The New York Times reports today on a RAND study that found that government-mandated (and taxpayer-subsidized) electronic medical records don’t save money. I predicted this in my health care reform proposal from 2009, under “Scrap Government-mandated Health Care IT”. Because we as a society were going to invest in IT in the dumbest possible way (hundreds of incompatible systems installed nationwide, each one chosen by busy physicians), there was no way that it could be anything other than a huge waste of money.
The report, the industry, and the country refuse to deal with the deeper issue: why did we ever think that this kind of IT would save money and improve care?
There are two ways to do an electronic health record: structured and unstructured.
Let’s consider what an unstructured electronic health record would look like and cost. You’d create a directory in Google Drive or Dropbox and give doctors and hospitals access to this directory. Physicians could type into a shared Google Doc with other physicians or upload scanned output from tests, etc. It would be paperless, organized, and electronic, but not very structured. To figure out what a cholesterol test result was from 2003, for example, one might have to read through a document in English rather than executing an SQL query. What would this cost? Nothing, basically (which is why Google and Dropbox can give you these services more or less for free). How about doctors and nurses? If they can create a Google Doc and type at a computer then they can easily add notes, test results, instructions, etc.
How about structure? A system for a hospital typically costs about $100 million to install. If it serves a community of 100,000 patients that’s $1000 per patient. Physicians and other providers spend a lot of time in training and a lot of time navigating through screens to get the information into exactly the right table, so the ongoing cost in time and effort is enormous. What value in terms of health benefits is delivered for all of that effort? Epidemiologists might be happy because they can now get an answer to the question “What’s the average cholesterol level for patients in this hospital?” by typing a three-line SQL query (assuming they have first hired 10 lawyers to address patient-privacy issues!). But where is the value to the patient? Does it help to have Patient A’s cholesterol information in the same database table when treating Patient B? No. That is fundamentally why little value is delivered in exchange for the $100-200 million cost of using a structured system.
Why is IT so popular in other industries? Consider a bank. There is a lot of value to having all of the accounts in one big structured database. It then becomes easy to ask “How much money is in the bank right now?” An airline can similarly benefit from a centralized and comprehensive reservations database in order to handle queries such as “How many empty seats are there on all of our flights and can we sell an unusual two-stop route from NY to San Francisco at a low price to fill up some of those empty seats?”
Fundamentally there is not as much value to be obtained by having the ability to do a structured query into multiple patients’ data. Nor is there much value in being able to do a structured query into a single patient’s data. Unless you go to the doctor every day of your life, it really isn’t that hard to scan up and down in a big word processing document or spreadsheet and/or use conventional word processing “find in document” tools and/or use Google Drive’s “search a bunch of documents” tool. I did a quick Google search and learned that the average size of an electronic health record, not counting images (which can easily be stored by date as regular files), is between 1 and 40 MB. The absolute top end of the range is 3-5 GB “for a person with several health issues including images”. In other words, your health record could fit into the memory of a modern toaster oven. [A doctor could keep a complete synced copy of all of his or her patients’ records on a mobile telephone.] Anything this small can be searched pretty easily, either by computer programs or humans.
[I actually asked a cardiologist who had recently invested in a $30,000+ system for her solo practice and who liked the system “How would this compare to using Google Docs to share referral letters and reports with the other doctors and hospitals that you work with? And then simply scanning test results and storing those as PDFs?” She replied that the Google Docs/scanned document system would be better for her and the other doctors, both in terms of ease of access and saving time for data entry but that it wouldn’t comply with all of the government regulations for both privacy and “meaningful use”.
Separately, lest anyone think that I am simply hostile to the brave new world of computers on doctors’ desks, note that I built what is believed to be the first Web-based electronic medical record system. This 1994 effort is described in a 1996 journal paper: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC116301/.]