Wednesday, April 22, 2009

Electronic Health Records; Pouring $19 Billion Down a Rat Hole?

Even a booster of electronic systems like David Blumenthal, who just started his Washington post as the national coordinator of health IT, points to the myriad of challenges when it comes to digitizing the nation’s medical records.

Sarah Rubenstein, “Are Electronic Health Records Worth The Risks?” Wall Street Journal Health Blog, April 21, 2009

Sometimes you grow so enamored with an idea that you think you can override all barriers. Such is the case with digitizing medical records and having all doctors and hospital data integrated into one massive national electronic health record.
The benefits, we are told, are enormous.

1) Less paperwork for doctors and staff.

2) Tracking prevention, surgical successes, medical morbidity and mortality, and performance of doctors and hospitals.

3) Outcomes research to see what works.

4) Facilitating sending of safe prescriptions to pharmacies.

5) Identifying national security threats.

6) Allowing interstate portability of medical data.

7) Permitting nationwide epidemiological, environmental, and pharmaceutical research.

8) Achieving more efficient, safer, and higher quality care.

9) In short, everything that government had ever wanted to know but has been unable to access.

If you doubt the enormity of these benefits, I invite you to read two recent New England Journal of Medicine pieces: “Stimulating the Adoption of Health Information Technology,” April 9, and “Use of Electronic Health Records in U.S. Hospitals,” April 16.

The only trouble with those who gush about e-health benefits are these:

1) Despite at least five years of government pushing for EMRs, only 1.5 % of hospitals and 4.0% of physician practices have “fully functioning” EMRs, and 10% of hospital and 17% of doctors have even partial EMRs.

2) When it comes down to it, HIT (Health Information Technology) is still only a record for health and medical trackers, not a useful guide for practicing medicine; EMRs are about documenting not doctoring.

3) As these records now stand, with their numerous variations, most systems don’t even talk to one another; an EMR functioning in isolation, said one doctor, is nothing but a giant invoice, and useless as a tool for communication.

4) Independent doc torso resists EMRs for good reasons: most systems are not up to prime time, i.e., as useful, doctor-friendly tools, and they cost a lot with no return on investment.

5) Government, i.e., Medicare payments for “meaningful use” or “certified” EMRs”, is relying on money, up to $44,000 for doctors for 5 years, and $2 million to hospitals plus an add-on fee based on DRGs, to move doctors to use with penalties for non-use: doctors do not necessarily accept Medicare as the gold standard, dislike being bought, and may drop out of Medicare, as 30% already do, rather than use EMRs.

6) Government subsidizing of widespread use of EMRs, with rewards for use, in Great Britain have not lived up to expectations. Here is that story, as told by Greg Scandlen Director for Health Care Choices, in “Research & Commentary: Health Information Technology,

“As part of the federal government's economic stimulus package, Congress has authorized spending about $20 billion on health information technology (health IT) and another $1 billion on comparative effectiveness research. These provisions achieved wide bipartisan support in Congress and in the health care industry, based on the hope that the investment will help improve efficiency, cut costs, and result in better care. The reality is likely to be far different.”

“Proponents of this spending rely heavily on a short RAND Corporation analysis from 2005 that predicted $77 billion in annual savings and improved outcomes. RAND estimated "implementation would cost around $8 billion per year, assuming adoption by 90 percent of hospitals and doctors’ offices over 15 years." It said, "The benefits can include dramatic efficiency savings, greatly increased safety, and health benefits."

“Unfortunately, RAND assumed an error-free system that’s quickly and enthusiastically adopted by virtually the entire health care system. That might happen, but it’s an absolute best-case scenario. Even then, instead of "dramatic savings," the $77 billion hoped-for savings amounted to a mere 4.5 percent of total costs, placed at $1.7 trillion by RAND.”

“Far more likely is that every penny of the $20 billion will be wasted on systems that don't work and can never be implemented. That was the outcome of federal attempts to upgrade technology at the IRS, the FBI, and the air traffic control system. And these are all relatively simple enterprises involving single federal agencies. Health it’s vastly more complex and must include hundreds of thousands of private organizations that have invested in legacy systems that work reasonably well and are as varied as there are providers.”

“This also has been the experience of the United Kingdom, which has been trying to adopt a similar information technology upgrade for its National Health Service (NHS) since 2002. This plan was far less ambitious than the U.S. version, involving merely 30,000 physicians and 300 hospitals, all of whom are already employed by the NHS. Originally estimated to cost 2.3 billion pounds, it’s already at 12.7 billion pounds--$18.4 billion, or about as much as provided in the stimulus package for the entire United States. A recent report to Parliament admitted the program is four to five years late and may never be implemented as envisioned. The project has lost two of the four vendors who were working on it, and some of the elements that have been installed aren’t meeting expectations.”

“This is not to say health IT’s a bad idea or that hopes for it are unwarranted. Quite the opposite. The health care system sorely needs better management tools and better application of technology. There’s currently a vast amount of entrepreneurial energy, innovation, and money being invested in developing, refining, and marketing the tools the system needs to come into the twenty-first century.”

“The danger is that massive federal intrusion will bring all that innovation to a screeching halt. Systems work best when they’re developed from the ground up, not imposed from on high. In ground-up development, flaws can be detected and eliminated without much system wide damage. Poor vendors can be removed without disruption to the whole system.”

“We don’t yet know what the optimal system will be. Imposing federal standards on health IT in 2009 means the entire system will be locked in to those standards for very long time to come and innovation will not be rewarded.”

“The RAND study said "market forces" are an obstacle to health IT. Just the opposite is true. The market is the best way to test and refine new ideas. The process of repeated testing and refinement may seem slow to people who want instant solutions and shortcuts, but the failure to engage in that process often results in massive mistakes and wasted billions.”

Maybe, just maybe, nationalized electronic medical records are too good to be true.

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