Tuesday, April 13, 2010

Yet Another Study Shows Health IT Does Not Bat The Ball Out of the Park; And, is HIT an Issue of States' Rights?

At "2009 a Pivotal Year in Health IT" I aggregated a number of reports and articles from that year shedding needed critical light on the irrational exuberance surrounding computers in medicine, an exuberance that seems to consider clinical professionals with years of hard training and expertise as simpletons who should bow to the cybernetic miracles created by the health IT cartel.

The critical reviews continue in 2010. Here's another in Health Affairs from a team at Harvard: Electronic Health Records' Limited Successes Suggest More Targeted Uses. The team, led by Harvard Medical School professor Catherine M. DesRoches, surveyed more than 3,000 U.S. community hospitals to assess factors such as inpatient costs and mortality and readmission rates.

Here were their findings:

Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.

On that last point, I disagree; it's not the use of HIT that needs to be encouraged, it's the remediation of HIT that needs to be encouraged/enforced to make HIT useful. More below.

The authors also report:

Hospitals with comprehensive electronic health record systems were compared with those with no or basic electronic systems, and the team only found slight differences in areas such as length of stay and surgical infection prevention.

Overall, the researchers determined that the technological systems, as currently implemented, do not have a significant impact on improving care and reducing costs, DesRoches said.

“Having a system is not enough,” DesRoches added. “We can’t expect that hospitals are just going to plug these systems in, and suddenly you’re going to see large improvements. [Not according to our President and the heads of HHS and ONC, who've explicitly stated that health IT will produce all sorts of technologically deterministic miracles - ed.] The systems are only going to be as good as how people are using them.”

I would differ from the authors on the last point, that "the systems are only going to be as good as how people are using them.” The authors seem to assume that health IT is a perfected technology.

I would say that "the results are only going to be as good as the systems clinicians are forced to use."

If the systems are crap, then the results of their use will be crap.

The authors concluded that "the study’s findings should not deter future technological advances in keeping medical records.

In fact, I think with results such as these, improving health IT through technological advancement is an absolute imperative. To do so, however, will require major advances in the health IT industry itself - its methodologies for health IT development and validation, its qualifications for leadership, and its regulation.

“With the amount of attention and money that the federal government is putting into this issue, I don’t think we can do anything but move forward at this point,” Desroches said.

Again, I disagree with the author's white-flagged surrender to the diktats of the Federal Government. The Federal takeover of health IT via the establishment on ONC by HHS made me uncomfortable when it occurred in 2004, and it is increasingly clear why.

When serious doubts are thrown on a technology being pushed on a critical profession and a nation's critical services, the imperative should be on slowing down and fixing the problems before spending hundreds of billions more dollars in a massive federal push, a push that even includes federal coercion in the form of Medicare penalties for non-adopters.

As studies like this show, HIT medical devices are experimental, yet increasingly serve as governors of medical care. They are "governors by cybernetic proxy", I might add. These devices put the federal government, and the health IT vendors as well, with their "best practices" criteria, directly in the exam room. This is done without true patient informed consent.

The rights to govern the practice of medicine reside with the states, not the Federal government. (Drug and device safety were made an exception via FDA regulation, but health IT is entirely unregulated, demonstrating incompetence at best on the part of the federal government in a matter critical to healthcare).

Perhaps the states need to take up the issue of federal pressure to implement experimental health IT. Health IT is technology that seeks to govern the practice of medicine but does not seem to have significant ROI the way it is designed and implemented today. It does, however, have a definite but unknown incidence of harm (the FDA's data on patient injury and death attributed to bad IT are suspected to be just the "tip of the iceberg" according to the FDA itself). Perhaps states' rights need to be invoked in order to slow the out-of-control, federally fueled locomotive.

It seems that federal imperatives to:

  • coerce clinicians to purchase experimental products of commercial health IT companies under duress of federal penalty (much as consumers are going to be forced to purchase health insurance from commercial insurance companies under threat of penalty, although at least those products are not experimental);
  • determine"meaningful use" criteria;
  • determine who can "certify" the technology;
  • set up federal "Regional Extension Centers" (REC's) and a national Health Information Technology Research Center (HITRC);
and the HITECH act itself represent a huge power grab that tramples states' rights to regulate the practice of medicine.

-- SS

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