For several years I have asked people "Why, in your appointment with your doctor, is his or her back turned to you, working on a computer?" The common answers: "She's writing down my words to remember them," "He's ordering tests," or "To get me better health care."
No, no and no: the primary purpose of the computer is billing. The Electronic Medical Record (EMR) is essentially a cash register. It was developed by technocrats as part of a mandate of the Obama administration in 2008, to help make medical records more efficient. It was a good idea: to make all clinical data from a patient's medical history readily available electronically to doctors and other health care workers. It would have worked, if it were used only for that.
But somehow the for-profit insurance industry got into the EMR, and linked the medical data part tightly to the money part—through billing. Its core function became coding diagnoses and treatments for payment. The EMR became ubiquitous.
The result is that there's a war taking place across the screen. Like all wars, this one is about money. On one side, your doctor is being forced by the hospital billing team—which actually monitors her EMR screen—to click on various boxes, which lead to another array of boxes, and another, to bill the most for your treatment. On the other side of the screen, an insurance worker's job depends on paying out the least.
The cost of installing and maintaining an EMR in a large hospital system can be hundreds of millions of dollars. Two recent overviews of EMRs by Kaiser Health News and The Journal of the American Medical Association (JAMA) note that EMRs have not been shown to increase the quality of care, or of patient safety during a hospital stay. However, they have increased the cost of health care, by many billions of dollars a year.
But that's not all. Even more important are the human costs. These costs endanger the health of both you and your doctor. The most widely-sold EMR system is called Epic. It is so unpopular that if you mention the name, some doctors will literally start to scream. A 2018 American Journal of Medicine paper addressed the recent epidemic of "doctor burnout," measured by the Maslach Burnout Inventory (a sense of lack of accomplishment, cynicism, and lack of enthusiasm for work). Authors Andrew Alexander and Kenneth Ballou found that the "only correlate with the three symptoms of rising burnout was the EMR," which was introduced in 2008. Another pivotal summary from the same year published by Wendy Dean and Simon G. Talbot in STAT says "Physicians aren't 'burning out.' They're suffering from moral injury" and posits that the accepted symptoms—increased doctor anxiety, depression, suicide (three per day, twice that of active-duty military members), drug abuse and retirement—are not "burnout," but rather untenable "moral injury," similar to injuries sustained from fighting in an unjust war.
For every hour your doctor spends with a patient, another two hours are spent in front of a screen—often at night at home. Interns and residents on each 16-hour shift spend about 80% of their time in front of a screen, not interacting with patients. Teaching at the bedside, "touching the patient," is a lost art. Residents are occupied at their screens to bill insurance—an average of 8000 clicks per shift. They complain, "We're not treating the patient, we're treating the computer." A recent Harvard Business School study shows that the resulting doctor "burnout" costs the health care industry an added $4.6 billion a year.
Distracted Doctoring
Your doctor is forced to focus on billing instead of on you—the patient—who, in turn, gets progressively more distant. The EMR screen looks like an iPhone on speed: 50 lines trembling horizontally and moving down and across the screen—peppered with multiple arrays of boxes to click. But while our phones are essentially static—with occasional alerts and incoming messages—an EMR is different. Doctors are constantly assaulted by this trembling jungle of data, being prompted to choose as many diseases, tests, consults and treatments of high billability as possible. Clicking on one box opens 20 more. Each additional clicked box adds cash. Prescriptions, which by hand used to take 15 seconds each, now require diligently clicking 20-box lists repeatedly. A single prescription can take three minutes.
The result is that we doctors are distracted—It's like texting while driving. Mistakes are inevitable. And a key to your care—a humanizing connection, eye contact, touch—is often lost.
Decades of science show the benefits of doctors being present with patients through their suffering. For example, the way in which "bad news" is delivered has a big effect on morbidity and mortality—done badly, it can worsen symptoms and even hasten death. But more and more, doctors don't have the time or energy to connect, which is ironically, the reason we became doctors in the first place.
A Better Way?
Recently, I was speaking with medical students about their training on the wards. They are discouraged about the lack of instruction from the residents. Patient rounds are now conducted using portable screens rolling up and down the corridor. The team rarely enters a patient's room. Rounds over, the residents break for their computers, trying to get in all their clicks. The students are stranded. They are screen-savvy millennials, yet they call Epic a terrible system. I ask if they know of a better one.
"Yes," said one, "the Veterans Administration." I asked why. "Well, their system is kind of clunky, but you can input notes about your patients, it's easy to understand, and it links to VAs all over the world. " I ask about the differences between Epic and the VA. They consider. "There's no billing at the VA," one says. "It's not for profit." Others agree.
In the EMR machine, patient care is linked tightly to billing. To improve patient care, we have to unlink them, and squeeze out the for-profit billing.
We should not click for cash, but for care. We can use the data to benefit the patient—and the medical professionals. This will allow us to go back to the EMR's original goal: sharing information. The benefits are well known: flagging drug interactions, sending scans and test results to outpatient clinics, linking family doctors to specialists, supervising difficult surgery in rural hospitals and so forth. Liberated from billing, doctors can practice the kind of medicine we signed up for.
The EMR could have been a lifesaver. It still can be.
If we get rid of on-screen, for-profit billing, and use electronic screens exclusively for care, we solve a lot of problems. We could create a true national health care system, modeled after our existing two national systems—Medicare/Medicaid and the VA. As in all other national systems, each procedure would cost about the same all over the country. On longitudinal charts showing the health of Americans as they age, a sharp rise in good health suddenly increases at age 65, when Medicare kicks in.
Furthermore, current participants in Medicare often buy supplemental private insurance. There is no need to abolish this. In almost every other national public health care system, there is a parallel private, for-profit system, market-driven or regulated, for all who want more coverage. In America, it can co-exist with the national system—as long as its billing is not linked to the EMR. As in the Veterans system, doctors would click only the relevant data, workup tests, diagnosis and treatment—each with a flat fee nationally (with slight variation across the country). No more billing wars against insurance fighters. No more insane clicking to game the system for cash. Time freed up for being with our patients, loved ones and friends.
How to Get it Done?
In our new national health care system, many billions of dollars will be freed up. Private health care spends 33% of its dollars on administrative costs; the rate for Medicare/Medicaid is only 3%. This 30% savings—many billions—could become available for real care. And if just a tiny fraction of money from other government expenditures—such as the $700 trillion Department of Defense budget—were also freed up toward health care, that would fund a great health system.
Have you ever heard, in a theater when someone falls down, the call go out: "Is there an insurance executive in the house?"
No. We doctors, nurses, hospitals and others in health care, are the workers. Without us, there is no health care. We all—as well as our patients—have to join together, forge a grand alliance and use our power to change medicine. We doctors then could give full attention to connecting with our patients for their care, and for our own care, too.
Too idealistic?
I plead sanity.
Samuel Shem, M.D., D.Phil., is Professor of Medical Humanities at New York University Medical School, and is the bestselling author of The House of God and its sequel Man's 4th Best Hospital (Berkley/Penguin), published in November 2019.
The views expressed in this article are the author's own.
Correction (11/4 12.20p.m.): An earlier version of this story mistakenly referred to Wendy Dean as Wendy Dean Talbot and Simon G Talbot as Simon G Dean. Newsweek regrets the error.
