Monday, February 10, 2014

You Can't See the Doctor, He's Checking Boxes Right Now

Anyone who has seen a doctor in the U. S. in the last few years knows that a laptop or notebook computer is now as essential a piece of medical equipment as the old stethoscope used to be.  The reason is that as of the end of this year, health-care providers will be penalized in the form of reduced Medicare payments for failing to use, and to show that they are using, a certified electronic medical record (EMR) system.  As columnist Charles Krauthammer pointed out recently, this quasi-compulsory adoption of software, some of which at least is clearly not ready for prime time, has led to the creation of a new paramedical profession:  that of scribe.  A scribe is a person who follows the doctor around with the laptop or notebook, taking down information that the doctor would otherwise have to enter manually.  Of course, not all practices can afford scribes, but according to Krauthammer, those who can't have to deal directly with endless lists of checkboxes that attempt to fit each unique patient's case into a straitjacket of database characterizations.  And did I mention that many of these certified EMR systems use different words to describe the same conditions? 

Due purely to reasons of economy and efficiency, many doctors and hospitals were gradually converting to electronic medical records before 2009, when the federal government enacted the Health Information Technology For Economic and Clinical Health Act as part of that year's huge fiscal stimulus package.  Among other things, that bill created the Office of the National Coordinator for Health Information Technology, where one can go online and browse through some 700 or so EMR applications that qualify as certified by the government.  In a perverse way, I suppose this part of the stimulus worked if the real goal was to create jobs, namely those medical scribe positions.  But I thought that the reason to adopt computerized medical records was to make things more efficient.  I suppose that shows I think more like an engineer than a politician.

Let's contrast the way the medical profession is being shoved into the computer age with the way the legal profession did it.  To my knowledge, there are no laws that compel a law firm to use software in its operations.  There may still be some old backwoods lawyer in Tennessee who uses a Dictaphone, and his secretary puts the machine's earphone up to her hearing aid and types documents out on an IBM Selectric.  But if they still want to work that way, nobody's going to exact legal penalties on them—they just won't get a lot of work done. 

Back in the 1980s, one of the first word processing programs to make a big impression on the legal profession was Corel's WordPerfect.  The personal-computer application world was still in its infancy back then, and it was a time when a variety of competing applications were available and shared the growing market.  Somehow, WordPerfect managed to capture a critical fraction of the law-profession market, and the network effect of dominant market share took over.  This happens when a product's output has to be shared among users, as word-processing output often is.  If everybody you work with uses Product X, you are under a lot of pressure to buy Product X yourself, even if you personally prefer Product Y.  So when X equaled WordPerfect, lawyers all over the U. S. began to adopt it as their standard word-processing software, and this remained the case even as the rest of the world dropped everything else and bought Microsoft Word. 

Even as recently as 2011, however, as many as half the law firms in New York City still use WordPerfect, even though it can't do things as elementary as generating .pdf files.  But lawyers have always wanted to be different than everybody else anyway—is there any rational reason that legal documents are fourteen inches long instead of eleven inches, like everybody else's paper?  Not that I know of.  The main point here is not the rationality of lawyers, but the fact that somehow or other, the vast majority of the legal profession adopted electronic legal records with no incentives or penalties from government.  It might have taken a little longer than if compulsion were used, but it happened in a way that didn't give rise to a whole new type of paralegal profession.  Instead, legal secretaries just went ahead and learned WordPerfect.  I'm pretty sure that lawyers now generate more paper with fewer secretarial staff people than in the old pre-computer days.

In his magisterial history of the last half-millennium From Dawn to Decadence, the late historian Jacques Barzun wrote in 2000 that "[t]he point at which good intentions exceeded the power to fullfill them marked for the culture the onset of decadence."  He says this in a passage in which he decries the gradual but nonetheless deadening rise of the power of bureaucracies over the average citizen in the late 20th century.  He wrote that ". . . hospitals. . . suffered the same difficulties as the government bureaucracies.  Those appointed to man them improvised their procedures, and as legislation augmented, laid down rules that filled hundreds of pages, an impenetrable jungle for citizens and officials both. . . . When [the common man] had to thread his way among the gears of an institution, he began a collaboration with an indefinite number of its representatives, amiable or grudging, but all armed with computers, who helped or delayed his rescue from entanglement."  Needless to say, Barzun did not view this as a positive development, but as an antidemocratic move toward tyranny, a tyranny ruled not by one supreme despot but by an army of faceless bureaucrats.

Ideally, engineered products such as EMR and word-processing software should make life better in some way.  "Better" can mean different things to different people, of course.  If you are someone who was unemployed before you got hired as a medical scribe, why, then, the EMR legislation was a good thing, I suppose.  But if you are a doctor who decides that, rather than facing another year of increasingly complex legal mandates, you are simply taking early retirement, then society has lost a valuable contributor for reasons that did not have to be that way.  Yes, even the free market can make mistakes, or at least peculiar decisions:  witness all the lawyers who still use WordPerfect.  But it is by no means clear that the heavy hand of the federal government has produced a net benefit to the health care of its citizens by the mandated move to certified EMR software. 

Sources:  Charles Krauthammer's weekly column appeared on Feb. 6, 2014 on the website of National Review at and was reprinted later that week by many national newspapers.  The statistic on how many New York City lawyers use WordPerfect was cited by blogger Jeffrey Zeldman in his blog at  The quotations from Jacques Barzun's From Dawn to Decadence (New York:  HarperCollins, 2000) are from pp. 778-779.  I referred to Wikipedia articles on WordPerfect and EMR (Electronic Medical Records) and the federal government website of the Office of the National Coordinator for Health Information Technology. 

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