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The makeshift militia forced their way into Hollingsworth's home and destroyed several weaving machines they deemed threatening to their trade. According to an account by Kirkpatrick Sale, writing in The Ecologist (Aug/Sept 1999), "That ... was the first attack on textile machines by men who called themselves followers of General Ludd, who would convulse the countryside of the English Midlands for the next 14 months -- and would go down in history -- and into the English language, as the first opponents of the Industrial Revolution and the quintessential naysayers to odious and intrusive technology."
The followers of Ned Ludd became known as "Luddites," a word that has become synonymous with opposition to technological innovation. The original Luddites are not the only example of discomfort with technology and the change it brings. Historical accounts of opposition to the steam engine in the 1780s, the economic power of factories during the Industrial Revolution, and our American opposition to, and fear of, the "horseless carriage" in the late 1800s, are just a few examples.
You may be surprised that even today -- amid the ubiquitous personal computers, iPhones, Wiis, Xboxes, smartphones, social networks, and blogs on any imaginable subject -- there are Luddites; those who eschew technological "advances." Bruce Landis is president and CEO of Southwest Physician Associates, a Dallas IPA with more than 1,300 physicians. As for Electronic Medical Records (EMRs), Landis insists, "I am not a Luddite. Physicians are people who have been through the development of CT, MRI and robotic surgery. We are not afraid of technology, but we are afraid of bad technology."
Election year debate about our health care system has moved the conversation on EMRs to the front burner. The debate has focused on the provider community, and while there has been some discourse among consultants, many practitioners may not be familiar with the concept. Linda Kloss, executive vice president and CEO of the American Health Information Management Association (AHIMA), has identified three essential capabilities of EMRs. They must capture data at the point of care. They must integrate data from multiple internal and external sources, and they must support caregiver decision making.
A 2003 U.S. Institute of Medicine (IOM) report, "Key Capabilities of an Electronic Health Record System," went further, listing eight core capabilities which, if present in an EMR, would "promote greater safety, quality, and efficiency in health care delivery." They are:
Health Information and Data -- The cornerstone of all EMRs, this would give doctors and hospitals immediate access to key information, such as patients' diagnoses, allergies, lab test results, and medications. According to IOM, this information would improve caregivers' ability to make sound clinical decisions in a timely manner.
Results Management -- This would enable all providers participating in the care of a patient in multiple settings to quickly access new and past test results. This data would increase patient safety and effectiveness of care.
Order Management -- IOM believes this would enhance legibility, reduce duplication, and improve turnaround time.
Decision Support -- This aspect would provide reminders, prompts, and alerts which, in conjunction with computerized decision-support systems, would help improve best clinical practices. It would also identify possible drug interactions and facilitate diagnoses and treatments.
Electronic Communication and Connectivity -- In IOM's definition, this would provide "efficient, secure and readily accessible communication among providers and patients and improve the continuity of care while increasing the timeliness of diagnoses."
Patient Support -- This component would equip patients with tools to access their health records, provide interactive patient education, and help patients carry out home-monitoring and self-testing. The IOM believes this will improve control of chronic conditions, such as diabetes.
Administrative Tools -- New scheduling systems and other administrative techniques would improve hospitals' and clinics' efficiency, while providing more timely service to patients.
Reporting -- IOM defines this as "Electronic data storage that employs uniform data standards that will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance."
These eight goals seem so slap-of-the-head obvious that it would be difficult to imagine opposition to them. Sadly, no imagination is required -- the resistance is right out there in the open. The reason has nothing to do with the inherent logic and merits of EMRs. Virtually all players agree on those. The problem is that once again, as we have seen with other initiatives and as we have discussed regarding consumerism itself, there is a giant disconnect between all of the parties.
A cynical observer might suggest that the "decision support" or "results management" components are the issue, citing many doctors' disapproval of pay-for-performance measures. But the sticking points are much more rudimentary than those esoteric arguments. Most physicians have not embraced EMRs for two reasons: they see records becoming an end in themselves, and they think the costs of creating and maintaining those records are not fairly distributed among those who benefit from the use of the records.
Dr. Landis makes the case for the former argument. "You have to realize that physicians have been trained four years in med school, then three to seven years in post-graduate training," he says. "The funny thing is that they want to take care of patients. They don't want to become specialists in creating medical records. They look at medical records as an incidental cost of doing business. Many EMR programs act as if the medical record is the whole point of the patient encounter. It is just not."
Landis, the self-proclaimed "non-Luddite," isn't alone. According to a report published in the June 18, 2008 edition of the New England Journal of Medicine (NEJM), electronic records were used in less than 9% of offices with three or fewer doctors. That office size encompasses more than half of the nation's medical practices.
Dr. Paul Feldan, a primary care physician in one of those small practices, says his group has rejected the notion of investing in EMRs. He estimated that the initial cost of upgrading the office's personal computers, buying new software, and obtaining technical support to make the shift would be $15,000 to $20,000 per doctor. Insult is added to injury when the time to convert from paper to computerized records reduces the time the doctors have to see patients. Says Dr. Feldan, "Certainly, the idea of electronic records is terrific, but if we don't see patients, we don't get paid. The economics of it just seem so daunting."
The NEJM study points directly to that problem. Doctors who use them say that EMRs have helped to improve the quality and the timeliness of care. The findings confirm that it isn't opposition to the EMRs per se, but rather the misalignment of the economic burden that is the brake on wider adoption.
While physicians bear the cost, the medical community's point of view is that private and government insurers and hospitals reap the savings. Once again, misalignment of costs and incentives is having a negative effect on consumers. Dr. Blackford Middleton, a health technology expert at Partners Healthcare in Boston, puts it this way: "We have a broken market for electronic health record adoption because the people who gain financially are not the people who pay."
The rest of the industrialized world is far ahead of the U.S. in the percentage of physicians who have adopted EMRs. While our adoption rate languishes at 28%, in the Netherlands it is 98%, New Zealand is at 92%, and the U.K. has an 89% rate. Other nations well ahead of us include Australia (79%) and Germany (42%). Dr. Middleton and others believe that the government should provide incentives or subsidies to speed the use of computerized records in the U.S.
In early June, the federal government unveiled a $150 million Medicare project that will offer incentives to doctors to move from paper to electronic records. The goal of the project is to convert 1,200 practices in 12 cities and states. Yet physicians don't need to wait for the government. According to a new Certification Commission for Healthcare IT study reported in Health Data Management (Sept. 25, 2008), at least 50 hospital organizations have launched programs to subsidize the cost for doctors. The study also reported another 40 EMR programs already underway at government agencies, insurance companies, employer coalitions, and public-private partnerships.
Once again, the one element so glaringly absent from the equation is consumers. If consumers knew the benefits offered by EMRs, and if the health care system would actually treat them as the market drivers they are in all other industries, we might have the world's highest adoption rate instead of one of the lowest.
The Luddites feared that new weaving technology would make their skilled hands -- and thus their jobs -- obsolete. Dr. Landis and others make the case that if doctors were afraid of technology, they would not have embraced the diagnostic and treatment advances made in recent years. Perhaps it is just the economics and the lack of consumer insistence that is keeping doctors from jumping on the bandwagon. Or there may be other forces at work.
In the coming months, we will continue to explore the dichotomy of EMRs as a clinical and quality tool and the problems some see with the government's plan to speed adoption. There are many interests with a stake in this, and serving them all without the unifying voice of the consumer will be difficult and perilous.
Readers may write to David Saltzman at Carolina Care Plan, Inc., 201 Executive Center Drive, Columbia, SC 29210. David is a past president of NAHU and has been a health, disability, life, and employee benefits consultant and broker for more than 25 years. He is the director of the large group segment for Carolina Care Plan.
