Then, in 2013, just as Obama was being sworn in for a second term, RAND issued a new and very different report on the prospects for information technology in health care. The exuberance was gone; the tone now was chastened and apologetic. “Although the use of health IT has increased,” the authors of the paper wrote, “quality and efficiency of patient care are only marginally better. Research on the effectiveness of health IT has yielded mixed results. Worse yet, annual aggregate expenditures on health care in the United States have grown from approximately $2 trillion in 2005 to roughly $2.8 trillion today.” Worst of all, the EMR systems that doctors rushed to install with taxpayer money are plagued by problems with “interoperability.” The systems can’t talk to each other, which leaves critical patient data locked up in individual hospitals and doctors’ offices. One of the great promises of health IT has always been that it would, as the RAND authors noted, allow “a patient or provider to access needed health information anywhere at any time,” but because current EMR applications employ proprietary formats and conventions, they simply “enforce brand loyalty to a particular health care system.” While RAND continued to express high hopes for the future, it confessed that the “rosy scenario” in its original report had not panned out.5
Other studies back up the latest RAND conclusions. Although EMR systems are becoming common in the United States, and have been common in other countries, such as the United Kingdom and Australia, for years, evidence of their benefits remains elusive. In a broad 2011 review, a team of British public-health researchers examined more than a hundred recently published studies of computerized medical systems. They concluded that when it comes to patient care and safety, there’s “a vast gap between the theoretical and empirically demonstrated benefits.” The research that has been used to promote the adoption of the systems, the scholars found, is “weak and inconsistent,” and there is “insubstantial evidence to support the cost-effectiveness of these technologies.” As for electronic medical records in particular, the investigators reported that the existing research is inconclusive and provides “only anecdotal evidence of the fundamental expected benefits and risks.” 6 Some other researchers offer slightly sunnier assessments. Another 2011 literature review, by Department of Health and Human Services staffers, found that “a large majority of the recent studies show measurable benefits emerging from the adoption of health information technology.” But noting the limitations of the existing research, they also concluded that “there is only suggestive evidence that more advanced systems or specific health IT components facilitate greater benefits.”7 To date, there is no strong empirical support for claims that automating medical record keeping will lead to major reductions in health-care costs or significant improvements in the well-being of patients.
But if doctors and patients have seen few benefits from the scramble to automate record keeping, the companies that supply the systems have profited. Cerner Corporation, a medical software outfit, saw its revenues triple, from $1 billion to $3 billion, between 2005 and 2013. Cerner, as it happens, was one of five corporations that provided RAND with funding for the original 2005 study. The other sponsors, which included General Electric and Hewlett Packard, also have substantial business interests in health-care automation. As today’s flawed systems are replaced or upgraded in the future, to fix their interoperability problems and other shortcomings, information technology companies will reap further windfalls.
THERE’S NOTHING unusual about this story. A rush to install new and untested computer systems, particularly when spurred by grand claims from technology companies and analysts, almost always produces great disappointments for the buyers and great profits for the sellers. That doesn’t mean that the systems are doomed to be a bust. As bugs are worked out, features refined, and prices cut, even overhyped systems can eventually save companies a lot of money, not least by reducing their need to hire wage-earning workers. (The investments are, of course, far more likely to generate attractive returns when businesses are spending taxpayer money rather than their own.) This historical pattern seems likely to unfold again with EMR applications and related systems. As physicians and hospitals continue to computerize their record keeping and other operations—the generous government subsidies are still flowing—demonstrable efficiency gains may be achieved in some areas, and the quality of care may well improve for some patients, particularly when that care requires the coordinated efforts of several specialists. The fragmentation and cloistering of patient data are real problems in medicine, which well-designed, standardized information systems can help fix.
Beyond standing as yet another cautionary tale about rash investments in unproven software, the original RAND report, and the reaction to it, provide deeper lessons. For one thing, the projections of “computer simulation models” should always be viewed with skepticism. Simulations are also simplifications; they replicate the real world only imperfectly, and their outputs often reflect the biases of their creators. More important, the report and its aftermath reveal how deeply the substitution myth is entrenched in the way society perceives and evaluates automation. The RAND researchers assumed that beyond the obvious technical and training challenges in installing the systems, the shift from writing medical reports on paper to composing them with computers would be straightforward. Doctors, nurses, and other caregivers would substitute an automated method for a manual method, but they wouldn’t significantly change how they practice medicine. In fact, studies show that computers can “profoundly alter patient care workflow processes,” as a group of doctors and academics reported in the journal Pediatrics in 2006. “Although the intent of computerization is to improve patient care by making it safer and more efficient, the adverse effects and unintended consequences of workflow disruption may make the situation far worse.”8
Falling victim to the substitution myth, the RAND researchers did not sufficiently account for the possibility that electronic records would have ill effects along with beneficial ones—a problem that plagues many forecasts about the consequences of automation. The overly optimistic analysis led to overly optimistic policy. As the physicians and medical professors Jerome Groopman and Pamela Hartzband noted in a withering critique of the Obama administration’s subsidies, the 2005 RAND report “essentially ignore[d] downsides to electronic medical records” and also discounted earlier research that failed to find benefits in shifting from paper to digital records.9 RAND’s assumption that automation would be a substitute for manual work proved false, as human-factors experts would have predicted. But the damage, in wasted taxpayer money and misguided software installations, was done.
EMR systems are used for more than taking and sharing notes. Most of them incorporate decision-support software that, through on-screen checklists and prompts, provides guidance and suggestions to doctors during the course of consultations and examinations. The EMR information entered by the doctor then flows into the administrative systems of the medical practice or hospital, automating the generation of bills, prescriptions, test requests, and other forms and documents. One of the unexpected results is that physicians often end up billing patients for more and more costly services than they would have before the software was installed. As a doctor fills out a computer form during an examination, the system automatically recommends procedures—checking the eyes of a diabetes patient, say—that the doctor might want to consider performing. By clicking a checkbox to verify the completion of the procedure, the doctor not only adds a note to the record of the visit, but in many cases also triggers the billing system to add a new line item to the bill. The prompts may serve as useful reminders, and they may, in rare cases, prevent a doctor from overlooking a critical component of an exam. But they also inflate medical bills—a fact that system vendors have not been shy about highlighting in their sales pitches.10
Before doctors had software to prompt them, they were less likely to add an extra charge for certain minor procedures. The procedures were subsumed into more general charges—for
an office visit, say, or a yearly physical. With the prompts, the individual charges get added to the invoice automatically. Just by making an action a little easier or a little more routine, the system alters the doctor’s behavior in a small but meaningful way. The fact that the doctor often ends up making more money by following the software’s lead provides a further incentive to defer to the system’s judgment. Some experts worry that the monetary incentive may be a little too strong. In response to press reports about the unforeseen increase in medical charges resulting from electronic records, the federal government launched, in October 2012, an investigation to determine whether the new systems were abetting systematic overbilling or even outright fraud in the Medicare program. A 2014 report from the Office of the Inspector General warned that “health care providers can use [EMR] software features that may mask true authorship of the medical record and distort information in the record to inflate health care claims.”11
There’s also evidence that electronic records encourage doctors to order unnecessary tests, which also ends up increasing rather than reducing the cost of care. One study, published in the journal Health Affairs in 2012, showed that when doctors are able to easily call up a patient’s past x-rays and other diagnostic images on a computer, they are more likely to order a new imaging test than if they lacked immediate access to the earlier images. Overall, doctors with computerized systems ordered new imaging tests in 18 percent of patient visits, while those without the systems ordered new tests in just 13 percent of visits. One of the common assumptions about electronic records is that by providing easy and immediate access to past test results, they would reduce the frequency of diagnostic testing. But this study indicates that, as its authors put it, “the reverse may be true.” By making it so easy to receive and review test results, the automated systems appear to “provide subtle encouragement to physicians to order more imaging studies,” the researchers argue. “In borderline situations, substituting a few keystrokes for the sometimes time-consuming task of tracking down results from an imaging facility may tip the balance in favor of ordering a test.”12 Here again we see how automation changes people’s behavior, and the way work gets done, in ways that are virtually impossible to predict—and that may run directly counter to expectations.
THE INTRODUCTION of automation into medicine, as with its introduction into aviation and other professions, has effects that go beyond efficiency and cost. We’ve already seen how software-generated highlights on mammograms alter, sometimes for better and sometimes for worse, the way radiologists read images. As physicians come to rely on computers to aid them in more facets of their everyday work, the technology is influencing the way they learn, the way they make decisions, and even their bedside manner.
A study of primary-care physicians who adopted electronic records, conducted by Timothy Hoff, a professor at SUNY’s University at Albany School of Public Health, reveals evidence of what Hoff terms “deskilling outcomes,” including “decreased clinical knowledge” and “increased stereotyping of patients.” In 2007 and 2008, Hoff interviewed seventy-eight physicians from primary-care practices of various sizes in upstate New York. Three-fourths of the doctors were routinely using EMR systems, and most of them said they feared computerization was leading to less thorough, less personalized care. The physicians using computers told Hoff that they would regularly “cut-and-paste” boilerplate text into their reports on patient visits, whereas when they dictated notes or wrote them by hand they “gave greater consideration to the quality and uniqueness of the information being read into the record.” Indeed, said the doctors, the very process of writing and dictation had served as a kind of “red flag” that forced them to slow down and “consider what they wanted to say.” The doctors complained to Hoff that the homogenized text of electronic records can diminish the richness of their understanding of patients, undercutting their “ability to make informed decisions around diagnosis and treatment.”13
Doctors’ growing reliance on the recycling, or “cloning,” of text is a natural outgrowth of the adoption of electronic records. EMR systems change the way clinicians take notes just as, years ago, the adoption of word-processing programs changed the way writers write and editors edit. The traditional practices of dictation and composition, whatever their benefits, come to feel slow and cumbersome when forced to compete with the ease and speed of cut-and-paste, drag-and-drop, and point-and-click. Stephen Levinson, a physician and the author of a standard textbook on medical record keeping and billing, sees extensive evidence of the rote reuse of old text in new records. As doctors employ computers to take notes on patients, he says, “records of every visit read almost word for word the same except for minor variations confined almost exclusively to the chief complaint.” While such “cloned documentation” doesn’t “make sense clinically” and “doesn’t satisfy the patient’s needs,” it nevertheless becomes the default method simply because it is faster and more efficient—and, not least, because cloned text often incorporates lists of procedures that serve as another trigger for adding charges to patients’ bills.14
What cloning shears away is nuance. Nearly all the contents of a typical electronic record “is boilerplate,” one internist told Hoff. “The story’s just not there. Not in my notes, not in other doctors’ notes.” The cost of diminished specificity and precision is compounded as cloned records circulate among other doctors. Physicians end up losing one of their main sources of on-the-job learning. The reading of dictated or handwritten notes from specialists has long provided an important educational benefit for primary-care doctors, deepening their understanding not only of individual patients but of everything from “disease treatments and their efficacy to new modes of diagnostic testing,” Hoff writes. As those reports come to be composed more and more of recycled text, they lose their subtlety and originality, and they become much less valuable as learning tools.15
Danielle Ofri, an internist at Bellevue Hospital in New York City who has written several books on the practice of medicine, sees other subtle losses in the switch from paper to electronic records. Although flipping through the pages of a traditional medical chart may seem archaic and inefficient these days, it can provide a doctor with a quick but meaningful sense of a patient’s health history, spanning many years. The more rigid way that computers present information actually tends to foreclose the long view. “In the computer,” Ofri writes, “all visits look the same from the outside, so it is impossible to tell which were thorough visits with extensive evaluation and which were only brief visits for medication refills.” Faced with the computer’s relatively inflexible interface, doctors often end up scanning a patient’s records for “only the last two or three visits; everything before that is effectively consigned to the electronic dust heap.”16
A recent study of the shift from paper to electronic records at University of Washington teaching hospitals provides further evidence of how the format of electronic records can make it harder for doctors to navigate a patient’s chart to find notes “of interest.” With paper records, doctors could use the “characteristic penmanship” of different specialists to quickly home in on critical information. Electronic records, with their homogenized format, erase such subtle distinctions.17 Beyond the navigational issues, Ofri worries that the organization of electronic records will alter the way physicians think: “The system encourages fragmented documentation, with different aspects of a patient’s condition secreted in unconnected fields, so it’s much harder to keep a global synthesis of the patient in mind.”18
The automation of note taking also introduces what Harvard Medical School professor Beth Lown calls a “third party” into the exam room. In an insightful 2012 paper, written with her student Dayron Rodriquez, Lown tells of how the computer itself “competes with the patient for clinicians’ attention, affects clinicians’ capacity to be fully present, and alters the nature of communication, relationships, and physicians’ sense of professional role.”19 Anyone who has been examined b
y a computer-tapping doctor probably has firsthand experience of at least some of what Lown describes, and researchers are finding empirical evidence that computers do indeed alter in meaningful ways the interactions between physician and patient. In a study conducted at a Veterans Administration clinic, patients who were examined by doctors taking electronic notes reported that “the computer adversely affected the amount of time the physician spent talking to, looking at, and examining them” and also tended to make the visit “feel less personal.”20 The clinic’s doctors generally agreed with the patients’ assessments. In another study, conducted at a large health maintenance organization in Israel, where the use of EMR systems is more common than in the United States, researchers found that during appointments with patients, primary-care physicians spend between 25 and 55 percent of their time looking at their computer screen. More than 90 percent of the Israeli doctors interviewed in the study said that electronic record keeping “disturbed communication with their patients.”21 Such a loss of focus is consistent with what psychologists have learned about how distracting it can be to operate a computer while performing some other task. “Paying attention to the computer and to the patient requires multitasking,” observes Lown, and multitasking “is the opposite of mindful presence.”22
The intrusiveness of the computer creates another problem that’s been widely documented. EMR and related systems are set up to provide on-screen warnings to doctors, a feature that can help avoid dangerous oversights or mistakes. If, for instance, a physician prescribes a combination of drugs that could trigger an adverse reaction in a patient, the software will highlight the risk. Most of the alerts, though, turn out to be unnecessary. They’re irrelevant, redundant, or just plain wrong. They seem to be generated not so much to protect the patient from harm as to protect the software vendor from lawsuits. (In bringing a third party into the exam room, the computer also brings in that party’s commercial and legal interests.) Studies show that primary-care physicians routinely dismiss about nine out of ten of the alerts they receive. That breeds a condition known as alert fatigue. Treating the software as an electronic boy-who-cried-wolf, doctors begin to tune out the alerts altogether. They dismiss them so quickly when they pop up that even the occasional valid warning ends up being ignored. Not only do the alerts intrude on the doctor-patient relationship; they’re served up in a way that can defeat their purpose.23
The Glass Cage: Automation and Us Page 10
