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Unhappy Camper (Volume 2, Issue 2)

Over the past month I have noticed a sharp uptick in what other doctors and websites are saying in a negative way about EMR adoption.   And this blog traffic seems to be not so much about how EMR systems are negatively affecting individual doctors – it’s more about how our adoption of EMR has unwittingly enabled, in very strategic ways, the demise of the traditional private practice of medicine.

I will not get into here the many various philosophies of how the practice of medicine should and should not be conducted within the United States. Suffice it to say conservative ideology might hold that the private practice of medicine should be protected, while those of a more liberal bent might say that we should all be on a government salary. This discussion is merely to point out my synthesis of these news blogs that seem to show that our rush to EMR adoption will have far-reaching effects on the style of medicine we practice in the future, for better or worse.

Foremost among these discussion threads is the realization that bureaucrats now have the data, imperfect as it may be, to suggest that non-physician health care providers, such as nurse practitioners, can do as good a job in basic primary care as can physicians themselves (See: http://www.nejm.org/doi/pdf/10.1056/NEJMp1012121 ).

By creating EMR templates for appropriate action in most medical scenarios physicians have given away the exclusivity of their professional turf to lesser-trained, and lesser-paid providers of health care. Now, fellow physicians know that there is a very wide gap in that knowledge, expertise, and responsibility, but the Federal bean-counters cannot see those differences.  Nor do they care. They only see that higher-level and mid-level providers all fill out the same EMR templates with identical results in most of the non-complex cases that make up the majority of office patient encounters within primary care. This comparative data, albeit nonsensical, was in earlier times very difficult to extract; EMR has made it much easier.  

There have been two scenarios proposed as a consequence of this paradigm shift. First, physicians will be in the future receiving increased competition from these mid-level practitioners who will both suck away the more profitable patient encounters from the physician while diluting reimbursements for all health care providers in general. Curiously, these changes may be most adverse to the primary care doctors rather than the specialist physicians, contrary to the government-speak promoting the role and reimbursement values of those physicians in primary care.

The second scenario is that all this may lead to an unanticipated stratification of health care delivery based on payment source (see http://www.healthcareitnews.com/news/physicians-worried-about-emrs-impac... ).  In this case, physicians would be treating the patients of better paying plans, while nurse practitioners and physician assistants would assume the patients of lower paying plans.

The next point being made in the blogosphere is that the independent practice of medicine is less likely to continue (See: http://www.healthcareitnews.com/news/top-10-trends-2011-include-it-new-c... ). The redevelopment of capitated payment systems under the guise of the new-fangled Accountable care Organizations, or ACOs for short, are made possible by our EMR data feeds to the bean-counters at the top of the food chain. The hope is for ACOs to increase the effectiveness of care for those patients with chronic conditions, all while driving down costs to the health system.  But ACOs also require the assumption of risk on a capitated basis.  You might like this, or you might not, but be aware that this is yet another indirect consequence of our adoption of EMR.

The third realization is that the enormous cost and complexity associated with EMR adoption is forcing smaller medical practices to fold, in droves.  The adoption of full-fledged meaningful-use compliant EMR system has been estimated at near or over $100,000 per doc in short-tem costs, and of which the governmental handouts will give, at the most. $66,000, if one can actually achieve meaningful use.  This is a topic I touched on here previously in http://www.docehrtalk.org/messageboard/2010/10/15/small-medical-practice... .  But recent surveys indicate that the effect on viability of the small, private practice mode of medical care will be much more profound (See http://email.openmoves.com/display.php?M=64164&C=d0a3f8b8e5853935fc08b05... ). 

Oh, and the last point, our darling EMR systems are still yet to prove their overall effectiveness in providing true benefits to health of our patients (See: http://www.ihealthbeat.org/articles/2011/1/20/report-finds-limited-evide... ).