either benefit or harm. With these thoughts in mind and using our Mission Statement as a guide, our position on EMR is as follows:
1. We support bringing EMR and related technologies to the practice of medicine in a manner that supports the doctor-patient relationship. We believe in health information technologies that reduce costs, improve efficiency, improve quality of care, enhance doctor-patient communication and protect the physician’s ability to practice medicine in an increasingly hostile environment. We advocate the use of EMR and related technologies, such as health information exchanges, to efficiently move data among providers and to automate those parts of health care workflow that are appropriate for automation.
2. We oppose the use of EMR as a vehicle for government (or any third party payer) intervention into the practice of medicine and into the doctor-patient relationship. It is not appropriate to use EMR to enforce comparative effectiveness guidelines or any other restriction of treatment choices. We condemn the use of EMR as a tool for the government or any third party payer to covertly monitor physician behavior.
3. The HITECH incentive program is harmful to the EMR movement. “Meaningful use” criteria are poorly conceived, overly burdensome and too complex. They suffer from a “one size fits all” approach to both general physicians and medical / surgical specialists. And, perhaps worst of all, they encourage EMR implementation for the wrong reasons – to satisfy arbitrary government requirements rather than to reap the true benefits of EMR.
4. EMR is the greatest cultural change to the practice of medicine in the past half-century. A tremendous amount of time, effort and money will be required to make a successful transition into the information age. In this setting the HITECH incentives are counterproductive because they pressure physicians to make hurried choices regarding the information systems they wish to use. The HITECH incentives deprive the medical culture of the necessary time to make a stable, controlled cultural change to an information technology environment. This increases the risk of failure and will paradoxically increase the time and resources that are ultimately required to complete the cultural transition.
5. Implementation of EMR must be physician-directed. Among the 3 cultures that participate in EMR (see above), physicians must lead. In this regard, physicians are woefully behind. The HITECH incentives are again harmful because they create a paradigm in which government sets the goals and the medical and IT cultures follow. The result will be a health care IT system that serves the whims of politicians, not the needs of patients. This is unacceptable.
6. The use of EMR has revealed that our current CPT-based system of physician payment is fundamentally flawed and must be replaced. The CPT coding system was created by the American Medical Association (AMA) over 40 years ago and has become an overly burdensome set of documentation requirements that intimidate physicians into billing less than fair market value for their services. The coding compliance industry must siphon billions of health care dollars away from patient care to help physicians comply with these incredibly complex guidelines. The AMA profits approximately 50 million dollars a year selling CPT and ICD-9 materials to physicians. Their support of CPT is not objective and cannot be trusted.
The CPT coding system assumes paper-based documentation. Using EMR physicians are now able to generate fully CPT-compliant documentation of care. We have learned that a fully compliant chart note is almost useless to the clinician. The relevant data are buried in a sea of white noise: patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes. The result is lengthy documentation that is dedicated to CPT compliance rather than to communicating useful health care information.
EMR gives us the opportunity to replace CPT with a new physician payment system based on information technology instead of paper charts. Such a system will allow us to re-direct our limited health resources from regulatory compliance back into patient care.
7. We advocate medical liability reform that recognizes the changes to medical liability that information technology will bring to health care. Technology in any form always brings unintended consequences. Health information technology will certainly bring unintended consequences, including unintended and undesirable de facto changes to the standard of care. We must watch carefully for these changes and support legislation that protects physicians from these unplanned changes in the standard of care until they are examined, modified if necessary and formally recognized.
Our Call to Action implores the medical culture, the IT culture and the government to work together:
1. The information technology community must acknowledge that health care is different from (for example) groceries and banking. The information technologies that have proven themselves in other sectors of the economy do not serve the needs of medicine well. IT professionals must be willing to collaborate extensively with practicing physicians to advance the state of the art of EMR software and hardware products so that mainstream physicians become willing and able to implement them – without government incentives.
2. We physicians must leave our “comfort zone” to take the leading role in bringing our health care system into the information age. Without the leadership of clinically active, practicing physicians the government will seize the opportunity to lead us blindly into a dysfunctional government-designed health care IT system. IT vendors will be forced to keep offering poorly designed, awkward to use products. The benefits of EMR will never be fully realized.
3. Politicians must accept the leadership of practicing physicians in developing EMR and the accompanying health care IT infrastructure. They must abandon the traditional government view of the health care system as an instrument of “social justice,” wealth redistribution and political reward. They must learn to accept that the main purpose – in fact, the only purpose - of our health system is to provide the best possible care to patients.
Recent events, from the formation of Docs4PatientCare in 2009 to the 2010 midterm elections, clearly demonstrate a significant change in the relationship between America’s government and her citizens. This new awakening calls upon physicians to hold our government accountable to the citizens of the United States and to be certain that EMR technology is not utilized as a government instrument to covertly destroy the physician-patient relationship in the name of "social justice" and cost containment. This document is our first step towards that goal.