Wednesday, February 9, 2011

Health Reform No-No’s, The Case of EHRs

Health policy folks have decided to get tough with their language. In the winter issue of the Health Policy Newsletter, produced under the auspices of the Jefferson Medical College and the Jefferson School of Population Health, an editorial appears entitled “No Outcome, No Income, CMS’s, ‘Meaningful Use’ Initiative.”

The editorial explains,

“For all involved, the embrace of meaningful use represents no less than a turning point in thinking about what we pay for in health care. Phrased in the language of quality, it can be summarized as ‘no outcome, no income.’ In other words, this program is not simply about purchasing hardware and computerizing medical records. Instead, policy makers view EHRs as the core of an emerging HIT infrastructure, which has the potential to improve the nation’s health care system and the health of Americans.”

A comment, if I may.

Language is important. “No outcome, no income” sounds like a threat. In other words, if you physicians don’t play ball with the government, we will not pay you for Medicare and Medicaid patients.

Coupling the heavy hand of government with the heavy use of language is not likely to gain friends and influence physicians. Instead, it is likely to induce paranoia among physicians, who are already chafing under the weight of complying with heavy government regulations. They may well opt out, rather than opt in.

Besides, physicians are still far from persuaded that EHRs improve “quality.” As defined by government, “quality” has come to mean “value, “ or outcomes/cost. “Quality,” in the eyes of government experts, means collecting massive amounts of data on outcomes from large populations of patients and then dividing costs spent on care.

“No outcomes, no income” may not be practical, doable, or desirable. At least, that's what many physicians think, and that's how they behave. After all, in the U.S. only 4% of physicians in ambulatory practice and 1.5% of hospitals have fully functional EMRs (New England Journal of Medicine,volume 359, pages 50 to 60, 2008, and volume 360, pages 1628 to 1638, 2009).

Frustrated by efforts to move “interoperable” EHRs across the national board and off the dime, government is now saying if physicians and hospitals meet 25 or so “meaningful use criteria”, they will qualify for incentive payments – up to $44,000 for Medicare physicians, $63,740 for Medicaid physicians, and millions for hospitals.

Sorry, wonks, but no cigar.

EHRs take $30,000 to $40,000 to install, $10,000 to $15,000 a year to maintain, and cut productivity, i.e., time spent with patients, about 30%. Time spent with patients is what doctors were trained for and where the money comes from to continue practice.

If those conditions are not met, it's no deal. In the words of a Catholic nun who ran a large hospital system, “No margin, no mission.” If physicians are going to lose money implementing EHRs while shouldering non-profitable paperwork burdens, they are unlikely to succumb to government bribes. Instead, they are more likely to absorb the 2% penalty for not installing EHRs, or to retreat into concierge practices, and to not see new Medicare or Medicaid patients.

Meeting regulations from third parties accounts for about 50% of overhead, calls for doctors to act as entry clerks, or to employ clerical personnel, distracts from time spent with patients.

Physicians may conclude, “ No government margin, no government mission.”

Richard L. Reece, MD, blogs a Medinnovation and has a website under constuction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with but does not speak for The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at


BobbyG said...

'Language is important. “No outcome, no income” sounds like a threat.'

No, it sounds more like the Free Market Uber Alles Economics 101 you otherwise take such great repetitive delight in exhorting.

Richard L. Reece, MD said...

I don't understand your gist. If you're saying I'm for bottom-up entrepreneurship rather than top-down regulations and control. you're absolutely correct. Government is the problem not the solution.


Richard, as a patient I like EHRs. Most of my many docs are associated with Barnes Jewish here in St Louis. They all can go to their computers while I am with them to see comments, lab test results, other pertinent entries by my other docs. I suspect the letters I receive from them after my visits and with test results are made much easier by the EHRs (the picture of my colon after the colonoscopy is especially exciting--ha). My eye docs at St Louis Univ Eye Center, to whom I was referred by my neighborhood eye center, must rely on information in a folder that is at least three inches thick. And Friday I'm to visit an oral surgeon who is affiliated with another hospital chain and to whom I was referred by my dentist. I'm thinking it would be nicer to hv my records on one system as a joint effort of the three systems. That's probably a long time from now, however.

FRIEND TOM HARDIN again said...

Oh, Yeah. I forgot to mention your comment abt government being the problem, not the solution, is repeated so many times by you and the GOP pols it is becoming pretty trite.

Richard L. Reece, MD said...

Tom, thank you so much for your comments. I'm glad you like EHRs. They seem to work with large organizations, but not for small practices. As for government being the problem as "trite," there is an element of truth in that. The comment dates back to Reagan who is now not considered to have been a "trite" president. The problem is that a benevolent, paternalistic government supplying all of our needs is too expensive. too inefficient, and too intrusive. Maybe there is a "common ground." I certainly hope so.

Gary M. Levin said...

The collection of lab results, imaging reports, delivered to the doctor while he is seeing the patient is about the only good thing about EMRs.