By Lambert Strether of Corrente.

I thought of working words like “debacle,” “scam,” or “bezzle” into the headline, but today is my day to be kind (and the entire topic really demands that I pull on my yellow waders and write another “Credentialism and Corruption” post, which I might do at a later time). However, the headlines give a sense of what a bombshell this study should be for the EHR industry. On the spectrum from reluctant admissions all the way through to The Bezzle:

The complete study (an “Original Investigation”) is here at the Journal of the American Medical Association. Unfortunately, the study is paywalled, and the study material that JAMA exposes muffles the bombshell. From the abtract, the methodology:

Design, Setting, and Participants This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system’s total cost of processing an insurance claim.

(The Harvard Gazette calls the “process map” methology “state of the art.”). And the results:

Main Outcomes and Measures Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Results Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures.

I don’t understand why the JAMA abstract merely lists the dollar costs of EHRs, rather than comparing them to non-EHR systems; however, the study authors have been happy to do that for us in the press. The Harvard Gazette:

“We found no evidence that adoption of these expensive electronic health record systems reduced billing costs related to physician services ,” said Kevin Schulman of the Duke Clinical Research Institute, the Duke University School of Medicine, and Harvard Business School, one of the study’s authors.

From Health Data Management:

“We keep hearing about electronic health records and how they are supposed to improve the efficiency of hospital administration,” says study co-author Barak Richman of the Duke University School of Law and the Duke-Margolis Center for Health Policy. “We found that, as a general percentage of revenue, the amount expended on billing and administrative costs is just as high as it was before EHRs were adopted . Some people thought that EHRs were going to be the solution—and, they’re not.”

And fom Modern Healthcare:

Administrative costs made up as much as a quarter of professional revenue for some patient encounters, according to the study, which focused on a single academic medical center. Researchers attribute much of the high cost to varying contracts between the hospital and health plans and payer as well as varying price schedules. “After investing more than $30 billion in health IT , we haven’t improved the administrative efficiency,” said Dr. Kevin Schulman, one of the study authors and the associate director of the Duke Clinical Research Institute. “That was one of the big promises of digitizing records.

(Ka-ching. Thanks, Obama!) And in an editorial accompanying the article, JAMA does explode the bombshell:

As high as these figures are, they likely underestimate the true financial burden of billing for physicians in most health systems. For one, the hospital and physicians of [the academic system in the study] share a single billing organization, an unusual efficiency for an industry in which hospitals and phyicians are typically separate business entities. In addition, billing costs in this study did not include costs within clinical department for credentialing [nota bene –lambert] and other billing-related functions or charge integrity costs (ie, the costs associated with ensuring that all health care delivery charges are accounted for and properly acrruved to each patient or discharge). While annual operating costs of the EHR were included in this estimate of billing costs, the capital costs of the EHR were not. When the full costs of EHR installation and implementation were fully amortized an attributed to billing, the calculated costs of billing increased by another 44% to 68% . As the authors point out, the appropriate allocation of EHR costs clearly requires further refinement.

(“Further refinement.” Dry. Very dry.)

In this brief post, I won’t review the many reasons why EHRs have always been a bad idea (except for those profiting from installing them, of course; see NC in 2014, 2014, 2014, 2015, and 2015). Rather, I’ll allow a doctor to explain how EHRs cause practitioners burn out. The New England Journal of Medicine:

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care. “We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “ At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work .”

You would expect the results of destroying the morale of doctors to be bad for patients, and so it is:

Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.

What to do? One obvious answer is to stop building EHRs and roll back the systems that are in place.[1] Why not use paper? Roy Poses writes in Health Care Renewal:

I now make a prediction for the future that, once again, seems obvious to me: Today’s EHRs, especially the sections for narrative clinician documentation, will be downgraded from their “template madness” time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper. Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s’ as at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html, but paper nonetheless. Data extraction of these notes for financial purposes will be done, once again, by coders.

But this solution might well be fit within a larger, systemic solution. Because why are EHRs so hard? Because — drumroll please — a multiple payer system is hard to program for. Modern Health:

“Adoption of certified EHR systems by hospitals appears to have been unable to cope with the complexity of multiple payer contracts,” the study authors wrote.

(That “certified” is important; CMS’s Medicare and Medicaid EHR Incentive Programs actually require providers to sign attestations that their systems are conformant.)

And the Harvard Gazette:

“To a large degree, the significant administrative costs measured in this study are the consequences of heterogeneous payment requirements across the multiple payers and health plans contracting with the academic health center,” said another study author, Barak Richman of the Duke University School of Law and the Duke-Margolis Center for Health Policy. “We need to understand better how complexity is driving these enormous costs within the system, costs that do not add value to patients, employers, or providers.”

Thus, as so often happens, what is framed as a technical problem is in fact a problem in political economy. In software, complexity is the enemy of quality, and in this case the complexity is created by the multiple payer system that the EHRs are trying to model. Dare I dream that JAMA is finally coming round to single payer?

NOTES

[1] An analogy between EHRs and electronic voting suggests itself. Why on earth are we trying to turn local election officials into IT specialists, when we could adopt a simple, rugged, and proven system like hand-marked paper ballots, hand-counted in public?