Friday, June 20, 2008

"Price Keeps Doctors From EMR's" - and Price Keeps Me From My Shiny New F22A Raptor

in the commendable article "Few Doctors Use Electronic Records Because of Costs", Bloomberg reporter Cristina Alesci reports on a Harvard University survey published in the New England Journal ("Electronic Health Records in Ambulatory Care — A National Survey of Physicians").

Its results summary states:

Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

The study is being widely interpreted to indicate the disappointing diffusion of the electronic medical record largely results from cost.

Yes, cost - that's all that keeps me from doing High-G Barrel Rolls and saving the planet in my shiny new, easy to install and operate, maintenance-free F22A Raptor.

This is the toy I just can't have because of cost.

Now, all we need is government "subsidies" to make this technology more "affordable!" Just the ticket to sap more of healthcare's precious, limited resources for the enrichment of the IT sector!

Oversimplifications and omissions of critical realities about health IT are not going to serve medicine and its practitioners well. The healthcare IT industry is one that doesn't know what it doesn't know, and doesn't seem to care that it doesn't know what it doesn't know. To the Moon in a Hot Air Balloon! (Hot air balloons go up. The moon is up. What's the problem? And balloons don't even cost that much!)

I really do love oversimplifcations! Especially when it involves the tool that's going to Revolutionize Medicine and let us Take Back the Future of Health Care, Cyberdyne's SkyNet -- oops -- er, the Electronic Medical Record system!

Now, if only the darn things would just somehow maybe come down in price, like oil, SHAZAM! - all medicine's problems would be solved!

I don't think so, and it case you didn't notice, I was being sarcastic. It comes after years of writing on the same topic and having responses known as the "bovine stare of incomprehension" (the look you get from a cow after explaining Einstein's General Theory of Relativity to the animal) and/or the "ostrich" response. (I am not even mentioning the ad hominem attack. Nope! Never happens over something as critical as healthcare IT!)

/Sarcasm off

/Serious mode on:

Back to the article. As I mentioned, in the excellent article "Few Doctors Use Electronic Records Because of Costs", Bloomberg reporter Cristina Alesci reports on a Harvard University survey published in the New England Journal. The survey found that:

Just 4 percent of doctors use software that includes electronic prescriptions and drug-interaction warnings. A larger group, 13 percent, opted for more basic software that only allowed them to enter notes and medical histories. Those who use the computer systems said they helped improve patient care.

I commend Ms. Alesci for her reporting of these figures to a national audience. Hopefully, the HIT industry won't do a Ross Koppel on her (Ross was attacked by those with industry interests, at one point having his research called "disingenuous" in print.)

Of course, she is reporting on what the experts are telling her, but not on what they're not telling her.

What say the experts? That some mysterious, unknown, unstoppable force out there that for the past 30+ years just keeps this miraculous, trouble-free technology from diffusing like the iPod. What in heavens' name could that unstoppable force be?


That's it. The technology just COSTS TOO DAMN MUCH! (Nobody EVER asks why. Here's the answer: because EMR's must be manufactured on computers made of solid platinum. That platinum is costly!)

Of course, other possible factors for the lack of EMR diffusion are simply Red Herrings and myths and opinions and anecdotes. Factors such as immaturity of the technology, bad design, unexpected adverse consequences, false assumptions, underestimations of difficulty, lack of understanding of sociotechnical issues that impair acceptance, unclear benefit and irrational exuberance over HIT, demands that clinicians use tools designed by business IT personnel who know nothing of medicine's "hiding in plain sight" complexities, designed and implemented via processes and methodologies best known for failure, produced by an industry rife with conflicts and deception, whose leaders often lack substantive credentials, produce ill-conceived and/or shoddy products whose use is mandated by non-clinician hospital managers and that several other Harvard physicians note in the NEJM here can impair medical practice and education.

I forgot to mention the exclusion from leadership of medical informatics professionals such as here , here , here , here , here , here , here , here and here where I wrote about difficulties these specialists seem to have in securing positions with a future : that is, leadership positions with true control of resources, career advancement opportunities into higher levels of healthcare management, and some degree of stability, instead of "director" or "C" level titles that in reality translate to “internal consultant” or "director of nothing."

Oh, and let's throw in the fact that "failure and de-installation of EHRs abound."

... a recently released survey of healthcare IT use conducted by the Boston-based Medical Records Institute found ... nearly 19% of respondents to [a] survey indicated they either have in the past experienced the de-installation of an EMR system (12%) or are now going through a de-installation (7%) ... Slightly more than 8% of those surveyed indicated they'd ripped out their EMRs and gone back to paper, with 6% indicating the uprooting occurred in the past, while another 2% responded that they were now experiencing the reversion to paper. In addition, 30% of respondents indicated they either have had an EMR in the past (12%) that not all clinicians used because some refused to do so, or that they now have a system (18%) and are experiencing the same recalcitrance by some clinicians [most often due to poor design and fit into real medical environments; physicians rarely refuse to use genuinly helpful technology, in fact they eagerly and sometimes cavalierly embrace it - ed].

Yes, let's just reduce the cost of this technology, and ... problem solved!

Nationalization of the HIT industry to reduce those pesky costs and move on with revolutionizing medicine, anyone? The government, after all, knows best!

-- SS


  • Of course, poor EMR diffusion is all doctors' fault.
  • The F22A Raptor only costs about as much as a hospital EMR or two, a bargain at only $142 million! Guess those EMR vendors should also get into aerospace!


will said...

I share your concern over the shallow dive by the NEJM study into factors preventing the adoption of EHR. The logical response from policy makers to this oversimplification will be to propose legislation which donates EHRs to small practices, and which would clearly miss the mark because the problem is incorrectly ascribed to software cost alone. In my neighborhood (rural Northern California) I prepared an EHR adoption roadmap for a local GI to move his solo practice from paper to electronic charting. Short version = $14,000 for the EHR install, $10,00/year for support, $52,000 for the 9 interfaces to external lab, pathology and radiology data streams, and unknown support costs for the external data streams. In other words, the cost of the EHR was trivial compared to the cost plus complexity of installing and maintaining the complex series of incoming electronic health data feeds. The absence of a standardized infrastructure of semantically interoperable data is one of many deal breakers. Cost of training and transition, suboptimal user interfaces, lack of affordable tech support options, expiration of volatile EHR software titles after the practice becomes dependent upon the package, etc. There are lots of skeletons in the EHR closet. My wife's office (a family practice with 2 providers, 3 exam rooms, 3 support staff and an external billing service) uses an EHR but struggles generally with IT support issues. The optimist in me hopes that the authors of the study can now pivot into a follow up study that dives deeper into the ecosystem of EHR deployments to wrestle with the many interwoven factors inhibiting robust adoption of the technology.

MedInformaticsMD said...

There are lots of skeletons in the EHR closet ... a follow up study that dives deeper into the ecosystem of EHR deployments to wrestle with the many interwoven factors inhibiting robust adoption of the technology.

Brilliant, apt phrases.