Sunday, November 8, 2015

How the Government Screwed the Health Care Pooch

When I get angry, I've learned to think, who do I think should be doing something that they're not doing? Then I can think, is that expectation valid? Sometimes it is, sometimes it isn't, and even when it is valid, thinking about it still kind of tempers my anger. At least, after a little bit. Personal anger management.

And so it is with our Federal government and Electronic Medical Records (EMRs). I complained to my brother Bob, who said, “What do you expect? Who do you think is in the government? The best? What kind of person wants to become a government employee?” He did not reference Donald Trump, but he could have, because that's one thing Trump is right about.

It's a well recognized phenomenon. When the ACA website imploded, veteran official Leon Panetta was thunderstruck: “Obama left that to the bureaucracy to do???” In other words, if it's important, make sure the government doesn't do it. Or, as I read in the WSJ yesterday about how Medicare doesn't check on the possible validity of claims before it pays them, as a modern credit card company would: “The government – yesterday's technology tomorrow.”

“The government” is a collective noun. It is composed of lots of people and agencies, and also the “advisers,” outside of government, often in academia, often in industry, who are supposed to be supplying the intellectual power. Maybe they're the ones I should be complaining about.

Anyway, here's the thing. When Obama came into office he needed to stimulate the economy with ARRA, the American Recovery and Reinvestment Act of 2009. Good, it was needed; in fact, more money than what they put into ARRA was needed, and he could have gotten more if he hadn't negotiated with himself, which I notice he has stopped doing, his current philosophy being, “I don't give a fuck.” Good; nice philosophy. But I digress.

So the health care “experts” thought that a program that put Electronic Medical Records into hospitals and medical offices would be just the ticket – marry the needs of the economy with the needs of health care. They claimed too much for what EMRs would do, they didn't really know much about them, and they didn't think they needed to know much about them. They had their theories, they had their analogies to other industries, they didn't need to get their hands dirty actually seeing what these programs were like. Details, details. The fact that EMRs generally suck didn't have to be addressed. The fact that it would slow down rather than speed up health care didn't have to be addressed. The fact that EMRs turned doctors into data input clerks didn't have to be addressed. Those were mere facts. In theory, it was brilliant.

My San Diego colleague Stu Cohen pointed out that the now-billionaire owner of Epic, Judy Faulkner, the major EMR system adopted in America, was a major Democratic donor and on the committee that inaugurated HITECH, the ARRA EMR program. A little self-dealing, seems like. What else is new?

When the Feds shelled out the money to get these EMRs into hospitals and offices, they unforgivably stupidly or cravenly or somethingly, (I don't know really how it was done so I don't know who to hate) didn't mandate that all the computer programs be standardized enough to be able to talk to each other., which is called interoperability. So here they all are all over the place, and they can't cooperate with one another.

In the words of North Carolina colleague Graham Barden:

What is even more WTF is that the Rand Report that was often quoted as saying how EMR’s were going to save vast amounts of money for the country, stated in the paragraph just above the often quoted figure something to the effect, “Once interoperability is achieved, ….” Unfortunately our 20 something leaders either did not read that paragraph or did not understand the big word…”

And more from Pasadena colleague Glenn Schlundt:

Over the years, there certainly appears to be a recurring and persistent, not improving theme about EMRs. Whereas a few people on this list sing their praises, and can't appear to imagine life without them, a significant fraction of posts speak to legitimate, persistent, and meaningful limitations that many EMRs presently appear to impose.

Here's my "off-the-top-of-my-head" list:

1. They don't talk to each other, so communication between them is essentially impossible.
2. They are absurdly expensive, and the return on investment on balance, while debatable in some instances, is pretty negligible.
3. They are expensive to maintain. The initial capital costs lead to monthly maintenance costs.
4. They are inefficient in that it takes doctors longer to do the same tasks, usually with little if any apparent benefit to the quality of clinical care provided.
5. Liability costs resulting from security risks, including HIPAA violations, may be considerable.
6. Some young physicians are declining to take employment positions where they will have to use hospital EMRs because they are unwieldy, inefficient, and time consuming (this from a
    previous post to this listserv).
7. They purport to allow doctors to collect data that will improve both patient care and cash flow, but other than auto-correcting doctors' previous undercoding, or allowing other doctors
    to purportedly "game the system" by clicking a few additional boxes,  well-publicized data or evidence for clinical or economic improvement appears lacking. Little convincing data suggests
    the financial benefits of EMR outweigh its costs, when measured directly, indirectly, or both.
8. They can weaken the doctor-patient relationship because some patients feel the doctor spends so much time looking at their computer screen, the doctor does not even know what their
    patient looks like. This has been used as a selling point for telemedicine, where, in a bizarre and peculiar twist, patient have reported they prefer telemedicine because "at least the doctor
    knows what I (the patient) looks like."
9. They can alter the way doctors are audited to include only data that supports downcoding or an insurer's interpretation of a clinical encounter based on data that is displayed. Several
    members of this listserv have noted that the medical decision making portion of their documentation, as measured by the software they use, drives payments, even when this does not
    appear to be the only or best criteria for medical work using CMS criteria.
10. The companies that sold or maintain them can decide to go out of business or change the terms of their contracts, creating additional access and liability issues

When one takes a Corporate Management of Risks in law school, one is taught that one frequent source of liability is over-commitment to a project or plan based on the time, effort, and resources that have already been invested. In short, one is taught that people and organizations find themselves in hot water because they are unwilling to objectively re-evaluate projects as they progress. At some point it is time to cut bait.

I'm not suggesting there is no role for EMRs; clearly in some cases they work, and work well. Nor do I mean to be either indiscreet or provocative here. What I don't understand is why, if having adopted a system that clearly has so many flaws and that it impedes efficiency, tarnishes one's balance sheet, increases liability and diminishes quality of life, why, at some point, the whole system doesn't find its way into the trash, and doctors don't just go back to the good ol' days (which, based on the animus transparent in many of the posts on this list, really are perceived as the good ol' days), until something genuinely better really comes along?

Why not just go back to paper for the time being?”

OK, that's bad, there was self-dealing, the programs are not ready for prime-time, and they don't talk to each other. Lots and lots of waste, and worse.

But, here's the deeper point of this post (sorry it took so long to get here.) There is an under-appreciated implication of the horrible omission of not requiring interoperability, which is brought out in a recent post from Boston health policy colleague Paul Levy:

Short look back: before the computer revolution, one of the foremost thinkers in health care organization was economist and ex-McNamara Whiz Kid Alain Enthoven. He proposed the model he called Managed Competition (MC). He envisioned many ICNs competing for business. He was a corporatist, and in those pre-computer days, the transaction costs of communication and information gathering were intimidating. Managed Competition was an attractive model.

The current incarnation of MC is called the Integrated Clinical Network (ICN) model, examples of which would be Kaiser, or the VA. In an ICN, when you are in the network, that's where you stay. Need a referral to neurosurgery? Off you go to the Redwood City Kaiser, where all their neurosurgery gets done. Need a neuro MRI? Off to Richmond, or wherever. It's all in-network. In theory, such specialization is good, more efficient, expert. But, if you are a clinician in a network, you don't have overt competition. The plan's members are a captive audience. You have to do well, maybe, but you really don't have to be the best. Each individual unit is shielded by the collective – the patient might choose Kaiser knowing there are some substandard units she hopes she won't need.

But now, with computers, another patient-centered model is possible. This is called the Centers of Excellence (COE) model. In a COE, you come to me, your primary care doctor. You need a referral. My job as your doctor is to get you to the very best place possible, and I have not just my in-network choice, but a full choice of the whole Bay Area, or even beyond. Several centers are competing for my business, and that's good for the patient. If they start to screw up one way or another, they will lose my business.

This is the real significance of interoperability of EMRs. The Mother Jones article cited above by Stu, written by an author with complex medical problems, points this out in great detail. To deliver the best care most efficiently, the primary care doctor and the referral unit need to have the same medical record in front of them. If the EMRs are interoperable, problem solved, COE feasible. If not, we have the same old difficulties of coordination, cooperation and efficiency.

If the EMR is not interoperable, referral within the system is easy, but referral to a possibly superior or more convenient center for x or y specialty is hard. But if patients might suffer, the same is not true of the ICN institutions at all. Although our economic system is based on competition, the role of individual corporations is to try to escape that discipline as much as possible, by combining with others to form oligopolies, or by fencing customers in to your network (as Apple does, for instance). So Epic won't cooperate with other systems – they sure don't want a small computer company that is great for a primary care doc networking into their system – God forbid! And for the integrated networks like Kaiser as well, interoperability is a threat rather than an opportunity.

The consequences of the Feds' decision not to require interoperability when they allocated $30 billion for EMRs are clear, then? This decision skewed the fight in favor if the ICN model, when the COE model has much to recommend it from the patient's point of view.

Maybe this situation is an example of LUC – the Law of Unintended Consequences. But “unintended” doesn't mean “unforeseeable.” The Feds, and if not them then their advisers, should have foreseen this consequence. Is this an example of inside dealing? Is this an example of selling out to corporate interests? Were the Feds convinced by others that “it would be too difficult” for them to insist on interoperability, and they settled for something less so they could “get the money out there?”

I don't know how it came about. They say when you need to choose between ignorance and malice, choose ignorance. Maybe. But at this time in our history, there is a very strong trend of increasing concentration within every industry, of corporate domination of government, of weaker and weaker government ability, and more and more violation of individual rights and welfare.

Sometimes it makes me mad, and sometimes it makes me sad. But either way, it sucks.

Budd Shenkin

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