Email access, online scheduling, and electronic records would all make healthcare easier for patients. Here's why some doctors are still reluctant to modernize.
Whenever I feel like taking a trip back in time, I save myself the trouble of building a time machine and instead just head over to a doctor’s office. For a Millennial, or really anyone who lives a modern lifestyle, getting medical care is a rare departure from an otherwise technology-fueled existence.
First comes making the appointment, which usually requires a phone call. My gynecologist's office, for example, doesn’t use online booking, so scheduling a visit means calling them from my "open plan" office and describing what, if any, "the issue is." Layered on top of this indignity, my last name is basically impossible to spell or pronounce. “Yes, once again that’s K-H-A-Z-as-in-zebra-A-N.”
Filling out forms in triplicate in the waiting room is, for me, relatively painless. By now, I've perfected my ability write my address, insurance ID number, and the words "allergies to most plants and animals" in about 15 seconds or less.
No, the biggest nuisances occur when there's any sort of communication required with or among doctors outside of the appointment. In the past 10 years, I've moved from Texas to Washington to California and back to Washington, but each time, I dragged along a filing cabinet packed with phlebotomy results and shot records. To this day, the trunk of my car contains a sinus x-ray the size of a Renaissance painting because it doesn't exist electronically and it's really expensive to get re-done.
Few of my doctors use email to communicate with patients, so medication refills, questions about side-effects, or reminders about appointments all require elaborate phone tag. This hassle is exacerbated by the fact that healthcare is one of the few consumer-focused industries where being a few minutes late is a sin so grave that it’s punished with a total cancellation of the appointment, and sometimes even the forfeiture of the fee.
I was ten minutes late to an appointment the other day, and the doctor poked his head out the door to let me know I'd have to reschedule.
"Can I come tomorrow?" I said.
"Give me a call."
I called. He wasn't there so I had to leave a message. He called me back during my yoga class.
As frustrated as I get, I am lucky that (at least for now) I don't have kids, which must be a medical-administrative hell I can't even fathom.
I have vivid memories of my frazzled mom rushing to ferry my brother and me to orthodontists’ offices and spending her free time filling out insurance reimbursement forms for obscure kids' medications. To this day, a common fight between my boyfriend and I ends with me wailing that he’s not "being the sort of guy who would deal with the pediatrician appointments." Cheat on me? Fine. Require me to remember to fax the kids’ immunization records on my lunch break? It's over.
One problem with American healthcare is that it attempts to staple a simple documentation system favored by doctors, who prefer to focus on patient care, onto an increasingly convoluted payment system favored by insurers. Nothing compares with the agony of losing the paper itemized receipt from an out-of-network doctor that you were planning to file for reimbursement using your insurance website. (Also, be sure you have a scanner at hand! Remember scanners? You bought yours in 1998.)
Usually this vintage record-keeping method is just an inconvenience, but sometimes it can cause some major health and financial trouble. Some people have jobs that discourage using the phone to make personal appointments during the day, so it can be hard to schedule or reschedule in time. And having health records scattered throughout multiple doctors’ offices can lead to dangerous drug interactions, especially if you can’t check in with those doctors electronically.
With a 2009 law, the federal government created incentive payments that aimed to nudge physicians and hospitals to adopt electronic health records, and increasingly, they are. About 48 percent of office-based doctors now use a “basic” EHR system (those that include functionality like patient history, clinical notes, medications and allergies, prescription orders, and digital lab results) according to new data released by the CDC, up from just 11 percent in 2006. Meanwhile, 78 percent now use “any” type of EHR system, a more loosely defined category. Importantly, though, the rates of adoption vary widely; only about 25 percent of ophthalmologists and 19 percent of psychiatrists use them, but nearly 70 percent of cardiologists do. They also varies by state, from 21 percent in New Jersey to 83 percent in North Dakota.
Starting next year, the federal government will start penalizing physicians who don’t digitize their patients’ files. The 20 to 50 percent of doctors who remain luddites isn’t a huge amount, but it’s a fair number when you consider the impending fine.
So why are there still so many holdouts?
First, electronic health records (or EHRs) can be expensive. In 2012, I spoke with one doctor who said he was sticking with paper because the vendors who sell medical records systems said it would cost somewhere in the range of $30,000 to install and $2,000 a month to maintain. Particularly for primary care doctors, who already feel that their reimbursements are too low, an enormous cost up front can be a strong disincentive.
Other doctors say it’s too arduous to import their decades of paper charts into the new electronic systems, or that today’s EHRs don’t adequately funnel all of each patient’s information into one place. What happens, for example, if the patient gets an antibiotic from a paper-chart doctor but then sees an EHR doctor for help with a side effect?
But aside from the expense and administrative troubles, physicians also seem to think computerized records aren’t as user-friendly as traditional, hand-written notes.
A new RAND study of 30 physician practices, which was financed by the American Medical Association, found that while physicians generally approved of EHRs in principle, “the current state of EHR technology appeared to significantly worsen professional satisfaction in multiple ways. Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction,” the researchers found.
Some doctors have resorted to hiring “scribes” to help with some of the EHRs’ data-entry aspects, but that, of course, only adds to the overall EHR price tag.
Digital records can also be less accurate. A report released earlier this month by the Office of the Inspector General for the Health and Human Services Department found that even though the federal government had funneled “considerable resources to promote widespread adoption of EHRs,” it has “directed less attention to addressing potential fraud and abuse.” Because it’s so easy to check boxes and copy and paste between different patients’ files with digital records, past investigations by the New York Times and others have shown that doctors tend to “upcharge”—or bill for more services than they performed—when they use EHRs.
And though experts and government officials say electronic records are more secure than paper ones, some physicians still worry about the risk of patient data leaks. A Maryland internist told me he was once asked if he knew about the cybersecurity risks of EHRs.
This was his quaint reaction:
“I said, ‘cyber-what? A guy like me, that’s the last thing I want to worry about.”
Some medical offices, of course, are blazing boldly ahead with 20th-century technology. One such enterprise is One Medical group, a primary-care startup that launched in San Francisco in 2005 and has since expanded to 27 locations, each with three to six providers. For a paper-hater like me, it’s a dream: You can email with your doctor or nurse, get medical records released by filling out a short online form, and schedule appointments or renew prescriptions with an iPhone app.
“Technology is infused into our culture,” One Medical’s founder, Tom Lee, told me.
Lee has a software background, so the practice built its own EHR that Lee says is nearly bulletproof when it comes to patient privacy, and it's money-saving for the office.
“By managing our administrative processes using technology, we can reduce our overhead and dedicate more time to patient visits.”
Of course, this type of digital concierge service comes at a price. Though One Medical takes most insurance, they charge a yearly membership fee of $150 to $200— that’s on top of co-pays and deductibles. Is that a small price to pay for freedom from phone tag? If we see more and more One Medical lookalikes start cropping up, it could be a sign that the answer for busy patients is a resounding yes.