Saturday, June 16, 2012

Electronic Health Records for the Birds for Some Physicians?
One man’s religion is another man’s pigeon.
June 17, 2012 – I have it from  a high health care authorities – two sets of authors in The New England Journal of Medicine – that the Health Information Technology Religion may not be  the carrier pigeon for an improved health care system.
The June 14 edition of the NEJM commences with these two disconcerting messages in their two lead articles.
·         One, from the Children’s Hospital Information’s Program; The Harvard –MIT Division of Health Sciences and Technology, and the Center for Biomedical Informatics, Harvard Medical School.
“It is a widely accepted myth that medicine requires complex, highly-specialized information technology (IT) systems.  This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation – while doctors become increasingly bound to documentation and communications products that are functionally behind those they use in their ‘civilian” life.”
(Kenneth D. Mandy, MD, MPH, and Isaac S, Kohan MD, PhD, “Escaping the HER Trap – The Future of Health IT”

·         Two, from the RAND Corporation, Boston, and Santa Monica, California, and the Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health,
“There is ongoing debate about the wisdom of the $27 billion federal investment driving the adoption of health information technology (IT) under the Health Information Technology and Clinical Health (HITECH) Act of 2009.  Proponents expect IT to catalyze the transformation of health care delivery in the United States from a fragmented cottage industry plagued by poor quality and high costs to a highly organized, integrated system that delivers high quality care efficiency. Skeptics suggest that the productive benefits have been overstated, arguing that is may crate safety probed and could even increase costs.”
(Spencer S. Jones, PhD, Paul S. Heaton, PhD, Robert Rodin, PhD, and Eerie C. Schneider, MD, “Unraveling the IT Productivity Paradox – Lessons from Health Care, “).

Maybe Better Said Elsewhere
Couldn’t have said  it better myself, and at the risk of self-adornment, perhaps I have.
The following article of mine,”Why DoctorsDon’t like Electronic Health Records, “ran in Technology Review, an MIT Press publication, on September 27, 2011.

“Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal "interoperable health information" infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn't had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

I suspect the answer may lay partly in something essayist E. B. White said about humor. "Humor," said White, "can be dissected as a frog can, but the thing dies in the process, and its innards are discouraging to any but the pure scientific mind." Similarly, humanity withers when it is dissected and typed into an EHR. As Jerome Groopman, a Harvard internist, wrote in How Doctors Think, "Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment ... but they quickly fall apart when doctors need to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact."

The computer is oversold as a tool to improve health care, implement reform, cut costs, and empower patients. The reasons are obvious to anyone who treats patients. You cannot look a computer in the eye. You cannot read its body language. You cannot talk to an algorithm. You cannot sympathize or empathize with it.

We physicians are not Luddites or troglodytes. We are savvy about using the Internet, technology applications, and social media. For us, medicine mixes art and science. What we seek from patients are clues, constellations of signs and symptoms, and stories. We choose not to be reduced to data-entry clerks sorting through undigested computer bytes.

A string of numbers containing demographic, laboratory, and other patient information, no matter how systematically assembled or gathered, is not narrative. It does not tell a story. It contains "just the facts," as Sergeant Joe Friday used to say.

That is why an ophthalmologist told me that when he gets an EHR summary, he ignores it: "It does not tell me the patient's story. It does not tell me why the patient is here, what troubles the patient, and what the referring doctor wants me to do."

There are also more mundane reasons why physicians, particularly in small practices, do not cater to EHRs or to their private enthusiasts and government backers. EHRs, you may hear physicians argue:

· are sold by so many companies—more than 100 at present—that no one knows how to separate the good from the bad and survivors from non-survivors.

· slow productivity.

· show negative investment returns.

· don't speak to one another.

· distract from patient time.

· require total reorganization of practices.

· conceal a strategy for monitoring, controlling, and dictating practice activities.

· can be misused or hacked to invade privacy, reveal sensitive information, and threaten the security of patient and doctor alike.

· raise practice costs.

A word on the final point. It is not only the $40,000 that software vendors charge to install an electronic records system and the $10,000 to $15,000 for annual maintenance. It is the hassle factor and the often prohibitive cost of hiring staff to enter the data and to comply with new rules and regulations. When added to the time and effort already required to deal with Medicare, Medicaid, and health insurance plans, EHR requirements are the final straw.

Many doctors are seeking refuge from bureaucratic demands by retiring, closing practices to new Medicare and Medicaid patients, or seeking hospital employment.

This is ironic, since many physicians believe that new apps, such as better speech recognition or systems that translate data into narrative, will make EHRs easier to use. "Free," government-subsidized, or cheaper models will enter the market; clinical algorithms, based on demographic and patient-entered historical information, will make diagnosis, treatment, and management faster and better.

But these features must evolve from below rather than being imposed from above. EHRs won't be useful and physician-friendly until physicians themselves have more input into their design.

The digital revolution, and all the improvements in health care that are promised, will remain promises until the EHR is more useful—in medical and economic terms—for doctors. “

E- Pigeons Coming Home to Roost?
Maybe, just maybe, the pigeons are coming home to roost on the Government’s $27 billion investment in EHRs and kindred data-gathering systems. Maybe  physicians aren’t birds of a feathers destined to  flock together under the  Holy Grail known as  Health Information Technologies .  Maybe the Big Data Religion, a cult that maintains all answers lie in statistics., isn't what it was cracked up to be and cannot live up to its promises.  
It is beginning to dawn that the herculean efforts and expense  required to produce this data impedes human  productivity.     It gets between doctor and patient. It does not   yield  greater convenience, access, quality and lower costs. 

 As Spencer Jones et al say in the second NEJM article, "Studies of the IT productivity paradox suggested that the productivity payoff of an IT investment did not follow quickly but required periods of intensive process reengineering." 

This is code language  saying:  the dream of a national integrated interoperative information system may be an illusion. It is a paradox requiring turning doctor-patient relationships upside down and defying the laws of practice economics.  
Tweet:  Two articles in the New England Journal question whether Health Information Technologies and EHRs yield greater productivity.


Kate Dunkin said...

Thank you for sharing this article on EHR Richard.I have been doing research online on this subject because I have been hearing so much about it. That's how I came across your blog. I found your article very interesting and insightful. I think more doctors need to embrace EHR because the positives outweigh the negatives to me but than again that's just my opinion. Thank you again for sharing!

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