Wednesday, September 01, 2010

American Board of Medical Specialties to "incorporate tools to promote meaningful use of health IT into its maintenance-of-certification program"

From an Aug. 16 article "Industry pushes meaningful use through incentives" in Modern Healthcare (signup unfortunately required):

... Physicians will also be feeling the pressure to be IT savvy in order to maintain their professional certification. The American Board of Medical Specialties said that it would incorporate tools to promote meaningful use of health IT into its maintenance-of-certification program.

More than 750,000 U.S. physicians are certified by an American Board of Medical Specialties (ABMS) member board, “so it’s readily apparent” [really? - ed.] that building meaningful use of health IT into [Board] certification maintenance will benefit patients, ABMS President and CEO Kevin Weiss, said in a written statement. Additionally, the merging of these two tools will help to facilitate physicians’ knowledge, skill and use of health IT, and in turn can improve physician performance and patient outcomes,” he said.

The bolded statements of certitude from ABMS CEO Kevin Weiss follow the familiar pattern I observed such at my July 2010 post "Science or Politics? The New England Journal and The 'Meaningful Use' Regulation for Electronic Health Records".

These are statements of certitude supported at best by scanty evidence, "estimations" and "projections", while refuted by a growing body of significant research on health IT as it exists now (such as the recent materials here).

It is unfortunate that the ABMS has now fallen away from evidence-based medicine and fallen prey to mysticism-based IT practices in medicine.

I did, however, see moves like this coming. I believe the ABMS move augurs future, more forceful demands from the healthcare IT "Trade Federation" that physicians and hospitals buy and use this technology, a form of totalitarian caprice considering the evidence base.

With respect to seeing this coming, here's what I wrote in my post Masochism, Medicine and Clinical IT: How Physicians Can Be Beaten Over and Over, and Still Come Back For More back in April 2009:

... Here is a tale about the companies that medicine will be dependent upon for EHR's and other clinical IT - now by force of government (financial at first, but I would not at all rule out punitive licensure and other measures as a possibility in the future for "EHR noncompliers")...

We're not there yet, but I would not be surprised to see moves in that direction in the future.

I also consider the ABMS succumbing to IT mysticism as another sign of the degradation of efforts towards true evidence-based medicine in favor of corporate interests.

Fortunately, some research organizations have not entirely bought into the irrational exuberance, although whether they can exert enough influence to reform the healthcare IT industry before billions of precious dollars are wasted on today's ill conceived systems is debatable.

For example, (and in another example of research done today affirming conclusions I'd reached years ago using observational skills, knowledge of Medical Informatics, internal medicine thought processes and common sense), McKinsey offers the following.

Per the recent McKinsey study "Reforming hospitals with IT Investment":

... The realization of the benefits from health care IT investments will require a radically new approach to IT on the part of the CIOs of health care providers, as well as the business leaders and clinicians those CIOs serve. Health care providers will need to use new approaches to achieve an inclusive governance process with streamlined decision-making authority, a radically simplified IT architecture, and a megaproject-management capability.

Based on observation alone, I'd written this in 2002 (and probably before as well, somewhere):

... From a dual perspective as both a clinician and computer professional, it is evident that critical clinical computing projects benefit greatly from an alternate approach to project preparation, development, implementation, customization and evaluation, as compared to management information systems (business computing) projects. Clinical and business computing appear to be different subspecialties of computing.

Instead of naïve, unquestioning IT exuberance, the ABMS and other medical professional organizations should long ago have put their efforts behind moving the health IT vendors and their hospital customers to adopt the 'radical changes' required as in the McKinsey report (and elsewhere, such as in the 2009 National Research Council's report on health IT). They should have done so before insisting use of the technology be a metric for qualifications to practice medicine.

They should be pushing for the approval of health IT as medical devices under the Federal Food, Drug, and Cosmetic Act (FD&C Act), such as the EU is now moving towards; see for example the Swedish Medical Products Agency 2009 report here (PDF). From that report entitled "Proposal for guidelines regarding classification of software based information systems used in health care":

A general opinion of the health care providers represented in this Working group is that from a patient safety point of view, it is desirable that stand alone software and systems intended to, directly or indirectly, affect diagnosis, health care and treatment of an individual patient shall be regulated under a Product Safety Regulation. The Working group has not been able to define any other appropriate regulation than the Medical Device directives when it comes to the definition of such systems.

... The Working group believes that software intended for a medical purpose must be regarded as a "device" and expressions such as "project", "service" and similar must be avoided describing a Medical Information System.

Further, ABMS should also be pushing for robust post-marketing studies of health IT.

If truly representative of ensuring medical practitioners' competence in the interest of patient safety, ABMS should be discouraging specialty societies from blindly buying in to this experimental technology, and instead encouraging them to evaluate health IT critically - as critically as any new medical device or technology - including a complete examination of the literature.

The ABMS should hold off on linking clerical capabilities of clinicians to board certification, per Brown University ophthalmologist Michael Migliori in the above-linked Modern Healthcare story:

“I don’t believe achieving meaningful use equates to maintenance of certification,” said Michael Migliori, an ophthalmologist in Providence, R.I. Maintenance of certification is a measurement of clinical knowledge, whereas meaningful use is a clerical designation, he said.

“I understand the clinical importance of electronic medical records both in terms of patient safety and quality [although not in today's form IMO - ed.], but we are not at the point where EMR and health information exchange are ready for universal implementation,” Migliori said. “They should not be linked at this time.”

In other words, today's health IT is not ready for national roll out, especially with any form of coercion in effect.

Here's a major problem in slowing this train. The following chart appeared in the aforementioned McKinsey report on "startup costs" of EMR systems. The figures are presented in the form of dollars per bed:

McKinsey on EMR startup costs, estimated at $80,000-$100,000 per bed - click to enlarge.

With these levels of money moving like an overflowing fountain of champagne to the IT industry, with likely tributaries into medicine's regulatory, representation and accreditation organizations, no research seems likely to bring the radical changes needed to ensure this technology is safe and effective.

(The McKinsey report also opines that well-done EMR's can recoup the gap between costs and government financial incentives shown in the chart within a few years; that is also highly debatable, even if the HIT is "done well" via radical reform.)

I have no answers to these problems other than the many suggestions I've written on these blog pages since 2004, and on my academic site on HIT since 1999. Without those in power willing to consider that health IT today is yet another bubble or mania, then like some diseases, it may only be tincture of time that corrects these problems. That is, when the current Jurassic health IT ecosystem collapses of its own dead weight.

What's sad are the expensive IT fossils -- and bodies -- that will be left behind for some future archeologist to discover.

-- SS

Addendum Sept. 5:

EMR use as condition of licensure appears to be heading for reality in at least one state: Massachusetts. See

Hat tip to Al Borges, MD. See his comment in the comments section.


Anonymous said...

I will resign my certifications if am forced to study monotonous multiple clicks or purchase a system and spend $1000 monthly maintenance to order an aspirin. Doctors will put up with much crap and come up with workarounds. This one is is the line in the sand.

Al Borges MD said...

The ABIM examination process has progressed to a point of yearly certification that is similarly absurd. It seems that they are out of control- now adding in EHR questions? What a shame...


Al Borges MD said...

>>> financial at first, but I would not at all rule out punitive licensure and other measures as a possibility in the future for "EHR noncompliers")...

In Massachusetts physicians will eventually be forced to buy an EHR in order to get licensed. OMG, what is wrong with that state? I don't see how they'll be able to stop the exodus of physician practices...



Scot M Silverstein MD said...

Thanks for that link, Al.

-- SS

Anonymous said...

The state is sucking up to Blumenthal. Perhaps, Obama will pick more advisors from Harvard after this gig is official.