The dirty secret of all electronic medical records (EMRs) is this: they are not primarily designed to help doctors record, review, or share information about their patients. No, they are primarily designed to capture the data necessary to submit bills to insurance companies and the benefit to doctors and patients is merely incidental. If you’ve ever seen a printout of a medical note, you have noticed how long, bizarre, redundant, and confusing it seems. This is because it is designed to be most legible for the purposes of billing. But it’s not just incomprehensible printouts — this purpose is reflected in many different aspects of EMRs’ design.
By contrast, here’s a fascinating story about the 40-year history of the Veterans Administration’s ugly-yet-functional electronic medical record (EMR). What distinguishes the Veterans Information Systems and Technology Architecture (VistA) from every other EMR is the fact that it was built to capture and use information for clinicians, not for insurance companies. Of course, maintaining a legacy system like this is expensive, and so some the VA is moving away from VistA to Cerner, the EMR that Mayo Clinic decided to ditch after years of working with it. (I have never worked with Epic, the system that Mayo switched to — but most people I’ve talked to say that it’s slightly better than all the others). Ostensibly, this is so that the VA and DoD can share the same system — though the two different patient populations differ greatly and given the massive cost and inconvenience of changing systems, it’s unclear what benefit the VA will see in the end.
The ideal EMR doesn’t exist and may never exist. I’ll grant that it’s incredibly difficult to create a records system that collects, organizes, and displays information that’s useful to a doctor in a way that doesn’t force him or her to spend the entire visit staring at a screen AND THEN allow that information to be shared between all the hospitals and offices you might use while keeping your personal details incredibly secure. But we’ve made things even worse with by subsidizing bad EMRs that can’t even talk to one another: if you usually go to Dr. Smith’s office but you had a test done at St. Mary’s hospital 6 months ago and you walked into the ER at St. Miriam’s hospital because you started feeling chest pain, you have to call Dr. Smith and St. Mary’s hospital in order for both of them to fax you a printout.
Unfortunately, there isn’t an easy solution at this point. A more “market-based” solution probably won’t emerge because once you’ve bought an EMR, it’s incredibly expensive to change it over. As long as the pain of the EMR is mostly felt by frontline staff and patients struggling to communicate around the screen, there’s not a particularly strong incentive to change. Even solving the interoperability problem is full of landmines. But the whole thing is a cautionary tale about the rush to adopt new technology that doesn’t really solve the problem it was created to solve while making everything else worse.