Dr. Martin Fee, an infectious disease specialist, doesn’t miss the
days of chasing medical records through the corridors of Orange County
“I spent half my time finding clipboards to find out if my patient
had a fever overnight,” said Fee, chief of staff at Hoag Hospital
Newport Beach. To learn the results of a patient’s CT scan, he said, he
would tromp downstairs to radiology to review the films in person.
Today, due to the federally mandated move from paper to digital
health records, he can call up patient data in seconds on his office
computer. For his patients with life-threatening infections, that can
mean a more rapid diagnosis and much earlier treatment.
But for other doctors, the requirement to shift to electronic health
records is threatening to bog down their practices, sometimes with
ruinous financial consequences. For many of their patients, personal
contact is being trumped by data entry.
“The screen is a tyrant,” said Dr. Ellie Bloomfield, a Glendale
internist who said she is seeing little medical benefit from a system
that can seem better suited to help insurance companies and the
government gather data.
The inputting takes time away from her patients, and some of them left her practice. She said her income dropped 25 percent when she phased in her new system.
As Fee and Bloomfield illustrate, the change sweeping through medical
suites is transforming the practice of medicine, for better and for
The vision calls for a vast system of digital records connecting
doctors, patients, hospitals and laboratories in a way that promotes
widespread efficiencies, reduces medical errors and generates vast
databases to boost medical research.
But the federal electronic records program – filled with incentives
and penalties for physicians – is also carving out a digital divide that
can favor large practices over solo practices, younger doctors over veterans, and specialists over primary care physicians.
Rolled out as part of the 2009 stimulus package by President Barack
Obama’s administration, the program primed the pump with $26 billion in
incentives for doctors and hospitals to meet goals ranging from
prescribing drugs electronically to sending patients’ test results via
In California, the federal government has delivered more than $700 million in incentives to about 20,000 doctors since 2009.
Doctors could qualify for up to $44,000 over five years to help get their systems functioning.
Starting next year, doctors who don’t meet compliance deadlines face
escalating penalties. By 2019, they could lose up to 5 percent of their
Medicare billings. Doctors who believe they can’t meet the deadlines had
to file so-called “hardship requests” by July 1 to try to avoid the
Some major medical systems will have no problem meeting the initial
federal goals. For example, Oakland-based Kaiser Permanente, the
nation’s largest not-for-profit integrated managed care health system,
is well ahead of the curve. It launched its electronic records
initiative in 2003, investing $4 billion over 10 years and digitizing
both doctor and hospital records by 2010.
Close to 68 percent of its 9.3 million patient members are accessing
records online, via computer or smartphone, said spokeswoman Ravi
But for many physicians, electronic records are more vision than
reality. Fewer than 54 percent of California’s office-based physicians
had basic systems working in 2013, according to a January study from the
federal Centers for Disease Control and Prevention. That was slightly
better than the 48 percent national average.
The price of buying
and upgrading software is beyond the budgets of many practitioners, with
some saying it would be cheaper to forgo the upgrades and pay upcoming
For doctors with decades of paper-based practice,
the learning curve can be far steeper than for newly minted doctors who
trained on digital systems.
Internists and family physicians bear the brunt of entering the data heavily used by Fee and other consulting specialists.
Primary care doctors already are buffeted by other changes.
are being pressured to align with hospitals and large groups called
accountable care organizations, or ACOs, said Dr. Don Goldmann, chief
medical and scientific adviser at the Institute for Healthcare
Improvement, a Cambridge-based think tank. ACOs are networks of
providers designed to improve care efficiency and reduce costs.
lot of primary care physicians are pretty burned out. There are older
physicians who are saying, ‘I’ve had enough,’” he said. “Then, if you
sit down with someone trying to provide care in the midst of a major
electronic medical record install, they may tell you that it’s a major
distraction and an enormous time commitment over a long period of time.”
Technical issues are proliferating.
government is urging doctors, who traditionally have kept medical
records in locked file cabinets, to preserve them on encrypted hard
drives instead. During the transition, millions of unencrypted health
records have been misplaced, stolen or hacked. In one of the most
notable cases, hackers in Eastern Europe got access to 780,000 Medicaid
records from the state of Utah in March 2012 before anyone noticed.
faced with a plethora of hardware and software complications, federal
regulators have postponed a requirement that doctors be able to
seamlessly share patient records with one another and hospitals.
American Medical Association and other national groups have called for
the U.S. Department of Health and Human Services to roll back other
deadlines and simplify the rules. But in the meantime, the digital
divide has become one of the defining elements of medical practice.
know it is a heavy lift,” said Dr. Jacob Reider, a family physician and
deputy national coordinator of the department’s office overseeing
health technology. By their nature, large practices are better prepared
for the shift, he said, but some solo practices are moving nimbly, too.
“It’s like the Galapagos Islands. Evolution happens at difference paces,” he said.
Fee was at his desk preparing to see his first patient of the afternoon when he heard a “ping” from a secure app on his iPhone.
The text came from a doctor colleague at Hoag Hospital, visible just
across the street from his office in a Newport Beach medical building.
doctor needed guidance about a patient Fee had been treating daily
since the patient arrived at Hoag two weeks before with a severe spinal
infection. Was the patient ready for a transfer? A scarce bed had just
opened up at an acute long-term care hospital nearby.
to his computer and called up the patient’s records, poring over the
vital signs – temperature, blood pressure, pulse – shown by jagged lines
across the screen.
The patient’s white blood cell count, a key
indicator of infection, had dropped from 29,000 upon admission to
13,000, closing in on a normal range.
“Temperatures are perfectly
average,” Fee reported. A few clicks later, Fee texted his colleague at
Hoag that the patient could be released.
records, Fee would have completed his office appointments before going
to see the hospital patient and hunting down that clipboard. By then,
the long-term care bed might be taken, he said, meaning another night or
more at Hoag and bigger bills to pay.
Now even the office visits are streamlined.
greeting the patient, Fee read the patient’s records and put on his
stethoscope in preparation for a physical exam. Visit finished, he was
back in his office, exchanging the stethoscope for a headset. He began
dictating into a voice recognition system.
“Prior infection in
that area appears to be resolved. Period,” he reported. The words
immediately popped up on the screen. He spent 10 minutes dictating,
toggling between his own records and Hoag’s system, answering questions,
adding test results, even filling out a billing form.
He swapped the headset for the stethoscope and was off to see the next patient.
was clicking away on a laptop in her Glendale office when a local
nursing home called, asking for details about a patient’s drug dosage.
the old days, she provided that information over the phone. Now she
called up a page on her screen called “Prepare Referral” and typed in
how many times her patient should take his Tylenol and vitamin B-12.
The page froze.
“Now it’s locked. OK, kill screen,” she said, and started over.
Bloomfield started investing thousands of dollars in 2011 to move her patients’ records from paper to computers.
That investment, she says, led to ever-escalating bills and dramatically less time treating patients.
Soon she learned she needed six new laptops for her exam rooms and
office staff, and had to pay $200 extra each month to upgrade her
Then came the challenge of converting patient records, filling three
lateral filing cabinets, into digital format. She hired a company to do
the scanning and, with extra costs, that bill skyrocketed.
She slowed from seeing 20 patients a day to eight, each taking an
hour of her time. “I was with the patient maybe 20 minutes. The rest of
it was working the computer,” she said.
Fewer patient visits meant less income, dwarfing the $44,000 in
federal payments meant to help doctors make the transition. She worried
she could not pay her bills.
Before the installation, her practice typically took in $350,000 a
year, she said. That dropped by as much as $50,000 in 2011 because of
the extra expenses and fewer patient visits, and began recovering only
in 2013. The difference came out of her own pocket, and she had to skip
the $10,000 in staff bonuses two Christmases in a row.
Three years after the launch, her patient flow is nearing normal but her system still can’t “talk” to other providers’ systems.
Bloomfield is considering “opting out,” choosing to lose part of her
Medicare income to penalties rather than meeting the next federal
deadline for upgrades.
For now, she’s trying a new tack. Three weeks ago, she hired a
“scribe,” a medical assistant who joins her in the examination room.
While she treats a patient, the assistant types.
She explains to patients that now she has more time to spend with them.
“They’ve all said, ‘Great!’” she said.
The CHCF Center for Health Reporting partners with news organizations
to cover California health policy. The center is based at the Annenberg
School for Communication and Journalism at USC and is funded by the
nonprofit California HealthCare Foundation.To read the original Orange County Register article, please click here.