When President-elect Obama outlined his economic stimulus package earlier this month, he emphasized the need to invest in the healthcare system’s infrastructure by pushing for electronic health records (EHR), nationwide: “We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.”
On the face of it, I like the proposal because Obama is talking about spending money on something concrete, something that we definitely need, and something that, over time, should make U.S. healthcare safer and more effective. At the end of the day, we’ll have something to point to that is just as substantial as a safe bridge and that, over the long term, should add to the health and the wealth of the nation. If done right, the pay-off would be better, more efficient care for years to come. And here’s the bonus: a roll-out of healthcare IT would provide jobs for all of the people needed to design the technology and train healthcare providers.
Still, this is an ambitious undertaking. And there are questions to be asked. So I began asking them. Some of the answers were eye-opening.
Why Don’t We Already Have HealthCare IT?
After all, we spend hand-over-fist in most areas of healthcare: why not here?
The problem is that the physicians and hospitals who the government expected to invest in electronic health records are least likely to benefit financially. For example, if electronic medical records reduce the number of redundant tests, the insurer and/or the patient enjoy the financial benefit: the physician does not. In fact, if the physician does the tests in his own office, he loses money every time he doesn’t need to repeat a test. Over time, health care providers might realize savings from EHRs, but experience suggests that it would take at least ten years.
Since insurers would be the first to enjoy savings from more efficient care, it would make sense for them to provide the initial funding for Health IT. But so far, relatively few for-profit insurers have stepped up to the plate.
In most developed countries government (i.e. taxpayers) has played a major role in developing and funding EHRs. The U.S. decided to wait for market competition to do the job. So far, that hasn’t worked out very well, and the new administration seems ready to take a more proactive role. But before making an enormous investment, someone should ask about the state of the art: are EHRs ready for a national roll-out?
The Difference Between a Hospital and an Office
The answer, says Dr. Scot Silverstein, the director of Drexel University’s Institute for Healthcare Informatics, is No! Over at Dr. Roy Poses’ Health Care Renewal, Silverstein has posted an open letter
to President-elect Obama, applauding him for the IT initiative, but warning that at this point in time “Health Information Technology (HIT) is an experiment”—at least in the U.S. It is, as yet, unproven on a large scale. There have been many warning signs that it is an experiment that could go awry.”
Silverstein notes that “after years of effort and billions of dollars spent,” use of HIT in this country remains limited. And where electronic health records are used, “Clinicians (physicians, nurses and others) are struggling to use awkwardly designed HIT, designed as if for quiet, solitary business offices yet costing millions of dollars per hospital.”
Silverstein blames information technology experts who do not recognize the difference between healthcare and other industries. They design systems that might work well in a bank will not cut it in a hectic ER. Silverstein stresses that clinicians must be involved in the design of healthcare IT.
A 2005 article in the Journal of Biomedical Informatics expands on this point : “Designers of healthcare information technology (HIT) must be exquisitely sensitive to the non-linear, context dependent, fast communication-dependent, interruption-filled, uncertain, and collaborative nature of hospital clinical practice,” writes the University of Pennsylvania’s Dr. Ross Koppel. The piece concludes: “That some HIT development has occurred without this disciplinary input and wisdom is deeply regrettable. (Thanks to Dr. Rick Lippin for calling my attention to Koppel’s work.)
Three years later, little has improved, says Silverstein. Rather than becoming more sensitive to the needs of a hospital, “the healthcare industry and the HIT sector have been reliably tone deaf on these issues, which results in the very low diffusion of HIT. Platitudes, excuses, and blame placed solely on endusers (i.e., the clinicians) are the norm.”
In a separate e-mail responding to my comments, Silverstein elaborated: “The takeaway is that HIT is a cottage industry. I fear our government has been spoon fed a steady diet of irrational exuberance on this issue and will proceed . . . naively down a path that might lead directly to HIT hell. “We are attempting to go from cottage industry to mature industry in one giant leap. I'm afraid Neil Armstrong's ‘giant leap’ for mankind was an easier task.”
Yes, a large investment in health IT would create jobs but, as Silverstein points out, given the state of vendor-designed EHRs, and the trouble healthcare workers and hospitals are having with them, “While HIT problems may be good for the IT and management consulting businesses, they are not good for the healthcare business, already struggling under great financial duress.”
“Turmoil, Toil and Trouble”
If phrases like "HIT hell” and “irrational exuberance” don’t give you pause, consider another open letter to the Obama Healthcare Team on TheHealthCareBlog.com (THCB). This missive was penned by David C. Kibbe MD MBA, a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies, and Brian Klepper PhD a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc—who I have quoted on HealthBeat in earlier posts.
They acknowledge that “the easy solution would be” for the administration “ to spend most of its health IT funds on electronic health records (EHRs). The EHR industry has made it easy by establishing a mechanism to ‘certify" EHR products if they incorporate certain features and functions.
“But the easy solution would not be the right one,” they explain. “EHRs still are notoriously expensive.” Moreover “often, practicing physicians do not consider many of the [“certified’] features and functions to be useful or important.” Meanwhile, “It can cost as much as $40,000 per physician in a medium size medical practice at the beginning of an EHR implementation. Even that regal sum may not completely cover the hardware and technical support necessary.”
Like Silverstein, they warn that “EHRs can be difficult to implement, upsetting practice workflows. In general, physicians' practices have not adjusted quickly or smoothly to the disruptive nature of the switch from paper to electronic systems for patient care. Implementations can take months or even years to stabilize. And the turmoil associated with the implementation can often have negative revenue repercussions for the medical practices they are intended to help. Physicians routinely report that, during the adjustment period, the number of patients they can see and treat in a day drops by twenty to thirty percent, with a commensurate decline in revenues.
“Nor is there conclusive evidence that the use of EHRs improves patient care quality.”
In addition, Kibbe and Klepper note: “EHRs from different vendors are not yet interoperable, meaning that patient information cannot yet be easily exchanged between systems. If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.
“These barriers to adoption…form the wall that has kept physician EHR adoption overall to less than 25 percent in this country. Even if a hefty federal subsidy reduced the exorbitant cost of the EHRs, many practices would suffer severe negative business impacts, and primary care access could temporarily be reduced on a national scale.” And, as regular readers know, we already are facing a primary care crisis.
Wait –it gets worse. Commenting on the TCHB post, Sherry Reynolds
of Allinace4Health observes that “ the challenges with interoperability (between hospitals) actually have very little to do with standards. In some of the major markets (Palo Alto, Seattle) you have the same vendor at multiple hospitals (PAMG, Kaiser and Stanford) who can't exchange data. The vendors know that their customer is the hospital not the patient who moves across systems and since hospitals want to own the patient there isn't a ‘business case’ from the hospital to share the data, but it isn't difficult to do from a technology standpoint.” In other words, Hospital A doesn’t want to make it easy for Hospital B across town to get your X-rays because Hospital A wants to make sure that you continue
doing business with hospital A (even if it is not as good at treating your current complaint.)
And the vendor cares not about the patient, but about what the hospital wants. After all, the hospital is paying the vendor. This serves as yet another example of how, in our largely unregulated and highly competitive profit-driven health care system, the patient’s interests often come last.
The Trouble with the Health IT Vendor Industry
When I commented on the THCB post yesterday, Dr. Rick Peters founder and former CEO of Oceania, one of the earliest enterprise EHRs, responded to my questions. First, he explained that while integrated medical centers like the Mayo Clinic or Geisinger may have succeeded in creating home-grown efficient EHRs that meet the needs of the institution very well, these EHRs are easily adapted to fit into other settings.
By contrast, the EHR systems designed by IT vendors are unnecessarily complex, says Peters, and “actually make the practice of clinical medicine less efficient than it was on paper. Advocates say this is the price you have to pay to get data in a computable form, but those advocates do not tend to be in the trenches. A good EHR improves efficiency, decreases tasks and redundancy, and simplifies rather than complicates workflow.”
Peters elaborates in a piece that he posted on THCB today, titled “Washington, Please don't Bail Out the Health Care industry. ” He begins by drawing a parallel between the Health IT industry and “the auto industry circa the 1970s”:
“A few large players who build big, expensive systems on outdated technology platforms dominate the industry. There are some Toyotas, Hondas, VWs, and BMWs in the mix, but the big players dominate the industry forums, standards organizations, and mindshare of the institutions – our academic medical centers and large health care organizations. They sell the institutions Cadillacs and Lincolns with big fins that wallow and weave as you drive down the road and they offer the rest of us Pintos and Vegas – smaller versions of the big systems that unpredictably catch on fire.”
Meanwhile, Peters confides, “the organizations set up by industry and the government to mandate standards, are controlled by the large archaic systems vendors. Standards selected and set by these organizations are unnecessarily complicated, expensive to implement, and protective of the big players. They stifle innovation and like the Big Three automakers, keep health care IT completely out of step with the general computer industry. Health care IT and HITSP standards are at least a decade behind the open data standards and open-source progressivism of the general computer industry.
“In a nutshell,” he pleads, “do not pour more money into this industry without completely rethinking how we drive innovation. Currently available EHRs from the major, CCHIT certified vendors will not save us money. Any assumptions about improvements in quality or patient safety will be offset by an across the board loss of clinical efficiency, a loss of productivity and a counterintuitive increase in the number of personnel, and increased clinical and administrative errors due to system and user interface complexity.
“Across the board the decisions by CCHIT have narrowly defined the criteria that constitute a ‘certified’ EHR,” he continues. “ They have made the hurdle artificially high and they have made the process as well as the required standards expensive for smaller innovative vendors to comply with and time consuming to implement. EHRs are not the solution, and this is very sad for me to say having devoted most of my professional life to them.”
How Can the Obama Team Advance Health IT?
Everyone who knows something about vendor-designed electronic health records seems to agree: investing in the EHRs that the industry is now producing would be a truly terrible idea.
Nevertheless, Kibbe and Klepper suggest that the administration should put money into “incremental and low-risk health IT.” They hold out e-prescribing as an example. “ E-prescribing has made it easy for physicians and pharmacists to electronically share prescription data, and it produces significant benefits to physicians over the short term,” while simultaneously providing a pathway to more comprehensive IT use over time . “
The technology is neither complicated nor expensive: “E-prescribing uses computing devices to enter, modify, review, and communicate prescription information. The entire process can be automated, from a prescribing doctor's fingertips on the keyboard to the receiving pharmacist's view of the medication order on his/her monitor. All this is possible through the use of standards- and web-based software that is free or inexpensive to the medical practice. The only technology required of the doctor is Internet connectivity and access to one of the popular browser software programs, like Internet Explorer or Mozilla Firefox”
Kibbe and Klepper offer other examples of ways that the government could pave the way for greater use of health IT—including investing in infrastructure in parts of the country that do not have broadband access. You can read about their suggestions here.
In the end, if the new administration refuses to throw money at EHRs, Kibbe and Klepper conclude that this would send a signal “to the EHR industry that, for national deployment, they need to come to terms with issues they have avoided so far, like interoperability and cost.” This is the same signal that the administration needs to send to other manufacturers in our health care industry: we don’t need exorbitantly expensive cancer drugs that extend life for a few months; we don’t need more bleeding edge devices equipped with all sort of new bells and whistles. We need safe, effective, affordable drugs and devices. Focus your research dollars on figuring out how to make your products simpler and less expensive. We are not going to continue to overpay for the “new new thing” that offers only marginal benefits.
When it comes to healthcare IT, Dr. Rick Peters agrees with Kibbe and Klepper: there are sensible investments that the government can make. He ends his plea to the Obama Health Team with his own set of constructive solutions. Here he describes five investments that, he argues, will save a “phenomenal amount of money for providers, payors, and the entire health care system, while doing more for patient safety than all the EHRs in the world. That’s for $70 million—not billion.”
He acknowledges that “The ‘experts’ and the established vendors will say this can never be done for this little money.” But Peters declares, “I’ll take that challenge.”
I am a family doctor, in practice for 19 years. EHRs for a small practices is at best an experiment, at worst a bogus money loser. It is yet another triumph of marketing over evidence. Remember HMOs and the gate-keeper model? After EHRs fail to deliver, we’ll be on to the next corporate-medical fad. Maybe patient-centered homes or something. At bottom, general medicine is about taking the time to listen to and examine patients. EHRs will not give us that time.
That’s why I stopped going to the HIMSS conference. A million different EHR vendors, none of whom sounded like they were even interested in what hospitals actually wanted or in what would improve the healthcare industry as a whole.
It seems like a company that was interested in providing a product that helped providers instead of hurt them would gain traction pretty quickly, though. I know Jonathan Bush at athenahealth is talking up their EHR tool constantly. Based on their success in billing he may be more than hot air.
But whoever does succeed at EHR is clearly going to do so with a 2.0 model of software as a service. It shouldn’t be too hard to find those companies and steer money towards them.
And surely the government could mandate transfer of this data to combat hospital desire not to share to protect market share. That doesn’t seem like a real obstacle to me. Hospitals are in no position to block progress.
Another problem with this entire debate is what out those who have already invested in EMRs. We spent 80 grand 4 years ago and Idoubt we will ever get a check for doing so, but if you wait long enough just like the mortgage you don’t want to pay someone will do it for you. So in essence you do everthing right and the government shoots you the middle finger and installs it for free to your competition.
In Life, you have to be VERY careful what you wish for.
EMR is one of those things.
I write all my patient records by hand, warn them that I am not including some of the more charged stuff, because it is all headed for Big Brother’s records keeping machinery, and sooner than they think.
EMR means that friendlies have instant access to everything.That may be good, maybe
EMR also means that the worst people in the world,the heaviest duty kind of UNfriendlies, like Insurers,like hackers, like the US Government, and other evildoers also have instant access to everything you just revealed to the diligent Provider tapping away at his/her keyboard.
You had an STD and want that fact kept quiet..tough shit!
You had a depression, years ago, and do not want that bandied about–tough shit!
EMR means that you will have to be on your guard every second you are in the presence of a Provider who is recording what you are saying, or what a lab or XRay reveals, because it is all going willy nilly into the EMR hopper for use/abuse later.
Big Brother is happening, now…
Years from now, you may sign a release in order to get Life Insurance, once again , tough shit!
Unless and until Insurance Companies are barred by Law from cherrypicking and overcharging and discriminating against consumers,whatever you tell the Provider using EMR is going to be used against you at some date.
Of that there can be no doubt. Insurance Companies keep and share a central data bank,upon which everything they have on you is being assembled/collected.
If that is a benign process, then so is EMR and we should all be for it.
There is nothing benign about Insurance Companies, so I am globally suspicious of any government policy that faciltates data collection by malignant forces to be used against the rest of us.
EMR makes childsplay out of denial and premium escalation by your Insurer.
I can hardly wait, it is right out of 1984, just 24 years late, is all.,
T M Bennettt MD
As far as I know unemployment in IT is not a huge problem and moving laid-off auto workers to health-care IT might solve one problem but would certainly spawn many more. Don’t talk about this in terms of jobs created!
If anything the IT giants are behind this thrust because they know that it will create windfalls of well paid consulting opportunties for them.
The issue is not EMR’s, the issue is integrated health care.
Buried in your article was the answer to why the healthcare delivery system is having such difficulty in adopting IT the way it has been adopted in virtually every other industry. Mayo and Geisinger have made EMR work because they are integrated systems. Contrast this with the norm in healthcare delivery – independent, small practices focusing on acute rather than chronic care. This model has given us higher costs and poorer outcomes than in any other developed nation, and many less developed countries.
Imposing EMR on the current system, whether government funded or by fiat, will only exacerbate already dysfunctional practices. If the Obama administration is serious about reforming healthcare it will have to focus on rethinking the delivery system at the same time it sets out to provide greater access to the system. One without the other is not sustainable. A truly integrated healthcare system will demand IT and it will be made to work. That is the place to start
Excellent post.Irrational exhuberance applies here!
I beg the Obama/Biden/Daschle admin NOT to rush into this as a panacea.
As a user of the world’s largest HIT system -namely the DoD’s failed AHLTA system -it is painfully apparant that incremental steps be taken. (SEE PREVIOUS POSTS ON THIS BLOG (HEALTH BEAT) BY NIKO KARVOUNIS ON AHLTA)
The primary reason the DoD cannot retain physician providers is AHLTA!
Much more “pre-engineering” and pre-implementation visit teams must take place where sociologists are included with the site visit teams especially if these top down”make it work” systems are purchased by large organizations are to attain any hope of success.
I support an incremental approach but again one that is removed from the excesses of the profit motive where,in the end,the patients get the short end of the HIT/EMR stick.
Dr. Rick Lippin
Southampton,Pa
Maggie,
Thank you for this most timely discussion. I have been observing this push by goverment and other stakeholders to inflict EHRs on the medical profession with a great deal of skepticism. For one, I have repeatedly scanned the literature to look for scientific studies to support the contention that EHRs improve patient safety. Very few exist and in fact some suggest that they can be detrimental to patient safety. Like many other so called technological advances in medicine, we are told how wonderful this will be for patient care, but with little evidence that it is worth the huge investment in time and trouble that it rquires.
Secondly, the points about hospitals hoarding data and refusing to share it with other providers is a very valid one. The hospital where I admit will not allow our medical group to exchange digital films betwen our diagnostic facilities and those at the hospital. Clearly this would improve patient care and convenience, but I suspect the objective is to make it difficult for the hosptials competitors. I would not consider adopting an EMR until a common database exists that can accept input from all providers and can be accessed by all who have a valid reason and release from the patient to examine their meical records. Until that time, big hospital operators are using EMRs as an anticompetitive tool to internalize and capture all of the health care market they can by making it more difficult for users to go outside of the selection of testing facilities or consultants that are not programmed into their system.
Maybe the role of goverment should be to provide the data wharehouses that would allow smaller firms to create niche products at a cheaper cost for each specialty instead, of what we currently have; that being unwieldly systems that try to fulfill all needs of the modern healthcare system, but in so attempting satisfy none of its various parts well. I would prefer a product that is well designed for my job as an internist and a complete record that tells me what happened to my patient during his ER visit while he was vacationing in Florida over the proprietary system of the hospital I admit to that only tells me the information that occurs at that hospital or its affiliated facilities. Do we expect that patients will be restricted to receiving their care only at a particular health system never to see providers or receive services outside this system. This type of sytem we once referred to as a closed model HMO and they were soundly rejected by consumers some time ago.
And why would anyone disrupt their buisness for up to a year and spend 20-40 grand per doc for a system that may not really benefit the patient or the physician, but sure is going to benefit the EHR vendor?
Thank you for raising these important questions!!!!
I recently came across your blog and have been reading along. I thought I would leave my first comment. I don’t know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.
Sharon
http://www.autoloans101.info
Just some thoughts on the soon to be realized Great American HIT debacle, it appears that there is a little to much academia without much practical experience nor well defined as to what the push back will be from the MD’s or the AMA (FYI-Harry and Louise was the AMA, not the payers), the AHA, etc.
If the healthcare committee sincerely believe that spending billions on technology will work, I would strongly suggest that someone from the administration go talk with WellPoint. If you recall, WellPoint spend $40 million on e-prescribing tools (hardware and software) for MD’s and the project failed.
Complete a deep analysis of the $50 million EMR pilot program sponsored by Blue Cross and Blue Shield of Massachusetts. Are these MDs who had an EMR furnished to them via the Massachusetts eHealth Collaborative truly utilizing the EMR technology? If so what percent 20%, 30%?
History if nothing else has demonstrated that physicians will not use anything that is free, nor alters their workflow, or further decreases their patient time (the payer community and the AMARUC has seen to this already). Doctors WILL NOT alter their workflow for technology that they receive minimal benefit from, the EMR vendors should know this.
Technology has to work within their workflow; there are simpler, less or non-invasive technologies in the marketplace that can and do accomplish what the administration is after without the high price tag associated.
A large hole that seems to have been missed by the administration is the employer groups – most large and mid-sized companies are self-insured today, the payer community acts as a TPA on a fee based model, this market is more than willing to partner on healthcare reform. I personally spent a large part of this past spring and summer with many of the large and mid-sized employers discussing prevention, healthcare technology and other tools to reign in healthcare spending, improve prevention measures, drive quality with lower overall costs (or spend).
If anyone is foolish enough to believe that EMR deployment will integrated health care they are greatly mistaken. The US healthcare system is not a system, it a fragmented delivery model.
Physicians and hospitals compete for patients. To assume that community physicians will now align with one of the two or three hospitals in their geographic markets to share health records is somewhat absurd. Who will make the decision as to which hospital will align with what physicians and what happens when a physician decides they do not like the alignment?
In addition, I would also strongly suggest that someone in the incoming administration take a hard look at what the core software language the EMR is written in since the optimal goals would be for a true interoperable record system. One will be surprised that some of the vendors in the marketplace are selling old outdated products who’s source codes cannot be updated. Despite great movements and development of the CCR and CCD there are still large EMR vendor products that cannot integrate these record formats, much less export / import templates into their systems, despite the CCHIT mandates for certification.
If MD’s wanted and saw a clear benefit for an EMR system that is in the marketplace today they would have found a way to pay for them as they do with office needs from medical equipment to staffing needs.
So will we look back at the Great American HIT deployment in a few years and realize that we have wasted billions more in taxpayer dollars only to benefit CEO’s and shareholders of corporations with marginal (at best) products? Or will the medical community and the PCPs, FP’s and other preventive medical practitioners take this as a wake up call to take action before the plans are implemented?
For the experts here who know a lot more about this than I do: Where does the VA’s Vista system rate in terms of quality, usability and the other issues raised here? Thanks.
Lex, this is Maggie’s post, but I’ve done some work on VistA here on Health Beat.The bottom line is that it’s really good, but could use some updating.
http://www.healthbeatblog.org/2008/06/sapping-vistas.html
Still, it’s better than AHLTA, the DoD’s system, which has proven to be a disaster:
http://www.healthbeatblog.org/2008/08/ahlta-continues.html
Maybe patients can bolster privacy by inserting legal terms of access (like an end-user license agreement) into the content of their electronic medical records. The terms could set binding rules for who may view data and when. The idea is not legal advice, just something to think about. –Ben http://hack-igations.blogspot.com/2008/02/contracts-for-patient-privacy.html
Below is a comment of mine posted at the Health IT Strategist website/list which is relevant both to the question about VistA about also to Maggie’s general point about how and why software gets supported and funded — or not.
Article published December 12, 2008
U.S. missing out on open-source VistA system
In response to part one of Joseph Conn’s two-part series on Perot System Corp.’s project in Jordan:
When this story was reported a few weeks ago, I told colleagues it was a crying shame that the U.S. won’t bother to do the same, even though VistA was created in our Veterans Affairs Department, with our taxpayer money. Instead we’ll continue to suffer from proprietary systems that cost way too much and don’t interact with each other.
So although, as this story says, “Jordan will be a pilot for other countries,” those other countries won’t include the U.S. Until we get single-payer, that is.
Andrew Pollack
Data/policy analyst
Maimonides Medical Center
New York
Benjamin,Lex, Carol, Sharon–Thanks for your comments.
(I’ll be replying to eveyone else later)
Benjamin– My guess is that they will work out the privacy problems. I realize some people are very concerned–and no doubt rightly so– but in the past we’ve been able to solve privacy problems when adapting technology in banking, etc. Certainly, though, we’ll need some legislation.
Lex–
On VISTA– the people I talked to while writing this post tell me that, as we have said on HealthBeat,
VISTA works quite well– within the VA.
But like many “home-grown” solutions that work well within a single institution it is not easily adapted to the fragmented medical world outside the VA.
Ultimately the administration needs to put together a panel of clinicians with a deep undestanding of health IT,
clinicians working on improving quality, health care economomists concedrned about affordability to put together a much simpler, less expensive, simpler, interoperable model.
I’m told that we have relied too heavily on health IT vendors –who are interested in designing and selling the most complicated, most expensive model possible.
Carol—
Thanks very much for a long and thoughtful comment.
I agree with much of what you say.
But when you write ”
Physicians and hospitals compete for patients. To assume that community physicians will now align with one of the two or three hospitals in their geographic markets to share health records is somewhat absurd.” I have to disagree.
The vast majority of U.S. physicians send the vast majority of their patients to just one hospital–occasoinally two. So it’s not hard to figure out how to form the virtual networks. (Dr. Eliot Fisher has written extensively about this in Health Affairs, and the Medicare Payment Advisory Commission has passed this info along in their recent reports.)
And hospitals and doctors compete for patients only when doctors own or have an interst in surgical centers. Health care reform is likely to crack down on self-referral, and doctor-owned facilities skimming lucrative procedures from general hospitals that need the revenue to offset teh costs of running ERs, burn units, trauma units etc.
Going forward, health care reform is going to try stive for more consolidation in our healthcare system– fewer smal practices, more docs working in integrated multi-specialty centers, certain procedures only preformed at large centers of excellence . .
As you suggest, herding docs is like herding cats, but younger doctors are much more interested in collaborating in large groups, using health IT in ways that improves their work flow and quality, etc. And women docotors, in particiular, like large groupr, regular hours, collaboration, medicine as a team sport..
You ask “Who will make the decision as to which hospital will align with what physicians.” The new
national health board that hte administartion is talking about. MedPac (the Medicare Payment Advisory Commission) has already recommended “bundling” payments to hospitals and doctors, including everyone invovled in a particular episode of care. (i.e. the primary care doc who sent the patient to a specialist, the specialist who recommended surgery and sent him to hte hospital, the surgical team, the hospitalist, the rehab team, the primary care doc who followed up. . .)
They will be rewarded with bonuses for good outcomes, divvying up the payment.
This isn’t ready for prime time today, but will almost certainly happen in the future. Everyone working on quaity has pretty much agreed that you want to pay for outcomes, not performance, and you cannot reward individauls for outcomes–too many different people are involved in any patient’s outcome.
Doctors won’t be forced to join the network or accept bundled payment, but they won’t be eligilbe for the bonuses for good outcomes unless they do. Patients will realize that physicians who don’t become part of the team aren’t being judged outocmes which could make them nervous.
And ultimately, physicians and hospitals that want to do business with the government (not just Medicare and Medicaid, but caring for governmetn employees, etc.) will have to beocme part of a more collaborative system. The government now pays for more than 55 percent of all healthcare in the U.S., and its portion will grow, making it very difficult for all but a few physicians to decide that they don’t want to care for anyone who is a state, local or federal employee, on Medicare or part of any public program.
But I entirely agree with you on the bottom line: government should not rush foward in funding EHR –or in altering the payment system– until we have devised a simpler, less expensive system that is adpated to physician workflow. See my comment to Lex- on the panel that the administration needs.
And govt definitely needs to talk to all of the people like Wellpoint about how and why their experiments failed.
Way too much “happy talk”
about EMRs as panacea.
Sharon– thanks for the kind words! Do come back.
I want to point out that a working demo of VisTA/CPRS is available free from the VHA.
Go to http://www1.va.gov/cprsdemo/
I use it in my teaching of graduate students in healthcare informatics.
To be useful, electronic medical records must be interoperable. I think taxpayers will need to subsidize their adoption and implementation, at least to some degree. At the same time, I think CMS should require that doctors and hospitals implement and use electronic records by some reasonable date certain in the future in order to qualify as an eligible (for payment) CMS provider. To foster the movement of doctors from individual and small group practices to medium size and large group practices, we could refuse to subsidize electronic records for individual and small groups. Hospitals should be able to implement electronic records on their own without subsidies. An exception might be necessary for inner city safety net hospitals who serve disproportionate numbers of uninsured and Medicaid patients.
It seems to me that electronic records lend themselves to a modular approach. Billing, for example, could be a separate module which many doctors outsource to third parties. The ability to allow patients to make appointments electronically could be a separate module as could patient access to test results and other records through a secure password protected site. Doctors could block release via the website of certain records if he or she wants to communicate the results in person first, especially if the news is not good.
The highest value part of electronic records, I think, relates to test results (imaging, labs, etc.), the patient’s prescription drugs, surgery results, medical history, and physician office notes regarding the diagnosis, recommendations, advice, referrals, etc. In theory, it seems that a much lower paid medical technician or other properly trained non-physician could enter such records into the system from a paper based or dictated source in either the doctor’s office or the hospital setting. It doesn’t have to be done in real time but should be done reasonably promptly. Once in the system, the paper records could be purged.
I know that in my own case, my cardiologist, whose practice is paper based, from time to time can’t find records from several years prior because they are in my first folder and he only has the second folder in front of him. Some patients have three folders, and doctors are only required to maintain the records for seven years, I believe, at least in New York. With decent electronic records, my entire history could be easily accessed as needed by him or any other provider who treats me as long as there was interoperability.
Since the federal government is such a large payer, it should be able to drive the system in the right direction. Forcing hospitals that resist interoperability because they want to “own their patients” and forcing doctors who cherish their independence to move toward larger group practices in order to make the overall system more efficient is a key part of the equation.
Maggie,
Certainly appears like the HIT folks have a head of steam and are bound and determined to get those fed dollars flowing into the hands of the EMR vendors (e.g., HIMSS’s Blueprint that was released yesterday).
Honestly, the adoption of HIT comes down to answering one simple question: What’s in it for me? To date, no one has provided small physician practices a sufficient answer to that question.
eRx, yes, that is great area for HIT but does it make a physician’s life easier (and their customer) if a number of meds can not be ePrescribed (some states Class II-V meds must still use paper). It doesn’t take a doc too long to figure out that paper is easier/less hassle.
As for broader EMR solution adoption, only one way this will happen, it will be via an SaaS model (athenahealth has done great things in rev cycle in the “cloud”). Don’t see much discussion on this topic but it is the one to watch.
Maggie: Thanks for the info.
Keith, Dr. Rick, Bill, Ginger B., Terry, jenga, Mike C. Jrossi, John, Barry & Scot
Thanks for your comments.
Keith–
Good to hear from you.
You write: “big hospital operators are using EMRs as an anticompetitive tool to internalize and capture all of the health care market they can by making it more difficult for users to go outside of the selection of testing facilities or consultants that are not programmed into their system.”
This is something that government regulation can–and should –stop.
You also point out that IT created by vendors often tries to be adaptable to many different specialties–and as a result does nothing really well. You would prefer EMRS developed specifically for your specialty.
This reminds me of a talk I had the other day with my eye doctor. He has EMRs
that appear to work brilliantly–he and his staff have no trouble using them, and he can print out color photos of my optic nerve, of the last three tests he did, of pressure levels and medications in an instant.
It all seems very organized.
I asked him if he had trouble learnign to use it, and he chuckledL-“There were some bugs, there always are, but I can hardly remember, it was so long ago.”
It turns out that this 50-something doc designed the IT for an his practice (eye surgery, and a specialiy in glaucoma) himself—about 12 years ago. He also said he has a partial interest in the company that distributes it. . . And he trained all of his people himself.
Since I’m not an IT expert, I don’t know whether IT designed to specific specialties is one answer, but I’ll ask around.
Dr. Rick– Yes, the DoD’s
use of AHLTA seems a good example of Bush administration corporate welfare. They were so busy throwing money at a private contractor that they were not paying attention to the goal: an efficient IT system. In this case, adapting VISTA would have (perhhaps still would?) make sense since DoD and the VA need to be able to talk to each other, and the VA system works quite well within the VA, even if it might not be as easily adapted to creating an interoperable system for hundreds of private practice docs trying to communitcate with each other and hospitals.
Bill — I agree, healthcare IT works best (or at least most easily) within an integrated multi-specialty system.
And, by and large , these integrated systems do a much more efficient job of disease management. In many cases, outcomes are bettter, patient satisfaction higher, doctor satisfaction higher and costs lower.
I think Medicare will be creating financial incentives for these delivery systems–as well as for community clinics that can also provide intergrated care, and by being open “after hours”, keep patients out of the ER.
And where Medicare leads, private insurers will tend to follow–as they do today.
Ginger B– Yes, I agree. Healthcare reform is not about creating jobs–it is about creating an effective, affordable health care system. If jobs are created, that’s a bonus, but not the main goal. And , from what everyone on this thread says, I very much doubt that the nation would benefit from more IT consultants peddling the wares of for-profit vendors.
Terry–
I agree we need community rating and guaranteed issue– in other words insurers must be required to insure anyone who applies and to charge everyone in a given community the same price for a given policy regardless of prior conditions or age.
In that situation, even if an insurer gains access to information about prior condtions, he cannot use it against you.
Otherwise, I think the advantages of electronic health records (if done properly) outweigh the risks of loss of privacy. It shouldn’t be impossible to keep these records private–away from the prying eyes of future employers, for example.
And the tradeoff–that if I land in an ER, unconscious, after a car accident, the ER can call up my medical record–seems to me worth the relatively small risk. Not to mention the fact that, in a hospitals, EMRs can save me from medication mix-ups and patient mix-ups that can be fatal.
jenga– it is true that if the government subsidizes
EMRs doctors who funded it themselves may be kicking themsleves. Though if the EMRS worked out really well (as for my eye doctor) they may be glad that they enjoyed the benefits years before everyone else.
Mike C-
Thanks for your comment.
Yes, it does sound as if the healthcare IT industry has turned into laissez faire chaos (like much of our hc system) with too little attention paid to clinicians’ needs, and too much attention paid to hyping the product.
An unbiased panel of clinicians with a deep understanding of and experience with IT needs
to begin to look at these products and sort things out.
And I agree, govt regulation can insist on transfer of data.
Jrossi– You write “At bottom, general medicine is about taking the time to listen to and examine patients.” Essentially, I think this is true.
But chronic disease management could benefit greatly from EMRs — as it does in the best integrated multi-specialty systmes.
The question of adopting health IT for small practices in a way that is affordable and does not intrude on work-flow is tougher.
If the EMRs are so complicated that they cut into the time needed to listen to , talk to, and diagnose a patient, hand’s on, then they are not worth it.
John–Thanks for the input.
It would seem that states that still require paper for some prescriptions are behind the times. The law could be changed to allow secrure e precribing.
AS I try to learn more about healthIT, I will ask about SaaS.–
Barry–
Good to hear from you.
We cannot set a deadline for EMRs because we don’t know how long it will take an independent, unbiased health board to sort all of this out.
And we cannot re-arrage a healthcare system where so many doctors are in small practices by refusing them access to EMRs.
How would you feel if the doctor you see most often told you that he was going to have to close his practice and join a large multi-specialty health center located 1 1/4 hours away from where he practices now.
(Clearly we don’t need a large integreated center in every town or small city)
People on the East Coast, accustomed to seeing a doctor who practices 15 minutes from their home would be very upset.
Some would be upset by the size of the integrated medical center, the fact that the receptionist didn’t know and recognize them, that the nurse-practioner who did the preliminary exam is someone they had never seen before, that if the exam goes well, they might not see their doctor at all . .
I agree that integrated multi-specialty centers have many advantages, and will, I hope be more commonplace in the future, but we can’t “force doctors who cherish their indpendence to move toward large group practices.”
We can offer incentives, and this will work with some doctors, not wtih others.
Most importantly, I don’t think that healh reform should pre-select “winners” and “losers.” There are many solo-practioners and small groups in this country that are practicing very good medicine.
Ultimately, it may not be the most efficient model; they don’t enjoy the economies of scale that we will probably need for the medicine of the future. But there are advantages to small practices in terms of intimacy, one doctor treating an entire family for years, etc.
We certainly don’t want to encourage good family practice doctors to retire early.
On the idea that “that a much lower paid medical technician or other properly trained non-physician could enter such records into the system from a paper based or dictated source in either the doctor’s office or the hospital setting.”
I would be wary of paying someone $10 an hour to do such sensitive important work. An error in your medical record could prove fatal.
I think you need someone who fully understands the meaning of all of the words, abbreviations and symbols that he is typing in–probably that means a R.N. or other well-trained, well-paid nurse.
Scot–
Thanks for the link to a working model of VisTA–
I’ll look at it
Maggie,
Thanks for the detailed response as usual. I would just like to offer a few follow-up comments.
First, with respect to requiring a date certain to adopt electronic records, I think we could (and should) do it as a catalyst for action. If it turns out that that we won’t be able to meet the deadline when it approaches, we could always extend it for a year or two if we need to.
With respect to technicians entering paper records into an electronic system, I’m obviously not an expert on this, but I don’t think we need a doctor or even a highly trained nurse to do it. I think a decently trained technician could do it. I’m not familiar with how most of these systems work, but if we are talking about scanning lab results and images into an electronic system, it requires minimal training. If we are talking about transcribing an operation report or office notes from a doctor’s dictation, I don’t think that takes a lot of training either. Whoever does this now to produce a typewritten paper report could do it for entry into an EMR.
Doctors who practice in rural areas or in small groups in more populated areas could be at least required to join virtual group practices. As for people who prefer to deal with a solo practitioner or a small group practice, it reminds me of the massive inefficiency we have here in NJ in our local town governments and school districts because we have so many of them for a small state. The fragmentation and administrative overlap drives inefficiency and, in turn, very high state and local taxes. As soon as someone suggests that we combine school districts or police departments to save money, opponents scream that we need to protect and maintain our cherished “Home Rule.” These same opponents are also the people who scream the loudest about high state and local taxes. We can’t have it both ways.
Everything in life involves tradeoffs and we all have to realize that we will need to make some compromises and accept some inconveniences if we want to make the healthcare system more efficient, more cost-effective and bring coverage to the currently uninsured. The stubbornness of every interest group from doctors and hospitals to lawyers and insurance companies to drug and device manufacturers to individuals is disheartening and is why I challenge every interest group to articulate what it is prepared to give up or contribute in order to make the overall system more efficient, cost-effective and competitive. Everyone can’t expect to solve the problem at someone else’s expense.
Barry–
I think your challenge is a good one.
It’s important that people understand that universal coverage will mean making trade-offs. Everyone– patients, doctors, durg-makers, insurers– is going to have to “give up something” that they are accustomed to–whether it is double-digit profits, or seeing an M.D. for routine care (when a nurse-practioner working with a primary care provider could give you most of your care; or recognizing that medicine has become a team sport when you are accustomed to working solo.
And insurers, I think, are going to have to give up the notion that they are in a business where the goal is to make money by cherry-picking.
They are going to have to agree to community rating and guaranteed issue–which means that they cannot charge the old, the sick, or those with prexisting condtioins more than others in the same communityi.
For the public, the trade off is that young, healthy customers will be paying higher premiums than they would today in a state that does not require community rating. But if we don’t have community rating, and insuers are allowed to gouge older, sicker customers, those younger people will have to pay more in taxes to cover the higher subsidies that sick customers need.
Ultimately, we’re all in one boat.
Most of the comments have focused on the MD practice side of IT. On the hospital nurse side, all currently available systems that I have seen are disastrous and the disaster is compounded by hospitals attempts to force the use of EMR on nurses despite the fact they don’t work well. I’ve become convinced that in this setting there is a whole ‘nother set of agendas at work – deskilling of nursing by taking out professional judgement – thereby facilitating future efforts to replace nurses with other, less qualified workers – focusing the nurse on the computer rather than the patient to break the bond between nurse and patient.
The effort to standardize and routinize things like caring that are not standard or routine is a failure.
Then there’s the whole issue of using the computer as a device for control and tracking of workers. Right now my hospital is trying to force the ICU nurses into computer charting, even though none of the people involved in setting up the system are ICU skilled and the system is incapable of tracking as many parameters as an ICU nurse needs to track. And the current paper chart can show all the parameters in graphic form on a single sheet while the computer system requires clicking to a different screen to see each parameter. And so on. The existing systems are not ready for use and may never be as far as I can see.
David RN
Thank you for a very thoughtful comment.
Everything you say rings true.
I believe that nurses know so much about what is going on in our hospitals–and what is wrong. But because they have been marginalized in the power structure, they don’t speak out.
I welcome more nurses commenting on this blog–telling us what we need to know.
The doctors I trust most tell me that I am right about what nurses know On the healthcare reform issue, those doctors and nurses need to get together. They share the same interest: patients and being able to do their job well.
As a healthcare risk manager and QI director, I have observed too many hospitals trying to implement the cheapest electronic record systems possible, resulting in poorly planned systems that detract from clinical bedside time (harming patients) and lack of any potential interoperability with systems that are likely to dominate the field in the future; it is a bit like the early 90’s, before Microsoft emerged as THE worldwide preferred office tool system; there are a bunch of competing entities hawking their goods to hospitals trying to do cheaply, an initiative that is inherently not inexpensive to do it correctly. Yes, I agree that we need user-friendly, interoperable electronic medical record systems that would, indeed, improve patient safety and time-to-care processes. However, the incredible focus I have observed on even small and medium non-profit hospitals trying to increase their “profit” margins, has greatly impaired their judgment when it comes to implementing software systems. In alignment with this dismaying and harmful focus on money above patient safety, I have also observed many hospitals either hiring incompetent IT support because it is cheaper, and / or, failing to adequately staff the IT department. Until someone or something forces most hospitals (there are a few exceptions to what I have stated)to adjust their perspectives (especially the so-called, “non-profit”) in the battle between money intake and safety and accessibility for patients, I predict that any efforts at EHS will, on a national level, continue to fail miserably. I believe that in our era, the only way to make hospital work honestly, even a for-profit cannot expect more than a 2% or 3% profit return on investment. This is not an enterprise that one should enter, if one anticipates making megabucks without fraud, deceit, and harmful practices.
Mike R–
I think you are absolutely right: the hospital business is not a business where you are going to make high margins.
It is, and always will be a labor-intensive business.
On top of that, it’s unpredictable. You need to have some excess capacity –and you can’t wait until the last minute to order that excess capacity.
In other words, many of the strategies that work in other businesses to save money do not work in the hospital business.
Unfortuantely, in the 1980s, Wall Street marketed for-profit hospitals as big growth businesses where the investor could make a killing.
Ultimately, we disocvered tha the high profits at many chains came only by harming patients, cooking the books, cheating Medicare and insurers etc.
FBI raids followed.
But meanwhile for-profit hospitals had set a model that whetted the appetite of many non-profits. . . .
And increasingly, the CEOs of these hospitals were MBAs trained to put profits first–not doctors who had been trained to put patients and patient safety first.
Thanks for your comment.
One of the issues I feel is very important and not many take this step and that is to assure the system being computerized works first.
Too many seem to be computerizing a system that is not very efficient and has mucho duplication of data and then all the computer does is make a bad system ‘badder faster’.
When the processes are mapped out and there is an understanding of how these interact and maybe even the sequence of the processes, then the computer can and will be a tool that makes things better. Without that, and some Federal standard for formatting the data, a lot of facilities will be spending money for years trying to get to where they can communicate well.
Just food for thought.
Mickey Christensen–
Thanks much for your comment.
You wrote: “assure the system being computerized works first.
Too many seem to be computerizing a system that is not very efficient and has mucho duplication of data and then all the computer does is make a bad system ‘badder faster'”
Yes– thank you.
As too much of expense will not be appreciated but any advancement and a enefit will cost.This is also a huge facility per se.
Thanks for sharing this informative article..
I was just out viewing blogs and came across yours.EMR can contribute in a major way for the betterment and advancement of health care and some studies have shown that electronic records can reduce medical errors and may create a better, cleaner record.
HI,
Set up the EMR system to communicate with several devices and entities, including: labs, hospitals and pharmacies; picture archiving and communication systems; diagnostic devices; and practice management systems. Consider paving the way for e-prescribing, patient e-mail and patient portal access.
Regards,
there are hundreds if not thousands of doctors and physicians switching to EMR services. They cut hours off of wait time and are highly accurate.