The EMR, and AI: Are they good? Pose risks? Both?

When I worked with residents in the hospital, the electronic medical record, EMR, was relatively new. We were fortunate to work in a hospital that invested heavily in a good, well-regarded EMR, and spent quite a bit on training the doctors to use it. In the end, almost all the “stakeholders” agreed on which one was best, and the hospital bought it, and had us trained. Good for them.

The EMR wasn’t perfect though. In addition, the hospital didn’t buy all the parts. EMRs come in modules, some necessary, some elective, especially back then. It was clear that the hospital had prioritized the modules for billing, and especially for maximizing billing. Also, anything that the subspecialists who earned the hospital lots of money wanted. Other modules, particularly those that would enhance primary care, were more rudimentary or absent. Some of the things that many of us thought would be easily facilitated by a computerized database and looked forward to having were not available. Surely, once everyone is loaded into the computer, it should be simple to print out a list of all the patients with diabetes assigned to a particular doctor! That would really help us to track them, contact them, make sure they didn’t fall through any cracks. Whoops, sorry, we didn’t buy that module. The maximization of potential billing, on the other hand, was not only there but required many different screens to be filled out, effectively transferring work to physicians from someone else.* And it was inconsistent in how it treated health risks. For example, tobacco use had a who series of questions, including information the patient themselves probably forgot about how much, when, etc., but there was only one on whether they drank alcohol.

There were many things that the EMR did make easier, though, including writing long notes in the chart, since people didn’t have to write by hand. Like the Word® program I am using, and most other computer programs, cut-and-paste became easy and routine. Residents’ notes got longer because they could cut-and-paste yesterday’s note and (hopefully) update it. But sometimes they might forget the update part; it could be embarrassing if yesterday’s note said “surgery tomorrow” and it still said it in today’s note, even though the surgery had occurred that morning! The EMR also facilitated making notes longer by importing all the lab results and radiology reports. This is important information, but it is also available elsewhere (i.e., in the lab and radiology sections). A simple “Radiology exams normal” or whatever they showed would have been much better than cutting and pasting the whole report, as well as briefer. Better because it would have required the resident to read it, make an assessment (“it’s normal”, or “it shows a tumor”) and write that. It would have required thinking. Not to say that they didn’t think, but a summary in their own words would have demonstrated that in a way that cut-and-paste couldn’t.

But the biggest problem with the EMR is the amount of time that it takes to complete, especially in outpatient clinic settings, and especially for primary care clinicians who usually have a wider variety of issues to address and less money to hire others (scribes, sometimes nurses or even NPs or PAs) to do their documentation for them. It is not uncommon for primary care physicians to spend more time documenting in the EMR, frequently at home at night**, than seeing the patient! And in the inpatient setting, hospitals hire nurses to comb charts looking for ways to “upcode”, to charge more. A part of the ongoing contest between providers and insurers to see who can hit the other up for more (except when they have been vertically integrated, more common in outpatient settings, see Vertical Integration saves money. And CVS and its competitors use that to line their pockets, not provide healthcare, May 21, 2026). And potentially costing the patient more, if the insurer refuses to pay it all.

And now we have AI. Or AI is having us. The debate on AI, on whether it will create a great new world or a “Brave New World” à la Huxley, rages on, now with the Pope getting involved with a new 42,000 word encyclical. AI is happening, will continue to happen, and will continue to have effects, many untoward, and some of those resolving – but not necessarily in ways that are good for people. And there are many different people, not just in the US but in the world. Recent commentaries have suggested the benefit would be greatest for the well-off and well-educated (well, almost all things do), although what seem to be “regular” people are using it to bolster their “home brewed lawsuits” and clogging up courts (good or bad?)

I know a lot of doctors who are thrilled about AI, and see it as a vehicle for reversing, or at least slowing, the constant drain on their time that comes from more documentation being required for billing, for insurers, and even for government regulations, in some ways a counter-weight to the EMR. They have apps that record the entire encounter, and then AI drafts a progress note that covers all the essential information in the conversation for both clinical and legal/billing purposes. Then the clinician reviews, augments, and corrects the AI-generated note. Hopefully. That is a danger. AI (as well as clinicians, it should be noted) can make mistakes, and provide incorrect information. With people, we know who to blame. However, recent experiences with friends and family encounters with the health care system suggests that once something gets into the medical record, especially a digital one (indeed, all digital data collection), it is there forever and efforts to correct it do not always take.

And, back to the residents copying their notes rather than creating original ones, it is comparable (if more high-stakes than) to students using AI to write their papers. It allows the appearance of creation and completion without the thinking required to learn to do the job right. Of course, AI advocates argue that AI learns to think more reliably than do people. Maybe this is not a scary idea. A recent opinion piece in the New York Times by Dr. Helen Ouyang suggests that AI (ChatGPT, in this case) gives good, well-researched medical information, and, more important, is accessible to answer questions when the doctor isn’t. The author notes that ”Of course, as a doctor, I know when to question the chatbot and when to ignore it. Many other patients don’t.” That’s right, and that’s a concern. Most of us who have used AI know that it isn’t always right, but if it’s a topic we don’t know about, we don’t know.

The other thing that Dr. Ouyang liked about ChatGPT was, ironically, its personality, since “I had always assumed the ‘human side’ of medicine was the part A.I. couldn’t touch.” The AI was unflaggingly positive, upbeat and encouraging, and never got irritated about repeated or “stupid” questions. People miss this when dealing with – people. While some doctors, like other people, are not, by nature, always warm, positive or supportive, the circumstances in which they work, the pressure from their employers (see several previous pieces, recently Why is it so hard to get medical care? And what should we do about it?, March 15, 2026, and The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., Feb 25, 2026). We should also remember, that while being nice, and friendly, and supportive is usually good, it is also a strategy for gaining your trust that has been misused by bad actors throughout history. And AI never gets tired of doing it, never wants to go home, never misses its kids, and doesn’t have to worry about spending as much time completing the EMR as it did seeing you! (see Does AI communicate better than real doctors? If so, why is that?, Nov 20, 2025).

So, I guess that the jury is not in on AI, or its most effective and reliable and accurate utilization. When it is, it will probably be too late to change it.

  

*This is only one example of work that has been transferred to the primary user. I have long made my own travel arrangements, and like it because I know what I want, but it takes a lot of my time.

**Another example of work transferred to the clinician, at the expense of their family.

Vertical Integration saves money. And CVS and its competitors use that to line their pockets, not provide healthcare

I have several times referred to the concept of “vertical integration” in the health care/health insurance/pharmaceutical industry, most recently on March 28, 2026, Everything is becoming more unaffordable, but health care may lead this list!. These posts often reference the posts of former insurance executive-turned-whistleblower Wendell Potter on his substack “Health Care Un-Covered”, including “With CVS’s Vertical Empire Under Threat in Tennessee, the Company Threatens to Leave”, which discusses the fact that CVS, most widely known as large pharmacy chain, also owns the Pharmaceutical Benefit Manager (PBM) Caremark. PBMs are add-on middlemen that negotiate better rates for insurance companies with pharmacies. CVS owns pharmacies, a lot of them. This may seem like conflict of interest (COI), but that is apparently a quaintly outdated concept in this era of mega-corporations.

Actually, the PBM-pharmacy COI is only a part of the CVS megalopoly. They also own one of the nation’s largest health insurers, Aetna, so they have both ends and the middleman! And, to round it out, they own a large primary care provider group (Oak St. Health) and long-term care company (Signify Health) and urgent care provider (Minute Clinic). Just read the AI summary if you Google “Companies CVS owns”, but if you want it, the comprehensive list by the SEC is here. This is what vertical integration is; you buy from yourself, and sell to yourself, set the prices (usually in a way that minimizes tax liability), and make a lot of money. The structure is not hard to understand, but it maximizes the conflict of interest. (For a discussion of why this is conflict of interest and not “potential” conflict of interest, see this blog post from August 20 2010, The AAFP, Coca-Cola, and Ethics: Serving the public interest? . In brief, COI exists when a decider has interests in both parties, and a decision one way would help their other interest. The conflict exists whatever the decision is actually made. A judge hearing a case in which one party is a company in which they own a great deal of stock has a conflict of interest; it doesn’t require waiting to see how they rule.)

To be clear, CVS is far from the only major player in the “healthcare industry” (quotes on purpose, and emphasis on “industry”) that is vertically integrated. The largest health insurance company in the US, UnitedHealth, also owns a PBM, (OptumRx), a primary care group (Optum) and a whole host of other companies (SEC listing here). So does CIGNA (their PBM is ExpressScripts). So, there is competition within the “healthcare” sector; it is an oligopoly (few companies) not a complete monopoly. But oligopolies don’t really compete in the way classic capitalist theory would have it; rather, they tend to set prices and divide up the market so they all do well (although they would prefer the other companies to go out of business, the existence of a few tends to forestall any governmental intervention that might occur with a true monopoly).

Is vertical integration bad? A major argument in favor of it is that it can, and often does, increase efficiency. If you own everything, from insurer to care delivery system to pharmacy, and all the other players in between, you can minimize the obstruction from a piece that is owned by someone else. Things can move more smoothly. Costs can be reduced significantly. These are the arguments most commonly put forward, to the public, by vertically integrated corporations that control a huge market sector, oligopolies as well as monopolies.

It is also the argument put forward to stockholders, particularly large stockholders like private equity firms. Especially the “reduced costs” part. This is very attractive to stockholders. It could also be attractive to those ostensibly served by the “healthcare” industry, those people needing – healthcare. After all, they are heavily burdened by the cost of their healthcare, which constantly goes up. This includes the portion that they are responsible for in the form of premiums, deductibles, copayments and “cost sharing” (meaning insurance only pays a part of the bill and you’re on the hook for the rest). Another recent Potter piece, The Bill That Never Ends, summarizes the situation and addresses the fact that deductibles reset every year, so people are constantly behind the 8-ball and can never pay it off. It reminds me of the compound interest that keeps former students in debt for decades even though they may have paid off far more than the original loan! It is an example of how our laws are set up to benefit large businesses, not regular people.

Which, of course, brings us to the issue of efficiency, and lower costs. To what use is this efficiency, this lower cost, put? Cui bono? There is an argument that such efficiency could decrease the overall cost of health care to the nation, as well as to the individuals who require care, which has actually been promulgated for decades by academics and others. There are fewer of them these days, as it has been demonstrated repeatedly that such an idea is frightfully naïve. Yes, money is saved, but it is all used for greater salaries and bonuses for management and greater profits for shareholders. If it were being used to lower premiums, decrease deductibles, lower the cost of drugs, or increase the availability and affordability of health care, we would have seen it. We have not. Too bad.

A weak, but possibly useful, analogy is to a family. The adults (usually) generate the income, and certainly choose how to spend it. This can be mainly to provide food and housing, education for children, health care (to the extent that it is available) and other benefits for the family. Or it could be spent on relatively transient pleasure for the adults – alcohol, tobacco and other drugs, gambling, etc. Most of us feel that the first is better, a “good” thing, and the second is not good, is selfish, and even reprehensible. Apparently, such moral judgement is not applied to corporations, certainly not, in this case, those involved in “healthcare”.

I keep putting “healthcare” in quotes when applied to the industry. This is because it is not an industry that is at any significant level dedicated to providing healthcare to our people; when it does, this is a byproduct. It is an industry that is dedicated to extracting the most dollars possible from the rest of the economy and putting them in their own pockets. While this is, of course, the goal of most of our industries, it seems worse that “healthcare”, perhaps because of the veneer that come from ostensibly doing something good, seems to be particularly effective at it.

A single payer health insurance system only addresses coverage. A national health service, such as in Britain, is a more comprehensive manifestation of vertical integration. It doesn’t always work well, mostly because it is starved of funds as a political act to demonstrate that the public sector does not run efficiently or effectively, thus an argument to privatize it, which has to some degree been done in the UK. And, like almost all efforts to privatize formerly public services, the cost goes way up, the service does not improve or gets worse, and the money that could have been used to benefit the people is lining the pockets of ganevem. This does not seem like a good use of benefits of efficiency and decreased cost arising from vertical integration to me.

Maybe we can do something about it! Imagine if the phrase “healthcare” industry didn’t have to be in quotes!

 

For more (or maybe just more terse):

“The health insurance company gets a cut, the pharmacy benefit manager gets a cut, the drug manufacturer gets a cut, and the patient…gets screwed!” Rep Alexandria Ocasio-Cortez, interviewing CVSHealth CEO David Joyner at a congressional hearing.

Also “Federal rules require the insurer to spend a certain percent on care. But, when you own the care, when the insurer owns the pharmacy, owns the PBM, owns the drug manufacturer, you also own the health care cost.”

The whole clip is not that long and makes the point about vertical integration very clear, including 1000% markups on some drugs! Thank you, AOC!  If you have time to do nothing else, watch this video!

https://ocasio-cortez.house.gov/media/press-releases/icymi-ocasio-cortez-calls-out-cvs-healths-corporate-strategy-monopolize