Wednesday, April 13, 2016

The Solution to the Problems of the Electronic Medical Record is Simple, Saves $Billions, and Helps Patients, not Insurance Companies: Video Recording, Period, and Nothing Else

Authors: David Behar, MD, is an adult and child psychiatrist in the Philadelphia area. Brian P. Moquin, Esq., is the president of Digital Abacus Corporation in Silicon Valley and has a law practice, doing civil litigation.

The electronic medical record (EMR) has been touted as a panacea for health care, by reducing costs and errors, increasing efficiency, improving access to care, leading to better diagnoses through data mining. EMR has been a dismal failure, difficult to use, with no interoperability, and focusing practitioner attention away from the patient.

Consider the EMR in psychiatry. An EMR template must be filled out for each patient visit. Patient sobs that her boyfriend was killed in a motorcycle accident. Facing a screen, I reply, “How is your appetite?” the next item on the template. Our relationship has become that with the staff at the Department of Motor Vehicles. Because of the data-gathering demands imposed by EMR, ordinary human sympathy has been replaced by impersonal form filling. These demands also turn a ten-minute medication visit into a fifteen-minute visit: in contrast to its promise, the adoption of EMR has added millions of hours in waiting room delays. While this is a nuisance in psychiatry, increased waiting times for the emergency room is unforgivable.

The problem is that EMR is not an innovation: EMR has replaced the piece of paper with a screen that shows a picture of that piece of paper. The input is still by the keyboard of a 1945 Underwood typewriter. The major difference is that the EMR forces the doctor to do his own transcribing, and doctors have poor transcription skills. Burnout, delays in access to care, frustration result.

One of the stated goals of EMR is to be the “single source of truth” regarding a patient. The set of fixed, predetermined fields (including check boxes) miss most information from each encounter. Problems in mapping a patient’s statements onto the predefined fields of an EMR, as well as the lack of free-form text areas in many EMR templates, virtually guarantee that an EMR will be incomplete, inaccurate, sometimes dangerously misleading. The EMR paradigm forces the health care practitioner to conform the information provided by the patient to a structured data format that offers little or no ability to capture subtleties, ambiguities, and qualities that are not easily quantified. To wit: I had to stare at a beautiful teenage girl because her pediatric record, three times, indicated her penis was anatomically correct, and her testicles had both descended. I just accepted her “No” when I asked if there was something really unusual about her. In short, the EMR paradigm ignores the realities of the practice of medicine as not an exact science.

We can do better.

A Solution: The Real Electronic Record (RER)

We propose a simple fix: the video recording of each medical encounter is stored, with no typing or dictation. We call this a “Real Electronic Record,” since it is an actual recording of the medical encounter. At the end of each patient encounter, the doctor also records a one-minute summary of “What We Found Today” and “The Current Plan of Action,” providing a brief recap of the visit for quick review.

There are currently 1.2 billion outpatient medical encounters per year with an annual cost of more than $700 billion. The estimated cost of storing HD video recordings of all of these encounters is approximately $400 million per year. If records must be preserved for seven years, the total cost would come to $2.8 billion per year. That seems like a lot until one realizes that the HITECH Act of 2009 included $20 billion in incentives for hospitals, physicians, and for infrastructure.

We do not advocate video recording against the will of the patient. Those refusing might have to pay a higher fee for record keeping.

Using Real Electronic Records, the doctor would spend no time transcribing data into an electronic format, instead devoting that time to patient treatment. We estimate a savings of 10%— $70 billion per year—which could be used to lower health care costs or to increase doctor productivity, allowing doctors to see more patients. The arrival of the uninsured could lead to a collapse of the system; consequently, freeing up doctor time is crucial.

With a RER, the patient could review her encounter on demand through a secure Internet portal, and videos will soon become searchable, allowing for direct data mining.

The RER will reduce malpractice claims and defensive medicine, saving another 5-10% spent on worthless care.

The $70 billion in savings should be returned directly to patients in the form of no co-pay. That offer is wildly popular with every patient whom I have ever asked.

Most importantly, when a patient sobs that her boyfriend has just been killed, the doctor will be able to hold her hand, look her in the eye, and express ordinary human sympathy, rather than having to transcribe information into an EMR. That means both patient and doctor can stay human.
Kennebeck, SS, Timm, N, Farrell, MK, Spooner, SA. Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department. J Am Med Inform Assoc 2012 19:443-447. (Longer ER waiting times due to EMR.)

U.S. Census Bureau, Statistical Abstract of the United States: 2012. Table 168: Ambulatory Care Visits to Physicians’ Offices and Hospital Outpatient and Emergency Departments: 2008. Available at (1.2 billion visits per year.)

Health Care Cost and Utilization Report: 2011. Health Care Cost Institute, Inc., Sept. 2012, p. 3. Available at ($709.2 billion in 2011.)

This assumes that the average medical encounter is 15 minutes in length, yielding 300 million hours of video per year. The estimated cost was calculated based upon current storage, equipment, connectivity, electricity, and data center facility costs. (Storage cost estimate.)

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