Electronic Medical Records: Will They Really Cut Costs?

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Not surprisingly, nationwide adoption of Electronic Medical Records is being pushed hardest by those who would profit financially from it. The slightly embarrassing financial reality of EMR is that large, mechanized medical operations like hospitals, clinics and big multi-doctor practices stand to make quite a bit of money by adopting them — given our current convoluted system of paying for health care. Two clear factors make EMR a money-winner: improved billing and internal cost control.

Medical billing, for both hospitals and doctors, is accomplished via a system of codes, which is already so complicated that there are special schools for it, granting degrees not just in coding but in special branches of coding. Coding boils down to assigning specific numbers to every problem (diagnosis codes) and other numbers to every treatment (treatment codes). Though the lists, in my field of orthopedics anyway, are woefully inadequate to capture how we actually think about or treat patients, they are still ponderous and complex. From common cold to brain tumor, open heart surgery to handing over an Ace bandage, there is a code that every doctor, hospital, therapist and supplier must use if they want insurance to pay them. (Read "Medical Records Go Digital".)

It isn't hard to see how a digital chart is a ticket to increased revenues. Instant communication from the health information side — with all the tests, diagnoses and treatments — to the billing side that pays for it all, makes billing faster and easier. Why give away that Ace bandage for free? This at least is efficient. But communication the other way, from billing to medical, will take place too. And this is more ominous. The doctor should tell the biller what he found and did. But that EMR program can easily be a very clever, covert way for the biller to tell the doctor what to say he found and did. We don't simply write whatever we want in an electronic chart: we must select from predetermined choices. And these choices offer an open invitation to hyped-up diagnosis and inflated bills.

When, for instance, does a urinary tract (bladder) infection become a pyelonephritis (infection involving kidneys and ureters)? There's no clear-cut answer. But when the computer reminds the doctor, every time he clicks on the "urinary tract infection" button, that the hospital gets many thousands more for the more serious condition, it's just as easy to click on the "pyelonephritis" button and make your administrators happy.

Or consider that nearly every patient who has a big hip or knee operation will run a fever for a while afterward. No one really knows why. But let the computer pick up the temperature elevation and make me address a pull down menu that includes "fever of unknown origin" and I have to add a diagnosis to the patient's chart that often means a bigger payment — though the only treatments for this fever are being given anyway.

Or go to the doctor with a sore knee and for some reason he is examining your ears. It might be that you have a very thorough doctor who is ruling out a rare ear-knee syndrome. More likely, the EMR program he bought is reminding him that notes on the chart about just few more body parts will kick your visit up into a higher-paying code.

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