Tuesday, December 04, 2007

On ACP's Endorsement Of "Single Payer", And A Call For An End To Irrational Exuberance over EMR's

A letter to the Philadelphia Inquirer that likely will never make it into print due to its iconoclastic, "reality that nobody wants to hear" content. Also cc'd to the leaders of the American College of Physicians, on the ACP's endorsement of "single payer" and the oft-stated panacea of the EMR as the tool "to reduce medical administrative costs."

I believe it's time to put the brakes on the "irrational exuberance" that characterizes today's EMR efforts. Healthcare IT is a field that unless brought back to sanity will transfer countless dollars to the IT sector that healthcare and patients cannot afford, and will develop tools that make patient care even more unbearable for clinicians than it is today through inept design and inept or disingenuous "performance metrics." For much more on these issues, see my web site "Common Examples of Healthcare IT Failures" at this link.

In fact, EMR's are still an experimental technology and should be thought of as such. They were invented by researchers and experimenters in medical informatics and were slowly and deliberately being perfected, until massive reductions in costs of computing hardware and increases in speed and ubiquity gave many in the IT, government and payer sectors (via a leap of logic of supernova proportions) the technologically deterministic idea that every aspect of medicine could and should be easily automated. And that it would be hysterically profitable to do so: profitable for everyone except, of course, practitioners and patients.

To: sburling@phillynews.com
From: MedInformaticsMD
Date: 12/04/2007 01:29PM
Subject: Re: American College of Physicians endorse single-payer

Re: American College of Physicians endorse single-payer (Phila. Inquirer, Dec. 4, 2007, http://www.philly.com/philly/business/12109247.html)

Dear Ms. Burling,

While one can argue the merits and demerits of creeping socialism, and while I find it ironic that the ACP endorsed "single payer medicine" at the same time that the people of Venezuela rejected socialism, there is one item in your story reflecting another "irrational exuberance" that should not be taken at face value.

That item is the oft-repeated statement that electronic medical records work miracles, in this case that the "greater use of electronic medical records (EMR) reduces medical administrative costs."

In fact, I increasingly believe the opposite is true, even when the electronic medical record project is successful, which most are not.

The majority of information systems developments in most sectors are unsuccessful, and the larger and more complex, the harder they fall ("Pessimism, Computer Failure, and Information Systems Development in the Public Sector." Public Administration Review 67;5:917-929, Sept/Oct. 2007). Healthcare is no exception.

A number of organizations have spent billions on EMR systems, such as Kaiser Permanente, have had massive delays and cost overruns, and are still years away from anything resembling "reduction of administrative costs." See my post at http://hcrenewal.blogspot.com/2006/11/kaiser-healthcare-it-meltdown.html.

Electronic medical records require a huge investment and significant "upkeep.' This "cost of ownership" puts a big doubt upon EMR projects as a cost-reducing endeavor. Rather, EMR's should better be thought of as a cost center.

An EMR for small-group and solo-practice physicians costs $44,000 per physician, and generates an average ongoing $8,500 per year in annual costs, the past ACP president herself, Lynne Kirk, MD told the house Subcommittee on Regulations, Healthcare and Trade of the House Committee on Small Business in October 2007. "The business case does not exist to make this kind of capital investment," Kirk told the Subcommittee.

In fact the use of EMR's will not significantly reduce overall health care costs, the director of the Congressional Budget Office said at the release of the agency's 2007 report on long-term health care spending. Peter Orszag , CBO's director, said that according to data from the report, the return on investment for EMRs "is not going to be as substantial as people think."

My own university's faculty practice plan at Drexel attempted to implement electronic medical records. Due to failure of the billing component, the exact component that was supposed to help "reduce administrative costs" but instead raised it by a few million dollars to manually correct the errors, the result was a multimillion dollar lawsuit (link to online court records here) by Drexel against the EHR vendor AllScripts and Allscript's partner Medicomp System s , a "corporation specializing in the development of point-of-care tools for Electronic Medical Records ... to help overcome physician resistance to adoption. " Temple University Health System delayed electronic medical records rollout due in part to unaffordability and a likely, justified fear of costly problems, which came to my attention due to the decision's delaying the doctoral thesis work of a graduate student here.

I also believe the EMR is rapidly becoming a tool for payors to minimize their costs and maximize their profits, while inconveniencing physicians trying to take care of patients under increasingly pressured timelines due to poor design. EMR's are largely designed under processes led by technologists, not clinicians.

Finally, with regard to effectiveness of EMR's in actually improving healthcare quality, even that is doubtful. A research article in the Archives of Internal Medicine entitled “Electronic Health Record Use and the Quality of Ambulatory Care in the United States” (Arch Intern Med. 2007;167:1400-1405, link to abstract here ) reached what to many was a counterintuitive conclusion. The authors, EMR experts, examined EMR use throughout the U.S. and the association of EMR use with 17 basic quality indicators. They concluded that “ as implemented, EMR’s were not associated with better quality ambulatory care ,” and were bold enough to publish their findings, sure to be unpopular in the health IT industry.

It appears the clinical case may not exist, either, for EMR's as they are designed and implemented today.

These issues are international in scope. Richard Granger, former head of the UK's “Connecting for Health” national EMR program, had this to say about a program described by some UK members of Parliament as “the largest government IT debacle ever” (see here for more):

"Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that [our large American clinical IT vendor] has put in recently is appalling ... [vendor] and [prime contractor] had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome -identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."

So, next time you hear that single payor systems enhanced by EMR's to "reduce administrative costs" are a panacea, think of Hugo Chavez' wondrous plans for a socialist utopia as President for Life of Venezuela.

You can read much more and see examples of EMR failure and mishaps at my web site "Common Examples of Healthcare IT Difficulties" at http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm

-- SS

Addendum: an editorial from a health IT publication whose editor understands reality, FierceHealthIT - Weekly News for Health IT Leaders:

The EMR rollout dilemma: The necessary evil
December 3, 2007

When it comes to EMRs, big healthcare organizations have a big, nasty problem on their hands. The problem? While they pretty much have to invest in an EMR system to stay competitive, by most IT industry standards this is a lousy time to jump in and do it. At the same time, however, they seem determined to move ahead.

Compared with other types of enterprise IT spending, EMR investments are a major crapshoot at this point, given the lack of support from some clinical staffers and the questions still floating around as to what features they should have. But in this case, providers are facing huge pressure from the federal government, some payers and hanks to ongoing PR efforts, even consumers to bring up an EMR system.

Sure, if they're going to spend the money, now's probably the time, rather than waiting five or ten years for the EMR product category to mature [I actually disagree with that - ed.] After all, organizations the size of Kaiser Permanente and Sutter Health--both rolling out the Epic EMR--will spend years integrating such systems into their already formidable infrastructure. So they have to begin getting their hands dirty with the technology now.

But there's still something odd [I would say "monstrously odd" - ed.] in how many formidable organizations are choosing to invest in a product whose feature set is still in question and whose popularity among key users is in doubt. In most industries, billion-dollar enterprises don't get pressured into buying a product this early in its lifecycle and cramming it into their operation. (The closest I can think of is the wave of ERP platform adoptions over the past decade or so--another very expensive boondoggle which only seems to be creating real value after years of heartache and expense.)

If nothing else, let's admit that the talk about avoidance of medical errors and efficiency improvements is a bit of a smokescreen--because if Kaiser was spending a few billion for that, it'd certainly be losing its shirt for quite some time into the future. While quality is a factor, I'd argue that most execs want to see EMRs in place so they can gather data needed for pay-for-performance incentives and shunt quality and outcomes stats to regulators.

As I see it, if health system leaders, health plans and government officials want EMRs in place so badly, they might want to start by being honest about their motives. Once they do that, they might get clinicians to see EMRs as more than just a necessary evil. -

To which all I can add is "indeed."

-- SS

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