One of the reasons for the widespread opposition by British medics to the Blair government's £12bn hyper-centralised health IT plan may be that so many NHS hospital trusts and GPs - who are contractors not employees - had already invested in incompatible systems. The switchover offered them low immediate benefits for substantial costs.

Oh, and there's an analogy with the slow take-up of digital projection in cinemas. The cinema owners have to bear the costs, while the benefits go to the studios, who can simply distribute films on reusable hard drives. This simple coordination problem has been to much for Hollywood to solve.

Sounds to me like the actual problem is that the companies selling EMRs don't recognize who their real customer is.

If they sold to those who benefit the most (insurance companies, government) rather than those who benefit the least (hospital and clinic owners), the rate of adoption might be a lot faster.

Forgive my pedantry, but for the zillionth time:

In addition, the learning curve for these programs is steep, increasing the amount of time a physician spends per patient.

A steep learning curve represents rapid acquisition; a flat learning curve indicates slow acquisition. Things that are hard to climb are steep. Things that are hard to learn are flat.

Regarding Patrick Minton's point. The first area computerized in most hospitals was the part insurance companies care about - the billing system.

The difference between computerization of banking and healthcare is that banks can tell their lowest-paid employees to use the computer or else. It has been and is much harder for healthcare entities to tell that to their highest-paid employees.

Ezra Klein writes:

Additionally, many of the software options are needlessly restrictive -- reliant on "yes or no" questions -- and few of the platforms can talk to one another, a particular problem given our fractured health system.

I don't know how true this is. When presented with a computerized form there are only so many ways information can be captured in a structured format without resorting to free text. Clinical systems in hospitals have been able to share data using standards like the execrable HL7 for almost two decades. I suspect this is probably too costly and difficult to implement and maintain in a doctors office.

Somebody should tell Kevin that numerous other industries ahve also had to overcome the expense and learning curve necessary to adopt technology. They did it anyway. When you have a client or a customer telling you to innovate or die, you do it. And eventually, this is what payers (or government payers) are going to have to do to health care providers.

The truth is, physicians and hospital spend lots on technology, but they have gotten into the inexcusable habit of believing that technology is only worthwhile if it leads directly or indirectly to greater reimbursement. Achieving higher quality is, apparently, not a goal within the medical system.

Aside from the fact that providers are justifiably concerned about adopting systems that turn out to be obsolete or not robust or not interoperable, the failure is basically a failure of priorities and nothing else.

Your ignorance of the system always makes for amusing post.

Medical records save insurance companies a nominal amount of paper and labor. THis is usually negated by the fee we need to pay to receive the information electronically.

Reducing claims from duplicate test and other achieved efficiencies COST insurance companies money it doesn't save them. You would have to have a clue how insurance works to grasp this, which you have never displayed, but for the benefit of your readers. Insurance companies make a % of premium as profit. They charge premium based upon the amount of claims they pay. Loss ratios are fairly steady over year periods. By reducing the $ amount of claims paid the $x they get a percent of is reduced meaning they make less profit. Insurance companies have an incentive for consumers to consume as much healthcare as possible and pay for it with inflated premiums.

Being of direct interest to any party argument is amusing as you refute it yourself. One paragraph you talk about all the errors that are prevented. When a doctor makes an error and kills or injuries someone they get sued. Medical records reduce the chances they make the error preventing them from getting sued. That would seem to be of direct interest. As more doctors do go with MRs I would suspect attorneys to start using it as an argument for their negligence. If Dr X had used MRs this error could have been prevented.

By your lack of logic why do Drs sterilize instruments? It cost them money, but doesn’t save them anything but the slight potential of infecting a patient, which would be hard to prove and unlikely to result in judgment.

The problem is you have no idea what you’re talking about. You read a biased and small source of material and regurgitate it without any research or analysis. The lack of MRs has everything to do with Doctors playing politics for a handout. A few years back Congress passed a law saying insurance companies and payers had to accept EDI claims. If a provider wanted to send us a claim via EDI we had to accept it or be fined. This cost hundreds of millions if not billions to accommodate. We didn’t get a single penny. If you wanted to stay in business you coughed up the cash and complied. Drs being the arrogant pricks they tend to be believe themselves above this though. Why should they have to dip into their comfortable 6-7 figure lifestyle to buy some software and hardware that saves lives and allows them to deliver a better product.

It also comes back to the inefficiency of liberalism. Why should we pay for it through taxes when the doctor can just up their fees? Your just looking for more opportunity to build your earmarks and slush funds.

This problem can be solved with a 1 page bill in 2 years, Congress did it with EDI. As of 1/1/2011 all providers who receive payment from Medicare, Medicaid, or VA must use MRs.

It won’t cost billions, won’t allow for any pet projects or social engineering but will have medical records in place by 1/1/11, then again that wasn’t really your goal anyways. It was just an amusing side effect of your politics.

"In other words, it's something of a collective action problem."

I call this a "George Mason Dilemma." George Mason owned slaves but was a strong opponent of slavery. He knew slavery was evil, but he also knew that he couldn't compete if he got rid of his slaves. So he kept his slaves and voted against the Constitution instead (which infuriated his friend, George Washington). And for that, he has been relegated to the sidelines of history, despite being a major influence on American history.

My advice to doctors would be this: bite the bullet and act on your own. We'll all be better for it, even you. It's better to be remembered like Washington than Mason.

We installed a true EMR (we had scanned, on-line records with communication tools and paper billing records) this August. It has not been a happy experience. The software, sold to us as "award winning", has been extremely bug-ridden and unreliable and just awkward to use. It provides very limited support for improved patient care.

Productivity is way down. We have to have 5 docs in the urgent care clinic to see fewer patients than 4 docs used to see (summer is our slow season and the economy sucks). Patients are unhappy that docs are spending more time staring at the monitor and docs are unhappy that they're spending 10-12 hours more per week on documentation.

Between the economy and the reduced number of patients that we are able to see in clinic, our group has taken a huge hit in income and that's after shelling out $1.5M for the software and $100K for annual support. The monthly staff meeting is a lot less soporific, however.

I was a software engineer for 10 years before I went to medical school working for a company that built large-scale training systems for the military. I'm appalled by the quality of the package that was purchased. I was a huge believer in EMR, but the tools that we've been given provide such a small improvement in patient care for such a high cost that I'm really disappointed.

This issue is a lot more complicated than Ezra describes above. A number of the comments help explain: from J Bean's comments on the disasters of implementation, Nate's (avoidably obnoxious) comment on government inability to place regulations on physicians similar to those put on other health care institutions, Barbara's comment that physicians are unwilling to change unless physicians receive compensation themselves-- all of those are true. Other include

-- unwanted transparency and customer service accountability
-- fear of increased malpractice litigation due to increased documentation
-- generational gaps in use of IT (physicians are a pretty old group), particularly compared to degree of intrusion on current practices
-- poor long-term stability among EMR providers (what happens is mine goes out of business?)

There are probably a few others that I'm forgetting. Kevin MD, as he does, focuses on how physicians are adequately compensated for changes in medical practice. Its a potential issue, yes, but there are many others that factor into the equation. Having government willing to regulate anything with respect to physician practice would be a start.

Nate makes the comment that I make, hopefully with less hostility:

There is a basic set of tools and practices that providers must have to be considered minimally acceptable. It would be unthinkable, for instance, for a hospital to stop doing laundry and just re-use the sheets. They don't get paid extra for clean sheets. It's part of their overhead.

At some point (maybe not yet) having EMR at least for things like Rx and lab tests is simply going to be the way things must be done, with no excuses about how much they cost.

J. Bean's point, however, is a real one -- I don't know if the system will improve over time through upgrades or because you become more adept at organizing your work flow around it. I have often thought that what doctors need are software products that build on the way they do things now, for instance, voice recognition (a lot of docs use dictation) or electronic notepads that you "write on" in your own handwriting that can be uploaded and converted into typeface. This would at least interfere minimally with the way physicians like to practice now, but still provide electronic record keeping capability. But my dentist has had electronic Rx software for at least five years.

What I don't think that I made clear is that we purchased a well established product. There's a lot of pie in the sky thinking about how EMR will improve patient care, but looking at what's available now I just don't see much improvement at all. I'm an early-adopter type when it comes to new technology and a software person and I'm underwhelmed, can you imagine how non-tech types feel about EMR? I currently work for a large (80+ doc) group and we already have an IT department and a room full of servers. For small practices there are an incredible number of hurdles to jump ... and little prospect of any gain once you jump them.

What do you suppose is the difference between physicians in Canada and the Netherlands? Are Canadians older, more tech fearful, more eager to obscure their records than their Dutch counterparts? Or could it be that Amsterdam invested in EMR for the country and Ottawa (or the provincial governements) has not?

My partner and I see doctors employed by what is essentially a very large group practice owned by one of the largest hospitals in the Detroit area, which has been using EMR for quite a while now.

To put it bluntly, I'm sold. My partner has medical problems requiring him to see several specialists, and everyone can see what the others are doing. Test results and imaging are available for all to see. Prescriptions can be filled out on the screen and sent electronically to pretty much any pharmacy in the Detroit area, and the software flags potential drug interactions. Now, for this hospital the investment was worthwhile, because everything is in-house, and I can see why smaller practices would resist EMR.

By the way, there definitely is a generational difference in how EMR is used. Older doctors still take notes by hand and rely on later transcription, while younger doctors (the ones who were using laptops to take class notes not long ago), just type directly into the system. Older doctors seem to enjoy printing out hard copies of scrips for us to take to the pharmacy, while the younger ones have taken to shooting them across electronically. Just depends on what you're used to I guess.

I know that I sound like a crank here, but I'm working from home today and taking frequent mental health breaks as I whack my head against the offending EMR in question.

Right after I hit the "Post" button the last time, my office called. An ER doc needed some info about a patient which had to be given to them the old-fashioned way. That's where EMR could shine, but doesn't. As Don K notes, it's great in an integrated setting. However, with current HIPAA laws it isn't legal for the people working in one practice to see the records from another practice. In France (and, I suspect, the Netherlands) all physicians have access to the same system. As people move from area to area, see specialists, undergo procedures, or are admitted to the hospital, their records are available for use. Clearly that reduces duplication of tests and improves communication, but, at this point, it isn't a legal option in the U.S., even if the available EMR implementations would support intercommunication.

I understand all the groaning but the great socialized medicine of Canada (where I live) is even worse. Go figure.

I have to take issue with that old fairy tale that information technology will automatically make everything better and more efficient. It has been fashionable for some time to call for laptops for school children. It was BS and has never been shown to have any positive impact on learning. I suspect EMR is another such fashion. Health care won't become better just because medical records are stored electronically (frankly, I would be suspicious of too much mechanization in the medical clinic). And I find it negligent to not even mention the issue of privacy and data security. Making these data available over the internet is a clear no-no. I am surprised of the claim that in France, any physician has access to the whole system. That would clearly violate EU privacy protection laws.

Nicer friendlier post

J Bean who developed your software? I haven’t done extensive research but my impression of most US systems is they where done by tech companies looking to make a huge fortune in the soon to explode EMR field. From my years of experience on the other side of the bill Insurance/Healthcare is very quirky and not like any other industry. The best software we used has always been developed by people in the field who created it for their own use, they are the only ones that understood all the idiosyncrasies that make it functional or not. Have any systems developed from homegrown solutions? Kaiser appears to be pretty happy with theirs surprised they haven’t spun it off for some profit. Quoted on a CDHC project for them and apparently they have no billing functionality at all which surprised me. Didn’t make it far enough in the bidding to get to play with it unfortunately.

Government does need to take on the role of Hub with an open system that allows as many spokes as the “market” wishes to create. I have commented on this before, something similar to the financial market. I can’t just take money out of Ezra’s bank account. By channeling my request through the fed though I can debit the desired funds. EMR should be the same way. Every provider with their shiny new Provider ID, I think everyone has one now don’t they?, maintains their patients records on their servers connected to the Federal Hub. If you get admitted to a hospital or see another Dr. that provider submits a request to the Federal Hub which aggregates the information from all the other spokes.

There is nothing fancy about the concept or not already being done. It’s just EDI with a couple more file standards. Your EMR software can have any feel or feature it likes. When it receives an 834 or XXX request it sends the data in the standard format. Fed grabs the data, passes it on to the treating provider who’s system imports and displays as desired. Most of the information is already mapped because of EDI.

This is a failure of politics and nothing more, the technology is already there and the cost should not be that great.

It seems that the advancement of coordinated electronic medical records would be so simple and cheap(!) if the AMA simply coordinated with the developers behind the already-launched 'Google Health' application to universalize the electronic records format used in hospitals nationwide. I think political will would help to articulate this goal and potential solutions (I hereby acknowledge complete ignorance on the subject), but I doubt we need government-run implementation.

My name is Kevin Hauser and I am the Director of New Business Development for MedeFile International. I had come across your blog in doing some research. I believe MedeFile helps in these situations that you speak of. Indivivduals can not rely on their doctors having pertinent information a tthe exact time it is needed. Due to that fact, MedeFile picks up where the doctors often do not.
In brief, MedeFile is an electronic medical records management service that collects, digitizes, stores, and organizes all of our member's ACTUAL medical records. MedeFile gives you the member, the ability to access your complete medical history 24 hours a day, 7 days a week, from virtually anywhere in the world. In addition, we provide each BASIC and Premium MedeFile member with a MedeDrive. The MedeDrive is a portable USB device that works with any Windows based PC. This device simply plugs in to a USB port and instantly auto loads that member's vital emergency information (Allergies, Medications, Medical Alerts, Emergency Contacts, etc). The MedeDrive also has a password protected area that contains all of that member's ACTUAL medical records as well. The MedeDrive does NOT require any internet connection in order to view its contents and can be updated anytime with no additional charges.
Our system also provides for the storage of Vital Documents. These may include your Advanced Directives (Living Wills, DNR's, Health Care Proxies), as well as other important documents. MedeFile has been featured on various news segments with regard to the devastating Hurricanes we have seen in the recent years. MedeFile may also qualify as a medical expense under a Medical Information Plan in IRS Publication 502.

It is important to note that MedeFile does the work for its members. We contact the providers and collect the records on their behalf. I urge you to visit our website at www.medefile.com for more information. Please feel free to contact me with any questions that you may have. Thank you in advance.

J Bean, I am dying to know what EMR you are using with such less than spectacular results so far. We are looking for solutons ourselves and would really appreciate it if you could share the product name so we can protect ourselves from making the same mistake. There is painfully little reviews online of EMR products and the lack of information really makes it easy to fall for false promises. For EMR to really catch on the good products really need to be vetted from the bad. As long as docs keep experiencing these nightmare scenarios everyone is going to continue to be very gun shy. You should feel comfortable sharing your experience with the rest of us, however if you would like to be more discrete please feel free to email me at domain123atgmaildotcom
Appreciate it!

Quoting Nate: "Why should they have to dip into their comfortable 6-7 figure lifestyle "

You may want to double check the facts on physician income as they are misleading.

A quote "fifth of PCPs earned less than $120,000 last year, according to our survey. Nearly half (46 percent) of GPs (who tend to be older than other primary care doctors), 29 percent of FPs, 22 percent of internists, and 23 percent of pediatricians were also in the under-$120,000 category"

http://medicaleconomics.modernmedicine.com/memag/Medical+Economics/2008-Exclusive-SurveymdashEarnings-Good-news-for-p/ArticleStandard/Article/detail/532638