Obama’s surprising answer on which part of Obamacare has disappointed him the most

There was this moment, about 50 minutes into our interview with President Barack Obama last week, that genuinely surprised me (and surprised other health care journalists, like David Nather, too).

My colleague Ezra Klein had asked the president a question about which part of the law had overperformed his expectations, and which part of the law had underperformed.

The president gave a surprisingly frank assessment of something his administration has tried, and failed, to do: Get doctors off paper and on to digital medical records.

“We put a big slug of money to encouraging everyone to digitalize and catch up with the rest of the world here,” President Obama told us. “And it’s proven to be harder than we expected.”

Obama then went on to analyze why this had been so hard — why in a world where, in the president’s words, “you can basically do everything off your phone,” the medical system remains buried under “mountains of paperwork.” His answer is worth reading in full:

We put a big slug of money to encouraging everyone to digitalize and catch up with the rest of the world here. And it’s proven to be harder than we expected, partly because everyone has different systems, they don’t all talk to each other, it requires retraining people in how to use them effectively, and I’m optimistic that over time it’s inevitable it’s going to get better because every other part of our lives, it’s become paperless.

But it’s a lot slower than I would have expected; some of it has to do with the fact that it’s decentralized and everyone has different systems. In some cases, you have economic incentives against making the system better; you have service providers — people make money on keeping people’s medical records — so making it easier for everyone to access medical records means that there’s some folks who could lose business. And that’s turned out to be more complicated than I expected.

President Obama doesn’t spend a lot of time talking about electronic medical records, but when he says his administration “put a big slug of money” into incentivizing health providers to adopt electronic records, he’s not kidding. There was $27 billion in funds for this exact purpose in the 2009 stimulus bill. And the results have been disappointing.

While most hospitals now have some type of electronic medical system in place, most do not have the ability to transfer information to another hospital outside their own system. Only 38 percent of hospitals say they can use or integrate data from another hospital into their own electronic records system.

Two explanations of why doctors have struggled to go digital

I generally agree with President Obama’s analysis of the problem, and why it’s difficult to solve.

For patients, it would be great news if any doctor or hospital could access their medical history. They could turn up at any office in their city, maybe even in the country, and with the click of a button a doctor could bring up their various scans and tests and personal history. It would become way, way easier to get a second opinion or switch to a new provider.

That's exactly why interoperability is bad business for hospitals: It makes it easier for patients to switch providers and take their business elsewhere. Hospitals with interoperable records would be taking away all the friction that's associated with switching providers in the current health care system.

One other challenge Obama didn’t mention, though, was the actual technology itself. I have yet to meet a doctor who likes his or her electronic medical record system, who says it makes their work as a doctor easier rather than harder. (If you are that doctor, please send me a message and tell me about it!)

Instead, I hear from lots and lots of providers — even those who are young and tech-savvy — who complain vociferously about their medical record systems. There are too many boxes to check and details to fill out, and it’s significantly more work than scribbling down a few notes on a piece of paper. Some research finds that electronic medical records make doctor offices less efficient, as physicians spend more time entering data into the digital system than they used to do on paper.

At this point, it’s not totally clear what will push doctors to go digital. The Obama administration tried big financial incentives, but those didn’t get them past the finish line. I’ve wondered whether this might end up resting on private industry, and someone designing an electronic medical record that doctors actually like, leading to more widespread adoption. You’ve seen this with apps like Slack for group chat — a technology that was hard and clunky to use until Slack came along and, all of a sudden, it wasn’t. So far though, that type of platform hasn’t come along in medicine — and even that wouldn’t fix the incentives to keep data private, rather than release it to other competitor hospitals and doctor offices.