Saturday, February 07, 2009

Healthcare IT Backwater: The $20 Billion Abyss? Case Two

(Note: case one of this series is here, case three is here.)

In my post "Will the U.S. spend the Economic Recovery Act's $20 billion for Healthcare IT more wisely than the UK?", I expressed concern that the answer to the titular question might in fact be "no."

In this second post of a series I present more cases that stand as exhibits to my thesis above, the first case of the series at this link being mine personally, the others being that of other individuals who shall remain nameless.

The overarching theme is that hospitals and healthcare remain an IT backwater that will likely phagocytize quite a bit of money with little to show in return. This is largely due to starry and/or dollar$ign-eyed HIT utopians and opportunists who do not understand the field's dependencies, complexities and politics - or do not care about them because it's bad for business.

Congress, are you listening?

Case Two:

This case was communicated to me by a former student of mine in healthcare informatics after an exhange where I wrote in my inimitable style:

I hate to point this out (and let the Joint Commission Sentinel Event Alert and the National Research Council reports on HIT be my witness), but ... $20 billion has just been queued up to be handed out to some good people, but also a lot of electronic snake oil salespeople. I'm almost certain I won't see any of it, because I actually know what I'm doing and don't tolerate fraud and incompetence in health IT.

The student, now a very talented applied consultant, wrote me as follows (names of people and companies redacted):

From the perspective of someone that sits on the funnel of information between HIT vendors, practices and hospitals, I can almost guarantee that ALL HIT vendors are snake oil salespeople.

For example, we’ve discovered a major performance issue with [our commercial EHR] which causes Microsoft SQL errors. Our clients called [EHR vendor], [EHR vendor] says that they don’t support Microsoft SQL. Can you say WTF?

The clients have NO support contracts with Microsoft so it is more than likely a $150/hr bill on top of already existing [EHR vendor] agreements.

The formula is fairly simple and very Business 101: Your best employee is your customer. Our research has shown the only way to make it fair for everyone, lower EMR costs, and to get our most bang for our buck is to make the patient manage their own records like the way we manage our bank accounts and credit cards. Once we get the patients to contribute effort, it will lower costs for the providers to be able to purchase the software.

I’m super surprised that the banking industry has not jumped on the bang wagon to develop a personal health record. If you think about it, the financial industry has already done the leg work on security, access and data warehousing. Hell, those smart chips in credit cards these days can be used as a key to access a patient’s record that’s sitting in a secure data center somewhere.

To which I replied:

Is this SQL issue publicly known? Also, Is MS-SQL the only SQL server that can be used, i.e., is [vendor EHR] dependent upon it and written to use it as its db engine? Does [EHR vendor] market MS SQL for use with [EHR] or say it can be used? Seems grounds for legal action if the above apply.

To which the former student replied:

I just got done speaking to [executive] who is the president of [EHR vendor]. He said he was going to pay the clients for any Microsoft bills. But my problem is, it took me to make them realize how wrong they were. Unbelievable.

Anyway, today I am in [another city] at a multi-specialty practice where I am performing an EMR readiness assessment. They are currently on [vendor Practice Management system] but do not have EMR.

They installed the Practice Management product a few years ago but unfortunately could not get enough consensus on how they want to use EMR so the EMR project was scrapped. Now just a few years later everyone wants the medicare incentives for ePrescribe.

Unfortunately for this group they have three major problems:

1) they do not have centralized billing which is causing some AR (Accounts Receivable) issues. So for example, John Doe the patient uses Ortho and cardio. If John Doe has a balance at ortho, cardio doesn’t even know about it and continues to see John Doe.

Also because they do not have centralized billing, there is an overabundance of billers at each speciality with an almost 1 to 1 ratio of providers to billers. Uh...someone doesn’t understand MGMA standards.

2) no centralized purchasing which causes them not to leverage group purchasing and “oh btw” has also afforded them to violate major Microsoft licensing laws.

3) all their providers, even those in the same practice, want their own custom templates. This actually cracks me up since they all use the same template when they are dictating which “oh btw” is sent via a gmail account and zero encryption to the transcribing company. Boy, are they going to be surprised when my buddy from OCR gives them a call tomorrow.

With everything stacked against them, I will more than likely tell them they are not ready. With their lack of standardization, it would be a complete waste of everyone’s time and money to even attempt this EHR.

This practice just absolutely thinks IT is a nuisance and treats it like an abused dog. Just to give you an idea, their IT director makes under $60K/yr and can barely tell me the difference between a serial port vs. cereal port.

Keep in mind, they expect this guy to be their infrastructure manager, [PM and EHR] administrator, project manager and HIPAA security/Compliance officer. On the whiteboard today he spelled HIPAA: HIPPA. I kinda feel bad for him because someone set him up to fail.

I will more than likely take over this IT department. Their proctologist is hilarious though. His boat has a domain-appropriate name, and because of his office location in he shows all of his patients his boat from the exam room window. You can just see his paternal pride.

And then this:

I'm getting to the point where I'm starting to become the Michael Clayton of HIT. The good guys and the bad guys all look to me for answers.

You will roll your eyes at this one: I found today where one of the billing companies where my team is managing their IT has lost $550K in claims and billable productivity because some providers use EMR, some don't and some are half in half out. There is not only the paper chase for the billing staff but it is also the electronic paper chase. And the reason we discovered this was because I saw the liability with these multiple silos of information so we created a pseudo-malpractice lawsuit and used the clinical system as the majority of the data store.

The sociotechnical issues in these case accounts are almost too numerous to lay out in a blog post. A full academic paper would probably be needed to do it justice. A skilled medical informaticist at the outset, however, might have prevented these problems.

It should be understood I am not "against" health IT nor a luddite. I completed a postdoctoral fellowship in Biomedical Informatics in 1994 out of love for the idea of improving healthcare through IT. It is clear, however, as these examples and others at my academic website "Common Examples of Healthcare IT Difficulty" illustrate, that significant further research is needed in order to determine how to best make this technology meet the needs of real world clinicians, and how to best implement it under real world conditions.

I do not advocate abandonment of health IT, only a return to the understanding that this technology remains largely experimental. This understanding was usurped in the past decade by an overaggressive and indeed opportunistic HIT industry, enamored of profit potential, and the irrational exuberance has now spread in a manner reminiscent of other speculative bubbles of late.

HIT should be treated as experimental, not as a drop-in panacea for healthcare's ills. In its present state is is perhaps as likely to exacerbate those ills. This is probably not technology that should be deployed en masse at present. We cannot afford as a society to learn how to do this by trial and error.

EHR today as a plug-and-play panacea that will save $80 billion per year? Or, $20 billion abyss?

I report, you decide.

Case three is here. Case one of this series is here.

-- SS

No comments: