Monday, January 14, 2013

EHR Myth
Myth is the secret opening through which the inexhaustible energies of the cosmos pour into human cultural manifestation.  Religions, philosophies, arts, the social forms of human and historic man, prime discoveries of science and technology, the very dreams of blister sleep, boil up from the  basic, magic  ring of myth.
Joseph Campbell (1904-1987). Author of The Power of Myth
January 14, 2013 -  I was just asked to be on the Laura Ingraham radio show today to talk about electronic health records (EHRs),  but the logistics didn’t work out. 
Nonetheless, the request got me to thinking about the magic of the Health Information Technology Myth, of which EHRs are a powerful manifestation.
The myth is that somehow computers, health information technologies, and clinical algorithms will aggregate data into forms that will lower costs, increase efficiencies,  and seamlessly  interconnect and integrate  patients, doctors, hospitals, health plans,  and government overseers into a more perfectly functioning union.
The myth is that if government can only spend and “invest”  enough money on health information science and technology, it can and will  produce the desired results.   In the $837 billion stimulus act of 2009(The American Recovery and Reinvestment Act of 2009), Congress set aside $22 billion to modernize health care information technologies.
This act no doubt had noble intentions, but as Samuel Johnson (1709-1784) forewarned us, “ The road to hell is paved with good intentions.” And as the subsequent Obamacare legislation in March 2010,  has demonstrated, the road of health reform is paved with adverse consequences and is littered with  unfulfilled promises (lower costs, better outcomes, more access to doctors, assured retention of health plans, fewer uninsured,  and protection against higher costs imposed by avaricious health plans and greedy providers).  
The myth of EHRs is that these electronic systems  would decrease costs by avoiding duplications of services, would tell doctors and hospitals what other doctors and hospitals had done or were doing, would provide concrete evidence separating good providers from the bad,  would be able to track outcomes to establish the best practices with best outcomes, would give government data to reward or punish doctors and hospitals, and above all, would create an “interoperable,” nationwide data-based health information system connecting all citizens for the common good.
They myth sounded too good to be true. How long, people began to ask, was this interoperable system going to take to implement?   After all,  President Bush proposed it in 2004.  Three National Coordinators of HIT Information had pushed it.  CMS and the Obama administration were solidly behind it. National organizations, RAND,  GE,  Cerner, and medical organizations had embraced it.  Nearly 300 EHR companies had gathered at the $22 billion federal HIT trough.  And government upped the EHR ante by promising to pay each physician over $43,000 for Medicare use and $52,000 for Medicaid use if the physicians would comply with meaningful use EHR criteria.
Despite the government hype and largesse, doubts began to surface about the practicality of a universal interoperable HIT system.    
·         In his 2007 book, How Doctors Think,  Jerome Groopman, MD, a Harvard professor on internal medicine,  said EHRs and clinical algorithms forced doctors to think inside the data box and discouraged out-of-the-box independent and creative thinking.  

·         The editor of Technology Review (MIT Press),   asked me to write an article on why doctors were so slow to adopt EHRs. It appeared on September 27, 2011 “Why Physicians Don’t Like Medical Records.” I  gave these reasons for slow adoption : EHRs slowed productivity by 30% or more, yielded a low return on investment, didn’t communicate with one another, distracted from time with patients, often  required total reorganization of practices;  concealed federal strategies of monitoring, controlling, and rewarding physicians who veered from government reform thinking; invaded patient and doctor confidentially and privacy;  was  not guaranteed to be secure from hackers, employers, or competitors ;  had no clear indications of how the data was to be used or who would use it;  EHR installation and maintenance significantly raised practice costs; EHRs had no narrative power, you could not dictate into them and they did not tell a story; and threatened to demean physicians by turning them into government data entry clerks and serfs.
I was not alone. 
·         The Wall Street Journal Health Blog of April 17,2010 entitled “Survey: Patients May Lie if Electronic Records are Shared, “ indicating nearly half of patients would lie if EHR data was shared with outside organizations. 

·         In July of 2011,   Miss Krasner, a founding member of Google Health, announced Google has decided to shut down its Personal Health Records Project.   

·         On December 30, 2012, Steve Lohr of The New York Times, wrote
  The limits and shortcomings of Big Data technology are building. Listening to the data is important, but so is experience and intuition. After all, what is information at its best but large amounts of data of all kinds filtered through the human brain rather than a math model?”
Steve Lohr, “Sure, Big Data is Great, But So Is intuition,” New York Times, December 30, 2012
None of these comments mean EHRs are dead or dying, but they do put EHRs in perspective.  EHRs can be useful tools,  especially in large organizations like Kaiser, large hospital systems, and academic medical centers,  but they are not the end-all and be-all of health reform.  In my opinion,their use should be optional and not mandatory; patients should be told how the data will be used; and their use should not pre-empt,  trump, and diminish clinical intuition and experience.

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