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.
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.
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.”
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
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.
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.
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
In the words of North
Carolina colleague Graham Barden:
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…”
more from Pasadena colleague Glenn Schlundt:
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.
my "off-the-top-of-my-head" list:
They don't talk to each other, so communication between them is
They are absurdly expensive, and the return on investment on balance,
while debatable in some instances, is pretty negligible.
They are expensive to maintain. The initial capital costs lead to
monthly maintenance costs.
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.
Liability costs resulting from security risks, including HIPAA
violations, may be considerable.
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
post to this listserv).
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
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
financial benefits of EMR outweigh its costs, when measured directly,
indirectly, or both.
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
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
what I (the patient) looks like."
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
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
to be the only or best criteria for medical work using CMS criteria.
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
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.
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?
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.
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
Sometimes it makes me mad,
and sometimes it makes me sad. But either way, it sucks.