The Glade 4.0

About a decade ago, a doctor friend was lamenting the increasingly frustrating conditions of clinical practice. “How did you know to get out of medicine in 1978?” he asked with a smile.

“I didn’t,” I replied. “I had no idea what was coming. I just felt I’d chosen the wrong vocation.”

I was reminded of this exchange upon receiving my med-school class’s 40th-reunion report and reading some of the entries. In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”

As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

I hear this everywhere. Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, “The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”

You may have zero sympathy for doctors, but think about the extraordinary loss to society — and maybe to you, one day — of driving away 40 years of irreplaceable clinical experience.

And for what? The newly elected Barack Obama told the nation in 2009 that “it just won’t save billions of dollars” — $77 billion a year, promised the administration — “and thousands of jobs, it will save lives.” He then threw a cool $27 billion at going paperless by 2015.

It’s 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity.

This hardly stays the long arm of the health-care police, however. As of Jan. 1, 2015, if you haven’t gone electronic, your Medicare payments will be cut, by 1 percent this year, rising to 3 percent (potentially 5 percent) in subsequent years.

Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.

Forget the numbers. Think just of your own doctor’s visits, of how much less listening, examining, even eye contact goes on, given the need for scrolling, clicking and box checking.

The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?

Because banks deal with nothing but data. They don’t listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.

Why did all this happen? Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.

As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

Like my old classmates who signed up for patient care — which they still love — and now do data entry.

I rarely do follow-up columns. I’m averaging one every 10 years. And while my last such exercise resulted in a written apology from the White House (for accusing me of making up facts over its removal of Churchill’s bust), today’s is not a complaint. It’s merely a recognition that the huge response elicited by last week’s column, “Why doctors quit ,” warrants both rebuttal and clarification.

Physicians who responded tended to agree with my claim that doctors are being driven out of the profession by the intrusions, interferences, regulations, mandates, constraints and sundry other degradations of their vocation that are the result of the bureaucratization of medicine. Chief among them is the imposition of electronic health records (EHR).

I’ve also heard from people who notice how much attention their doctor must devote to filling out EHR boxes on a computer screen rather than to engaging with them during an office visit. To the point where a heretofore-unheard-of profession has been invented — the “scribe” who just enters the data so the doctor can actually do doctoring.

On the other hand, my critics, vocal and many, had two major complaints. First, that I’m just a Luddite unwilling to adapt to the new digital world and looking for excuses not to. Second, that while I might have a point about the bureaucratization of medicine, could I not have made it without satisfying my anti-Obama tic and blaming it all on him, and my other itch and blaming it on liberalism?

First, I don’t oppose going digital. Properly used, it brings many benefits. The gains, however, are coming not from massive databases attempting to cover and extend to all of medicine but from far more narrow and tailored adaptations. In radiology, for example, one is dealing with artifacts — X-rays, CT scans, MRIs — that can be easily categorized, digitized, filed, transmitted and shared in a way impossible in the age of the shadowed X-ray film held up to backlight.

The problem with the EHR, however, is that the pretense of universality leads to information collection that is largely irrelevant to the patient. And, more fundamentally, that the EHR technology, being in its infancy, is hopelessly inefficient. Hospital physicians will tell you endless tales about the wastefulness of the data collection and how the lack of interoperability defeats the very purpose of data sharing.

As for my complaint about President Obama and his fellow liberals: Again, I don’t oppose going electronic. What I oppose is the liberal instinct to impose doing so, giving substance to that old saw that a liberal is someone who doesn’t care what you do, as long as it’s mandatory. Why could they not leave the decision of when and how to go electronic to those who use the technology and can best judge its ripeness and usefulness? Instead, the Obama administration decided arbitrarily six years ago that EHR should be universally in use by 2015. Time being up, doctors who did not conform are now penalized through partial loss of Medicare reimbursement.

In time, we will surely develop more tailored, specific and efficient data-collection systems that doctors and hospitals will adopt if only to keep up with the increasing efficiency of their digitized competitors. Why, then, the punitive mandate?

I was in no way arguing that the bureaucratization of medicine began with Obama. It is the inevitable and inexorable result of the industrialization of everything from cloth making to food service, now extended to health care. My point is that, given the consequent loss of autonomy and authority of doctors, why are we compounding their demoralization by forcing an EHR mandate that robs them of both time and the satisfaction of proper patient care?

Yes, in principle, vast record-collection will create mass databases that in theory could be mined to help administrators, and perhaps even to yield medical insights. But it is somewhat ironic that with incessant complaints about NSA collection of telephone metadata — as of last Sunday, now banned in these United States — as an assault on privacy and civil liberties, we seem not at all disturbed by the current amassing of mountains of medical data about you and your insides, a literal and far more intrusive invasion of the self.

My argument is simple. If electronic records are such a great boon — as I believe they eventually will be — they will be adopted over time as the benefits begin to exceed costs. Let the market work. Let doctors breathe. And while you’re at it, drop the Medicare penalty.

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I am generally sympathetic towards doctors and their grievances regarding over-regulation. In this case however, learn to use a **** computer. Yes, there will be costs. Yes there will be people who take the initial transition to commit fraud.

I am dealing with the same thing at my own job. We're getting rid of paper as much as possible. We are finding out how much easier it is to find **** now that it's all in electronic form and searchable. Join the late twentieth century.

The problem I see people complaining about is not EHR themselves but the way it has been implimented via complex rules and procedures.

I am generally sympathetic towards doctors and their grievances regarding over-regulation. In this case however, learn to use a **** computer.

It's not as simple as learning to use a computer. There are so many poorly developed and implemented systems that don't play well together.

As one small example, just this afternoon I spent the better part of an hour watching an Orthopedic Surgeon try to access some imaging and radiology reports that were done across town in an ER that is associated with a different medical organization. The doctor had access accounts on both systems, but was unable to view or import the records from my ER visit on any of the systems affiliated with the medical group he is part of. Several of staff members attempted to access and encountered the same problem.

It turns out that the individual who saved the record of my visit didn't check a box that would make the data accessible by anyone except the individual who created it.

No problem! I always ask for a digital copy of my imaging for just this very reason. I handed him the DVD, and he spent another 20 minutes trying to find the right combination of import tools to pull the (proprietary) images into his database.

No such luck.

He was finally able to view the imagery by using a laptop that wasn't affiliated with the hospital network (thus he was able to install the necessary software to view the data).