Falling victim to the substitution myth, the RAND researchers did not sufficiently account for the possibility that electronic records would have ill effects along with beneficial ones—a problem that plagues many forecasts about the consequences of automation. The overly optimistic analysis led to overly optimistic policy. As the physicians and medical professors Jerome Groopman and Pamela Hartzband noted in a withering critique of the Obama administration’s subsidies, the 2005 RAND report “essentially ignore[d] downsides to electronic medical records” and also discounted earlier research that failed to find benefits in shifting from paper to digital records. RAND’s assumption that automation would be a substitute for manual work proved false, as human-factors experts would have predicted. But the damage, in wasted taxpayer money and misguided software installations, was done. EMR systems are used for more than taking and sharing notes. Most of them incorporate decision-support software that, through on-screen checklists and prompts, provides guidance and suggestions to doctors during the course of consultations and examinations. The EMR information entered by the doctor then flows into the administrative systems of the medical practice or hospital, automating the generation of bills, prescriptions, test requests, and other forms and documents. One of the unexpected results is that physicians often end up billing patients for more and more costly services than they would have before the software was installed. As a doctor fills out a computer form during an examination, the system automatically recommends procedures—checking the eyes of a diabetes patient, say—that the doctor might want to consider performing. By clicking a checkbox to verify the completion of the procedure, the doctor not only adds a note to the record of the visit, but in many cases also triggers the billing system to add a new line item to the bill. The prompts may serve as useful reminders, and they may, in rare cases, prevent a doctor from overlooking a critical component of an exam. But they also inflate medical bills—a fact that system vendors have not been shy about highlighting in their sales pitches.
The biggest assumption that we tend to make with digital records is that they would necessarily be cleaner and would enable all sorts of digital improvements and technology advance. However, what we need to consider is that most digital entries still require human inputs. In the perspective of healthcare, electronic medical records have the potential to actually distract a doctor’s attention. Most software implementations also require the buy-in of the stakeholders and a good focus on data cleanliness. These things tend to derail digital implementation projects. from fulfilling their full potential.
