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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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Want to know how to make a billion dollars in healthcare and change the world for the better at the same time? 

You can make a billion dollars in healthcare by inventing a better Electronic Medical Record (EMR) system. If you’re a rising software engineer looking for a Holy Grail, this is it. Round up your smartest engineer buddies and invent the electronic medical recordkeeping system every hospital needs. You’ll become rich, and America’s doctors, nurses, and patients will bow to your achievement.

The push toward EMRs started in 2009 with the American Recovery and Reinvestment Act. President Obama approved billions in spending as an incentive the for the healthcare industry to use EMR technology. Doctors and hospitals who failed to adopt a government-approved EMR system by the end of 2014 faced cutbacks in their Medicare reimbursements. The strategy worked. Today 99% of U.S. hospitals have an EMR system.

Nationwide the current leading EMR system is called EPIC, a product of a company called Epic Systems Corporation, based in Wisconsin. EMRs are expensive. Stanford Hospital adopted EPIC over ten years ago. One department chairman estimated the cost of installing EPIC at Stanford $500 million, and that’s just for one hospital system. How can a hospital recoup this cost? Some money will come via government incentives, but much of the cost has to recouped by more effective and comprehensive bills to insurance companies and patients via the EMR system. Physicians see EPIC as a software system designed to make billing efficient for the hospitals, so that the hospitals can capture a charge for every dose of medication and every procedure. Alas, doctors and nurses serve as data-entry technicians for the EPIC system of billing.

A recent article in Forbes outlined the downside of EMR systems, including thousands of serious, even fatal medical errors. 

EPIC is a poor system for doctors and nurses working in a hospital. Let’s examine what’s involved when an anesthesiologist uses EPIC for a general anesthetic case: 

It takes multiple steps to log into EPIC. First you type in your user name. Then you type in your password. Whenever you move around the hospital, even in a single day and for the same patient, you must repeat these sign-in steps. After EPIC opens, you must click through various screens to bring up the chart on your patient. There are multiple tabs within that patient’s chart. You select the tab for Chart Review, and the information you wish to review is divided into 15 different tabs, and you must click on each individually. Within each tab there is a dropdown menu which is chronological. For a patient who has been in the hospital for a long duration, or who has had a single prolonged hospitalization, there may be dozens or even hundreds of entries under each tab. Each decision requires a mouse click. It may take fifty to one hundred mouse clicks to review all the pertinent preoperative information. 

When it’s time to write a pre-op evaluation anesthesia note in EPIC, you can choose a template which lists all the usual and normal findings, and then click on pertinent positive or negative additions to this template. In medical school, physicians learn how to present only pertinent positive and negative findings on each patient in both our oral communications and in our written notes. Computerized EPIC templates read like Russian novels with copious normal information, through which you must sift to find the relevant information. When I review a patient’s EPIC chart for medical malpractice legislation, I typically must read through 1,000 – 3,000 printed pages of information for one hospital stay, of which no more that 30-40 pages (the doctor’s admission note, the doctors’ progress notes, procedure notes, all surgical and anesthetic perioperative records, specific lab tests, and the discharge summary) are important to the medical developments of that case.

As an anesthesiologist in the operating room, you will have your own EPIC computer next to the anesthesia machine. You enter information by mouse-clicks. In the paper systems used in the 20^th century (and which we still currently use in smaller outpatient surgery centers and doctor’s offices), our charting was simple. To document that we injected 2 mg of midazolam into a patient’s intravenous line, we simply wrote the number “2” in a grid at a point where the word “midazolam” and the correct time intersected. In EPIC, this same entry takes multiple steps: you must click on the word “midazolam,” then click on the dose “2 mg,” and then click on the time, and then click Close. Four mouse clicks. This information can also be entered by four touches on the touchscreen of your computer, but the “midazolam” row on your touchscreen is only five millimeters high. It is neither possible nor practical to try to tap a finger on such a small line. So four clicks it is. That’s not so bad, you say. But it is. A typical anesthetic requires multiple medications given at multiple times. Multiply each entry by four, and you have a cumbersome data entry system. A zoomed in larger touchscreen display would be an improvement, or perhaps a system which recorded via verbal input. But as of December 2019, EPIC and other hospital EMRs are only primitive versions of what will someday follow.

A cumbersome EMR like EPIC interferes with the doctor-patient relationship by placing a keyboard and a computer screen between the doctor and the patient. In acute care settings such as an intensive care unit, an operating room, or an emergency room, entering data into a computer system has to be a distant second priority behind treating the acute needs of a sick patient.

Let me give you a contrasting example of user-friendly computer software: Every time you identify an item you want order online on Amazon, it takes about one minute to complete the mouse clicks to complete the transaction. Why is the transaction made simple? Because an easy transaction makes money for Amazon. EPIC transactions make money for the hospital. The hospitals (so far) do not care how much time it takes each doctor to input information.

In large hospitals (500+ beds), EPIC the leading EMR (58% market share), and the distant second place EMR is Cerner (27%). For all sizes of hospitals, EPIC leads (28% market share), followed by Cerner (26%),  MEDITECH (16%), CPSI (9%), Allscripts (6%), Medhosts (4%), and athenahealth (2%). These multiple different EMR products cannot talk to each other, so if you were previously a patient at hospital A which used the EPIC EMR, and now you’re a patient at hospital B which uses the Cerner EMR, your two electronic records cannot be merged, transferred, or follow you around the country if you move. This dilemma blunts the utility of having EMRs nationally. Imagine if your cell phone was on the A T & T network and your friend’s cell phone was on the Verizon network, and your phones could not talk to each other. That’s the current situation in healthcare EMRs. 

Why does EPIC have the leading market share? It’s perceived to be slightly better than the other systems. I’ve used both EPIC and Cerner. I find EPIC more intuitive than Cerner, but both have major flaws that slow down medical care. 

EMRs are here to stay. America’s hospitals are not going to return to paper charting, but a better EMR is in our future, currently brewing in the minds of some computer geniuses. These computer geniuses should consult with practicing doctors to make ergonomically efficient software and hardware. Or ideally these computer geniuses need to BE doctors, and create the EMR product that will change healthcare in the United States forever.

Healthcare spending represents a huge share (20% ) of the U.S. economy. The Vanguard Healthcare mutual fund increased in value 19.38% year to date in 2019. Some of the contenders for the 2020 Democratic presidential nomination have recommended scrapping our current system for a single-payer system in order to curtail costs. I am skeptical regarding when (or if) the U.S. population will become so fed up with the current healthcare system to warrant the $32 trillion Medicare-for-all system that Elizabeth Warren touts. One thing everyone can agree on is that there is a lot of money spent and earned in U.S. healthcare industries. 

I recently read a book called The Four, written by New York University professor and entrepreneur Scott Galloway.  The book is an insight into the four leading tech companies: Apple, Amazon, Facebook, and Google. Galloway explains how The Four have been changing the world, and he explains the trends they’ve set and the methods they’ve employed. I couldn’t help but wish these giants of the tech industry would set their sights and engineers on improving healthcare software and hardware.

Apple changed the world by putting a touchscreen computer/camera/phone in everyone’s pocket. There are 3.2 billion smartphones in the world today, serving the world’s population of 7.7 billion people, meaning 41% of the world’s population carries a smartphone. Perhaps Apple can invent a hospital EMR that runs on iPads. Google changed the world by inventing a search engine to answer questions in a millisecond. There are 63,000 Google searches conducted every second. Perhaps Google can invent a hospital EMR equally efficient. Amazon hired Harvard surgeon and author Atul Gawande to lead its healthcare division. My wish is that the software and hardware geniuses of these companies could succeed in making a user-friendly, doctor-friendly, nurse-friendly, patient-serving EMR to replace EPIC as soon as possible. If not Apple or Google or Amazon, then perhaps some tech startup staffed by brilliant young engineers can answer this bell. 

Adam Smith defined the Invisible Hand as the unobservable market force in an economy which helps the demand and supply of goods in a free market reach equilibrium automatically. Whenever enough people demand something, it will be supplied by the market and everyone will be happy. 

There is money to be made in designing a better electronic medical record system. Someone will rise to the challenge and invent it. The sooner the better. 

The sooner the better.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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