Tuesday, January 15, 2013

New York Times: "In Second Look, Few Savings From Digital Health Records", and AMA Med News on EHR Harms

This post should perhaps be entitled "I told you so."

A letter I wrote in response to the Wall Street Journal's "A Health-Tech Monopoly", Feb. 11, 2009 was published Feb. 18, 2009 under the header Digitizing Medical Records May Help, but It's Complex.

I wrote:

Dear Wall Street Journal,

You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.

I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.

For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors.

HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine.

The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker.

I can only hope patients get something worthwhile for the $20 billion.

Scot Silverstein, M.D.
Faculty, Biomedical Informatics
Drexel University Institute for Healthcare Informatics

I also had penned essays on the need for a moratorium on HITECH (Nov. 2008, "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" and Jan. 2009, "I Ask Again: Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?").  My theme was that the issues with implementation of good health IT and elimination of bad health IT, and the issue of how to implement most efficiently, needed to be better understood before a national rollout.  Hold off multi-billion dollar national initiatives "until we know how to get HIT right", I wrote.

Now the New York Times has this, citing a new RAND paper:

In Second Look, Few Savings From Digital Health Records

January 10, 2013

The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.

Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.

“We’ve not achieved the productivity and quality benefits that are unquestionably ["unquestionably?" why?- ed.]  there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.

Noted is the provenance of the 2005 report that created the windfall for the electronic records industry:

RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

A retraction:

The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems ... But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.

In my Feb. 2009 WSJ letter, I'd written that "it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants."  It appears I was correct.

Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.

Not mentioned are harms that bad health IT is creating.

The recent analysis was sharply critical of the commercial systems now in place, many of which are hard to use and do not allow doctors and patients to share medical information across systems. “We could be getting much more if we could take the time to do a little more planning and to set more standards,” said Marc Probst, chief information officer for Intermountain Healthcare, a large health system in Salt Lake City that developed its own electronic records system

A "little more" planning?  How about several years' worth, to ensure the technologies are safe, effective and properly vetted, along with a system for post-market surveillance as exists in other healthcare sectors?

Technology “is only a tool,” said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. “Like any tool, it can be used well or poorly.” While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.

Dr. Blumenthal seems to be triangulating from his earlier 2010 NEJM statement that:

... The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice.

Meantime, in the real world signs of my expressed concerns about a quagmire are appearing:

... Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously.

A clue as to the candidness of the new report:

... The new analysis was not sponsored by any corporations, said Dr. Kellermann, who added that some members of RAND’s health advisory board wanted to revisit the earlier analysis.

Finally, this from the horse's mouth:

Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.

I repeat my admonition from 2009 that I can only hope patients get something worthwhile for the $20 billion, which by now is probably many times that amount.

Finally, I note the American Medical News cites me in a Jan. 14, 2013 article as follows:

... Other experts on health IT said the Pennsylvania [PA Patient Safety Authority] study probably underestimates the extent of health IT safety problems. They say that is because the research is based on voluntary reports and that health professionals are unaware that a patient safety incident was caused by an EHR failure.

“These systems are incredibly complex,” said Scot M. Silverstein, MD, a consultant in medical informatics at Drexel University in Philadelphia. “They’re not just huge filing cabinets, they are enterprise resource management systems. There are many ways that things can go wrong that may not be seen as the computer having caused the mess-up in the first place.”

For example, he said, it would be difficult for a practicing physician to detect when data are missing from a record or that an alert failed to pop up.

Yet the title of the article is "EHR-related errors soar, but few harm patients" with a table at the bottom labeled "How rarely EHR problems harm patients." More evidence that EHRs always receive special accommodation. 

I was an invited reviewer of the PA Patient Safety Authority report, and wrote about the major deficiencies of its dataset at my posts Dec. 13, 2012 post "Pennsylvania Patient Safety Authority: The Role of the Electronic Health Record in Patient Safety Events" and a follow-up Dec. 19 post "A Significant Additional Observation on the PA Patient Safety Authority Report -- Risk."

My major point was that one simply cannot know what one cannot know, when using a very incomplete dataset gathered in a setting of systematic impediments to accuracy and completeness.  For instance, as I wrote in those earlier posts, through my work I personally know of cases of harms up to and including death that should have been in the PA database, but apparently are not - and I'm just one person.

We simply don't know in 2013 how many EHR errors harm patients, and the effects of increasing adoption by organizations and physicians less technology-able than current adopters.  I hope the magnitude of harms is truly small, but hope is not enough; this study and report was just a 'dipping of the toes into the water' towards understanding the realities.

Incidentally, we also don't know how severely the known toxic effects of bad health IT might affect care in times of duress, e.g., an epidemic.  However, I am certainly not sanguine about EHRs in their present state as robustly facilitating national emergency preparedness.

My dreaded prediction for the future?  A 2016 AMA News story entitled "Known EHR-related harms soar."

-- SS


Anonymous said...

The outcomes of care from the $ billions spent on HIT have not improved. Costs are high. The deaths, errors, near misses, and adverse events remain obfuscated, ie covered up by the vendor-hospital duet. Doctors and nurses are punished professionally for disclosing the truth about HIT.

Did Cerner purchase results? Those numbers were way out there, unfathomable. One would hope not, but there is a conspiracy of silence about adversity from HIT, system wide crashes, delays in care, and neglected patients. There is not a conspiracy of silence about Cerner's profits achieved subsequent to the first RAND study, as reported in the NY Times.

Trevor3130 said...

A touch of reality is on view in this 2012 documentary series by British medico Kevin Fong. During his visit to St Barnabas in The Bronx, he observed the ER room for a few sessions. At the start, he asked to see a listing of the problems that brought patients to the Trauma Center, led by Ernest Patti.
A staff member put a ledger, red cover and two inches thick, into Fong's hands. He paged through the hand-written entries, many of them 'GSW' alongside the ID sticker. Maybe there is a computerised listing at that ED, up-to-date and ready to be printed at the press of a button, and Fong chose the red book for dramatic effect. But, in the workings of that, or any other busy ED, a dozen or more sets of eyes, ears & hands in common purpose, it's hard to see how keyboard & screen could be anything but a hindrance.

InformaticsMD said...

Trevor3130 said...

in the workings of that, or any other busy ED, a dozen or more sets of eyes, ears & hands in common purpose, it's hard to see how keyboard & screen could be anything but a hindrance.

Unless, that is, you consider an ED a meat-processing plant that needs to make money.

I recall my days in the ED well. I cannot imagine having to be a data-entry clerk to some foolishly-designed EHR system in that type of environment.

I feel sorry for my former colleagues in that position, I really do.

-- SS

Trevor3130 said...

Wonks on the other side of the Atlantic seem to disagree, Scot.
In Going paperless 'would save NHS billions' the old mantra is re-run.
Mr Hunts comments come as a report by PwC suggests a potential£4.4bn could be put back into the NHS by using better use of information and technology. Using electronic prescribing and electronic patient records would also give staff more time to spend with patients.
There are at least two fundamental (and, probably, insurmountable) problems with this arithmetic.
One, duplications & paper-shuffling, clerical tasks, make up a large part of the inefficiency. Clerical tasks = salaries = jobs.
Two, even if a magic wand could eliminate unnecessary activity in one sector, there would be immense resistance against transferring resources to another. Take an example in pediatrics, where magic (or vaccines) eliminated all childhood infections. Any pediatrics department could quote a figure for the proportion of their resources absorbed in caring for children with infections, but try to take that exact proportion away from them, when infections are gone?
The other issue with PwC's claims is that any transfers of resources under efficiency gains would be "owned" by the consultancy industry, in collaboration with healthcare management. The two classes (management, consultancies) are pretty much the same thing, after all, since personnel rotate between the two as a matter of course. There's no doubt that transaction fees would suck the life out of any gains created by eHealth.
If low-level employees in the public health systems sign up to the kind of nonsense being perpetuated by PwC they will find out to their pain that they are the first to go under New Management.

Anonymous said...

Neither the US Government nor the HIT vendors and industry partners have put the safety of the patients first.

OzLurker said...

Guess what? The UK Secretary of State for Health appears not to be a reader of your blog, or the Rand report, or the NY Times, or the IoM Report or the Report of the Ombudsma of Victoria on HealthSmart...


In fact he hardly appears to have a grasp on reality at all, probably as a result of years listening to Rupert Murdoch's (allededly) advice when Culture Secretary...

Anonymous said...

Americans have become dumb and powerless as the machines take over control of their health and privacy, at great monetary and social costs. The sickness requires epidemiological study.