Who's
to blame for the Electronic Health Record debacle? And a debacle it
certainly is, at least for clinicians. The latest bite of criticism
has hit the oped pages of the Wall Street Journal. Drs. Mass
(pediatrician) and Fisher (nephrologist) from the Massachusetts
General Hospital do a good job of chronicling its ills. MGH uses
Epic, the near monopoly of enterprise-level EHRs. I call Epic “by
engineers, for engineers,” so unintuitive that the pathways rival
those of the old city in a European capital where only the natives or
the guides can find their way, who use their special knowledge for
fun and profit. With this and other EHRs, doctors become
unproductive data entry clerks typing and clicking away to fill up
the boxes and navigate the menus, often at home late at night
finishing up charting the day's patient notes. The indictment goes
on: the software design often causes errors rather than preventing
them. The content of the notes is frequently filled with garbage
designed to gather more money according to coding rules and to
protect the practice legally. For instance, in pediatrics we are
used to receiving ER notes that assure us that our three year old
patient has attested that he does not smoke, and the pages and pages
of verbiage makes finding what actually happened at the visit a
needle and haystack adventure. And of course we often receive these
notes not by computer but by fax, because the EHR programs are most
often not interoperable as they were envisioned to be. The promise
of all patient information available everywhere all the time? No
way. Everyone looks at the same record within the system,
generally hosted by a large medical complex, but you can't see the
record if you are outside the system, as smaller independent
practices and other units are. So why did we go through all this
investment and work for a more troublesome and less productive state
of affairs?
It's a
familiar catalogue of frustration and vitiated hopes that we all
share. What makes the article particularly congenial to the Journal,
however, is its attribution of blame and the proposed solution.
Blame goes to the government, for funding, encouraging, and requiring
that the work of doctors be computerized before the programs were
ready for mass consumption. Subsequent blame comes to government
also for requiring far too much certification by vendors which, they
claim, inhibits innovation. If only this vendor protection were
removed, the authors aver, Amazon and Apple and other consumer
electronics companies would invade the medical space and bring it up
to speed and down in price. In other words, deregulate. WSJ red
meat.
But I
have to say to these doctors and WSJ, not so fast, my friends. It's
not so easy and it's not so simple. For one thing, consider if the
medical field and the field of consumer electronics are really so
compatible. Medicine is far more complex than the stereotypic tasks
of ordering a household item, and the market is far more constricted.
The big tech software companies make their money on volume, and
there are a lot more ordinary people in the world than there are
doctors. How much money would it take to really attract the A team?
Is the profit possibility really there?
But
that's not the major objection I have; maybe they would come in,
maybe not. My major objection is that I think the source of the
problem is deeper than it appears. The physician authors might want
to think of their medical training. Sometimes a rash is pretty
simple and can be cured with a simple cream. But sometimes that rash
is the harbinger of a deeper disorder that needs far deeper
intervention. I'm afraid that this is one of those more serious
situations, where the symptom of the poorly functioning EHR emerges
not only from clunky governmental functioning and their less than
acute ministrations to the health care system, but also from the
organizational structure and political-economic interests of those we
call “stakeholders.” Thus, I would not be drinking the Journal
deregulation Kool-Aid just yet.
Should
the federal health officials and the other pezzonovante who make up
the health care establishment have pressed the Obama Administration
to include EHR funding in ARRA, taking advantage of a unique time
when big time money would be available? Were EHRs shovel-ready?
Probably yes, they should have, and no, the EHRs really weren't
completely ready. If they hadn't taken the cash opportunity when it
presented itself, how could the medical world be computerized? It
would have taken a lot longer time, and the money to buy and install
and maintain the EHR systems could only have been raised by the
institutions that were already predominant. So, the government's
getting into the game seems well founded to me.
But did
the government, under the Office of the National Coordinator of
Health IT (known as ONC) screw the pooch in their administration of
the program? To me, unequivocally, yes. They went for
micromanagement of what was “meaningful use” (MU) of the EHRs
that the practices and institutions bought – making sure that they
weren't ripped off, that the government got what it paid for, it
seems. He who pays the piper calls the tune, and the ONC didn't want
to be accused of a giveaway to industry, understandably.
Understandable.
But
what the ONC screwed up was in hitting the wrong notes. What they
should have concentrated on was interoperability, not every little
use modality that took so much effort to document, prone to such
error and inconsistency. What they didn't understand was that
interoperability is the key. They should have mandated that all EHRs
be absolutely interoperable, and then let the smaller details take
care of themselves. This was their cardinal sin. Was it a sin of
ignorance or one of influence? Were they not sophisticated enough
about the usual pathway of progress in free market systems, or were
they influenced by the most powerful pezzonovante in the EHR world,
and the world of medical institutions?
I can't
answer that question because I don't know how the process went. But
we do know that interoperability is technically quite feasible, and
that lack thereof is a political rather than technical issue. And
it's quite clear that the ONC decision to go easy on interoperability
only reinforced the controlling forces in our health care system. I
detailed in a blog post last November why this is so important, as I
described how large organizations have essentially weaponized the
EHR.
http://buddshenkin.blogspot.com/2017/11/weaponizing-ehr.html
Seeking
business dominance by patient and clinician capture, the large
medical centers and enterprise level software manufacturers have
essentially weaponized the EHR by keeping it private and unsharable.
When patient information is available only within an EHR network, the
patient is “nudged” to access only in-network providers and
facilities. Likewise, the externally impenetrable EHR pressures
clinicians to renounce their independence and join the network not
only to defray EHR costs, but also to achieve “featured” status
for referrals on the EHR as the networks “nudge” referrals
inward, and to utilize data in treating patients that they would have
only laborious access to otherwise.
Maintaining
strong EHR boundaries for network commercial advantage is
regrettable. If large networks are to achieve dominance, they should
do so by lowering costs and raising quality, which has been difficult
for them, rather than using the EHR as a cudgel. Closed networks and
closed EHRs provide diminished incentives to improve efficiency and
quality, as services need to be just “good enough” rather than
truly excellent to attract captured patients. A closed system even
presents an ethical problem, since the primary care provider, who is
ethically bound as a medical fiduciary to seek the best and most
efficient referral resource for the patient, is nudged by the system
to respect instead the financial needs of the network.
The search for
root cause leads us inexorably to the organizational
structure of health care. Although you wouldn't know it from
the density of the propaganda cloud emanating from the large
corporate networks, there is a good argument that smaller,
decentralized units strung together by modern communication
capabilities would deliver better and cheaper care than the large
networks. But fighting to remain dominant is typical of economic
behavior in any society. That's what is going on now. For a 2,000
word explanation of this argument, see:
http://buddshenkin.blogspot.com/2017/06/policy-for-emerging-organizational.html
So, to
return to the start and Mass and Fisher's capitulation to WSJ
ideology, what would be the effect of deregulating EHRs?
Unfortunately, deregulation would not lead to interoperability.
Since interoperability would simply give ammunition to the
competitors of the large integrated enterprises, it is likely that
they will be content to keep their systems closed.
What is
needed is not deregulation, but smarter regulation. A legitimate
role of government in our mixed system is to regulate the marketplace
so that competition occurs on a level playing field and benefits
accrue to the public. Smart regulation would recognize Epic as a
dominant platform and regulate it as such, much as the government
regulated Microsoft, another dominant platform. If the government
made interoperability mandatory, and if they were to require the EHR
to display referral opportunities equally, the playing field for
clinicians inside and outside the system would be more level. If
they also mandated that Epic and other platforms be open to module
substitution, EHR competition would be improved. For instance: in
pediatrics we have some EHR programs that work fairly well for us
because they are specifically designed for us. Other specialties
have something similar. If these practices join a big network to
help them gain access to referrals, they must give up their more
functional module and accept the more generic and inferior Epic
module. If plug-in capability were required of the platform, all the
EHRs would be subject to competitive pressure and would improve. It
is even possible that Amazon, Apple and other A-list companies would
enter the field.
That's
it in a nutshell. For a more discursive treatment, check this out
also, my best effort to describe the organizational structure dilemma
facing our system:
But for
the smallest nutshell at all, here is the letter I wrote into the WSJ
and, mirabile dictu, they published it.
