Friday, December 07, 2007

EMR's: Take it or Leavitt, HHS secretary says (while putting a gun to doctor's heads) - and should physicians boycott EMR's as a political statement?

I wrote here about an "irrational exuberance" regarding electronic medical records (EMR's). Well, here's an example of the escalating irrational exuberance, Don Corleone-style.

From AHA News:

Leavitt: Medicare should link higher physician payments to health IT

Any legislation to stave off a reduction in Medicare reimbursement rates for physicians in 2008 should require physicians to implement health information technology to be eligible for higher payments, Health and Human Services Secretary Mike Leavitt said yesterday. “Such a requirement would accelerate adoption of this technology considerably, and help to drive improvements in health care quality as well as reductions in medical costs and errors,” Leavitt said. “I’m confident that many members of Congress are of a like mind on this issue and I will actively work with them in the near future.”


From my introductory essay at my web site "Common Examples of Healthcare IT Failure":

...the use of electronic health records, without a major change in health care delivery, would 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 EHRs "is not going to be as substantial as people think."

... With regard to electronic health records ( EHRs ), 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 and paradoxical conclusion. The authors examined electronic health records (EHR) use throughout the U.S. and the association of EHR use with 17 basic quality indicators. They concluded that “as implemented, EHR’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.

These findings are indeed troubling. An EHR for small-group and solo-practice physicians costs $44,000 per physician, and generates an average ongoing $8,500 per year in annual costs , ACP president 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.

Contrast that with Leavitt's actual words:

The benefits of utilizing health information technology for keeping electronic health records and other purposes are clear. This technology will produce a higher quality of care, while reducing medical costs and errors, which kill more Americans each year than highway accidents, breast cancer or AIDS. Congressional leaders are working on legislation to address Medicare's physician payment system, staving off a reduction in reimbursement rates that is set to take effect in January and is required by law. In my view, any new bill should require physicians to implement health information technology that meets department standards in order to be eligible for higher payments from Medicare.

Regarding EMR exuberance, there's science, then there's fiction -- and then there's science fiction. See additional references below.

I remind that outright coercion further escalates the battle of the technologists vs. those with sociotechnical wisdom regarding health IT, i.e., those who understand that it's not wise to shove semi-proven (or unproven) information technology down people's throats.

Also, one wonders, say, why airline pilots are not forced to purchase, out of their own pockets, computers in their cockpits designed to prevent pilot error or collisions, but that in testing actually often doesn't work, or just makes piloting a plane harder without strongly proven benefits.

Oh, wait ... pilots could just refuse to fly until the systems worked!

Oh, wait ... pilots can just go to their union steward and complain, and then the union can call a strike and shut down the airlines!

Oh, wait ... pilots can just leave and go fly cargo planes in the Caribbean!

But to doctors, the government can make an "offer they can't refuse" with impunity.

This raises a fundamental issue. Physicians can't even associate and share information such as on setting fees or compare their managed-care contracts due to antitrust laws, and have basically lost control of their profession. EMR's are increasingly being shoved at them with the expectation that the costs and increased efforts required to use them will be donated, gratis, and the data from the EMR's will likely be used by payers to increase their own profit further, at physician expense.

Now, the concept of outright "ransom" is being raised -- purchase and use EMR's, or else we will cut your (already not exactly overly generous) Medicare reimbursements!

I am, however, unaware of any laws against physicians, especially those in private practice, boycotting purchase and use of EMR's, as a political statement at the very least. [addendum - see comments section for more discussion of this point - ed.]

Perhaps that's a first step towards regaining control of the profession.

-- SS

Some additional references. EHR as panacea: Science, or science fiction?

- "Sociotechnical Issues in Clinical IT: Common examples Healthcare IT Difficulty" by this author. link

- It Ain’t Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs. Health Affairs, 25, no. 4 (2006): 1079-1085 (link)

Abstract: Electronic health record (EHR) advocates argue that EHRs lead to reduced errors and reduced costs. Many reports suggest otherwise. The EHR often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the EHR is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the EHR alone.

- Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9;293(10):1197-203. (link)

- Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure. link to pdf

- Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007 Sep-Oct;14(5):542-9. (link)

- Expected and unanticipated consequences of the quality and information technology revolutions. JAMA. 2006 Nov 22;296(20):2439; author reply 2439. (link)

- Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument. Int J Med Inform. 2007 Oct 9. (link)

- U.S. Court In Illinois Declines To Limit Damages In Hospital's Claim Against Health Record Information System Supplier - ref: Rush Univ. Med. Ctr. v. Minnesota Mining and Manuf. Co., No. 04 C 6878 (N.D. Ill. Nov. 21, 2007).

- Adverse Effects of Information Technology in Healthcare. The Knowledge Center at this link presents a collection of taxonomized information assets on the adverse effects of information technology in its application to healthcare.

- ”Electronic Health Records Raise New Risks of Malpractice Liability” (link to PDF) by attorney Joel B. Korin and Madelyn S. Quattrone, ECRI Senior Risk Management Analyst, the emerging legal issues are summarized.

- Bad Health Informatics Can Kill. This site contains summaries of a number of reported incidents in healthcare where IT was the cause or a significant factor. It comes from the Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI)


Anonymous said...

Just because you have a hammer, not everything becomes a nail.

Steve Lucas

Vince Kuraitis said...

Dear Dr. Curmudgeon,
Why don't you take your analysis to the next logical step and just suggest that doctors kill a few patients as a sign of protest?

How can you call yourself "MedInformaticsMD" when all you can write about is how the glass is half empty?

Anonymous said...

You are not alone in your conclusion.
Many doctors feel that the EMR is a "noose".
In fact, several colleagues have used that term precisely.

I disagree.
However, probably not for the reasons you think.

Yes, I do believe that digital medical records have benefits over their paper counterparts.
But these benefits can be outweighed by the impracticality of most EMR systems for many physicians.

The real reason I disagree with you is that digital medical records and moving towards a completely paperless office are steps one and two of a five step process for healthcare reform recommended by "Doctors for Healthcare Reform".

Paperless offices can streamline and reduce overhead.
But even more importantly, paperless offices can become WiPPs.
- Lou Cornacchia, M.D.

InformaticsMD said...

I leave it to readers to determine what potential conflicts of interest, based on this commenter's bio on blogger, might have caused Mr. Kuraitis to deliver what is basically an ad hominem attack on my suggestion that clinicians should react negatively towards political coercion to pay for and use a costly technology fraught with problems, and actually have a say in what technologies they take a cautious approach towards (especially considering, ultimately, their liabilities in use of said technologies).

It was also an attack not just on myself, but on those who take a cautious, studied, critical approach to healthcare (e.g., as in my shortlist of literature references).

His comment also reflects incomplete information, e.g., my HCRENEWAL posting just prior to this one.

Not to impugn his considerable credentials, which are impressive, but I note that jumping to conclusions with incomplete data is just one of the major weaknesses when unidisciplinary personnel are given leadership roles in domains that require cross-disciplinary expertise for proper leadership, e.g., healthcare IT.

Vince Kuraitis said...

Dr. MedInformaticsMD,

You are correct -- my comment was an ad hominem. I apologize for writing in the heat of the moment, for pouring out my frustration in a personal way, and for any hurt I might have caused you.

I also hope that you were writing at the heat of the moment when you suggest that physicians should boycott EMRs.

Doctors should be LEADERS in advancing the dialogue for health care IT, not foot draggers.

One can easily make an analytical case about the challenges of EHR implementation, as you have done eloquently and repeatedly in your blog postings.

But what the logical conclusion that one should reach from your argument? That we should abandon the EHR implementation process because it's difficult? That we should go back to paper and fax? That doctors should take their marbles and go home? That the evidence of what IT has done to revolutionize every industry other than health care should be ignored?

You don't offer an alternative implementation path. It's easy to criticize. It's much more difficult to lead toward a constructive solution.

Secretary Leavitt offers a constructive alternative. Providing economic incentives (carrots) for EHR adoption is a rational approach. Your describing this as "coercion" redefines the meaning of the term.

InformaticsMD said...

I also hope that you were writing at the heat of the moment when you suggest that physicians should boycott EMRs.

Doctors should be LEADERS in advancing the dialogue for health care IT, not foot draggers.

Apology accepted! :-)

Seriously, though, I am a strong proponent of clinical IT. However, it must be good clinical IT. I expect of the clinical IT world an adherence to the same standards of rigor that is expected of clinicians.

My website on health IT sociotechnical issues is indicative of my beliefs that good clinical IT can make a difference, and that is my personal experience as a clinical IT leader as well.

In medicine, a key ideology is "first, do no harm." All is not well in the world of clinical IT, and there is an increasing body of literature on the downsides that are not being addressed. For example, sociotechnical issues, incompetence (see my story on computers placed on ceilings of ICU's), IT hauteur, lack of clinician input, and others. See the reading list from INFO780 posted on my website 'other resources' section, for example.

I actually do believe physicians - especially primary care physicians currently using paper - should consider boycotting the acquisition of new EMR's as a political statement, under threat as they are of decreased payment (or, more correctly, exclusion from a reversal of decreased payments) for their services from Medicare.

I also believe it's premature to start forcing the sinking of clinician's money into such endeavors - representing a transfer from the medical to the IT world - unless the clinicians choose to do so via persuasion, not coercion. The money might better be spent for care at this point in time.

Primary care is already facing shortages of new trainees willing to make the sacrifices at current levels of reimbursement. Such coercion can only make that situation worse.

I believe I made my point in the body of the post, regarding expense and the findings of questionable improved outcomes in the article “Electronic Health Record Use and the Quality of Ambulatory Care in the United States.”

I believe that "irrational exuberance" describes precisely the runaway enthusiasm shown by many parties with interest in clinical IT. In the UK, billions of pounds/dollars may have been spent needlessly.

Shouldn't that be a sufficient cause for caution, and a cause to allow clinical IT - and the management thereof - more time to reach a state of higher maturity?

InformaticsMD said...

And by the way, on "coercion", I stand by my interpretation.

It's not a "carrot" to say "we won't exclude you from the cuts we're reversing [reversing due largely to the outcry about the economic damage to clinicians and hospitals such cuts would cause] unless you pony up for clinical IT."

That's a stick, and a quite inflammatory stick at that.

Providing economic incentives (carrots) for EHR adoption is a rational approach

Why then does not Leavitt offer for HHS to cover the costs of EHR for practitioners to some (significant) extent? That would be a carrot.

InformaticsMD said...

Anonymous wrote:

The real reason I disagree with you is that digital medical records and moving towards a completely paperless office are steps one and two of a five step process for healthcare reform recommended by "Doctors for Healthcare Reform".

Moving towards a paperless office via clinical IT as it is currently designed is like trying to reach the moon via hot air balloon.

No amount of process, committees, consensus, focus groups, resources, etc. will accomplish that goal due to inherent flaws in the approach.

Would someone PLEASE refute the findings of some of the researchers whose articles I posted? If it can be shown that they are wrong and that technological determinism is operative in clinical IT (i.e., clinical IT's goodness unequivocally outweighs its negative aspects at this point in time), then the basis for substantive debate has been reached.