Washington orthopedic surgeon Vincent Desiderio doesn't mind flipping through folders. His office has seven filing cabinets full of patient charts, some as thick as two inches. Despite feeling the federal government's push to move to electronic medical records, Dr. Desiderio, who has been in practice for more than 30 years, likes his paper file system and might retire before he's convinced to switch.
"I think that electronic medical records are the future — there is no doubt the industry is going to go paperless," he said. "But I don't want to go through an extensive revamping of how I see patients."
Dr. Desiderio isn't the only one who would rather stick with a traditional system than take part in medicine's digital revolution, which would take him months to transition into — and cost plenty. In August, the Centers for Medicare and Medicaid Services released the final battery of rules — known as Stage 2 — for how doctors should use electronic health records (EHR), but some have yet to computerize their offices to any degree at all.
To nudge doctors to make the switch to electronic records, which are said to be more efficient at tracking patient care, the federal government is offering financial incentives, and in 2015, it will penalize physicians who lag behind. To date, around 55 percent of doctors have complied, about on par with the government's projections. But many well-established physicians are not wild about making the transition.
Jonathan Plotsky, a Rockville, Md., internist who has been in practice for 20 years, is sticking with paper for now. He said that over the past year he has met with countless EHR vendors; they would install the required software for about $30,000 and charge $2,000 a month in subscription fees. But Dr. Plotsky feels that the software doesn't do enough to guard against gaps in treatment. For example, an EHR wouldn't automatically register that a patient of his received a flu shot at another medical office, he said.
Technology has changed most industries in recent years, but many doctors' offices still run as they have for decades, with receptionists requesting faxed paperwork and physicians leafing through thick manila folders with years of scrawled medical history stapled inside. Medical students may now be accessing textbooks on their iPads, but much of "health care has stubbornly held onto its cabinet and hanging files," as Health and Human Services Secretary Kathleen Sebelius remarked at a conference last year.
Policymakers sought to breach that technological gap with a 2009 law, part of the anti-recession stimulus package, that aims to increase EHR adoption to 90 percent for physicians by 2019.
Since last year, the government has been offering up to $44,000 over the course of five years in extra Medicare reimbursements — or up to $63,750 through the Medicaid program — to physicians who had become "meaningful users" of certified EHR technology. "Meaningful use" includes such tasks as prescribing medications and inputting lab results electronically into a patient's e-file.
The Stage 2 rules dictate that doctors seeking this money must be using a system that provides digital summaries of each office visit and allows patients to view their health information online.
Starting in 2015, physicians who don't use the digital records will see their Medicare payments cut by 1 percent, a penalty that will escalate to 3 percent by 2017.
But many doctors say these carrots and sticks aren't enough, given the hassle of the switch.
The office of Peter Lavine, an orthopedic surgeon in Washington, is lined with old Broadway posters and rows of paper charts. Office managers code insurance claims on a billing system that was invented in the 1970s.
Lavine said he will most likely invest in an electronic chart system soon, but he'd like it to incorporate data on patients he treated in prior years. Aside from the expense of doing so, he knows that it will be a huge endeavor to load the information in all the paper charts — which fill every corner and a few storage rooms — into a computerized system.
Then there's the security issue. When Plotsky was weighing EHR options, a colleague asked him if he had cybersecurity insurance in case of a data breach.
"I said, ‘Cyber-what?' " he recalled. The insurance seemed pricey — about $300 a month — but if a patient's digital record was somehow stolen, it could mean thousands in legal fees and a messy court battle. "And what do I know about cybersecurity? A guy like me, that's the last thing I want to worry about," Plotsky said.
Some doctors and hospitals have also complained that the electronic systems can go down just when you need them.
The push for electronic systems has come under fire from House Republicans, who say the Department of Health and Human Services has failed to ensure that doctors purchase systems that can share health information with other offices. Investigations by the Center for Public Integrity and others have shown that having an EHR system can also increase upcoding — charging an insurer for more services than were actually provided — because of the ease of push-button billing.
Changing to a new record-management system also can cost doctors time as they learn to operate it. Doctors saw fewer patients and worked more hours on average in the initial months after implementing EHR, according to a recent survey of 31 physicians by Medical Economics, though they eventually return to their previous pace.
David Fischman, an internist, said he saw about one-third fewer patients after he implemented Salar Team Notes in his Harrisburg, Pa., office. "When you put a system like this in place, there's a huge learning curve," he said.
In general, greater investment in technology does result in improved efficiency for physicians — eventually, according to Rosemarie Nelson, principal at the MGMA health-care consulting group, which advises medical practices on EHR projects.
And many physicians who have already started using electronic records boast that they find they are more organized and efficient than before.
Joseph Quash, a cardiologist in Washington, has had an EHR system in place for three years and recently added software to manage insurance claims.
"When you first go to EHR, it's really a nightmare for the first three months in terms of trying to get comfortable with the system," he said. "But now, it helps our work flow, and we have fingertip access to information."
But Quash is relatively young — he's 38 and has been with the practice since 2008 — which puts him in the demographic that's more likely to go paperless. Older physicians are less likely to use digital records, in part because, like Desiderio, they've accumulated mounds of charts and aren't sure they'll be practicing long enough to make transitioning to a new system worthwhile. An April study in Health Affairs found that in 2011, 31 percent of physicians older than age 55 used a basic EHR system, compared with 40 percent of doctors younger than 40. Those in small practices also lag.
Plotsky, the Rockville internist, says his brother, a Bethesda, Md., ophthalmologist, installed an electronic record system and loves it. But Plotsky says a practitioner in internal medicine — where patients often bring up several, complicated problems in one visit — may not see the same benefit from EHR that, say, an ophthalmologist or other specialist might. "We have 10,000 diagnoses and thousands of medicines. It's not like automating that would make it easier," he added.
Naysayers also believe the new tools that come with the records software haven't lived up to the hype. Like many doctors, Desiderio dictates his notes into a tape recorder to be transcribed later, but he says new voice-recognition software that is often built into EHR systems isn't as sharp as his transcriptionist, who knows his voice and makes edits when necessary.
He also grumbles at what he considers to be the digital systems' over-emphasis on binary propositions and checklists. "Computers are designed to say ‘yes' or ‘no,' " he said. "And a fair share of what doctors deal with is ‘maybe.' "
Sure, some patients roll their eyes at his paper charts, Desiderio said, but once they leave, "they say, ‘Okay, that was a good doctor.' "