Electronic Health Records: Should Congress “Defund” the Stampede to Convert to EHRs? No, But . . .

Health care information technology [HIT] “is not ready” warns Dr. Scot Silverstein, a clinical IT expert on the faculty at Drexel University’s College of Information Science and Technology. Writing on Roy Poses’ Health Care Renewal at the end of last week, Silverstein argued that Health IT “is dangerous in unqualified hands, which most every medical center and physician office is in 2011 (i.e., an IT backwater).

“The field of health IT [has] somehow [been] transformed from an experimental field into the 'savior of medicine’” Silverstein added, “without the proof of value and safety that would ordinarily be required to move an experimental technology from lab to national rollout. Per the Washington Post, this process appears to have been a highly politicized one, favoring the corporate elites. The Washington Post’s 2009 article on the influential HIT vendor lobby ‘The Machinery behind Healthcare Reform’ is at this link.”

Set Silverstein’s words side by side with what software expert Dan Fornes had to say on The Health Care Blog yesterday, where he reported that vendors selling health care software are “spending like crazy,” and a larger picture begins to emerge.

Fornes, founder of the “Software Advice” blog, is considerably more enthusiastic about the current state of Health Care IT than Silverstein. Nevertheless, Fornes points out that the market has been moving at warp speed. (Apologies for a anachronistic metaphor from the hi-tech explosion 1990s. But sometimes it is helpful to realize that we have seen a phenomena before.)

“Most software markets evolve over a twenty or thirty-year period,” Fornes writes. “Consider the enterprise resource planning (ERP) market: the first ERP vendors were founded in the early 1970s, but rapid growth and innovation continued until about the year 2000. The [Electronic Health Record] EHR market, however, will mature in the next five years. This is because healthcare providers are buying EHR systems sooner than they otherwise would, to make the most of massive federal subsidies and avoid penalties. Consequently, EHR vendors are in a mad rush to gain market share.”  (See this HealthBeat post on “Irrational Exuberance Over Electronic Medical Records.”)

When he speaks of “massive federal subsidies,” Fornes is referring to the $27 billion that Medicare and Medicaid is giving out under the Health Information Technology for Economic and Clinical Health (HITECH) portion of the American Recovery and Reinvestment Act (ARRA) of 2009. The HITECH program began this year. A doctor who adopts electronic health records (EHRS) can receive up to $44,000 under Medicare and $63,750 under Medicaid, while a hospital can receive millions of dollars, depending on its size. (In just four years, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.)

Vendors “that win will own a massive customer base paying recurring support fees,” Fornes explained. “Those that lose will become irrelevant from a market share standpoint and will be ingested into a larger vendor (if they’re lucky; some will just go broke). As a result, EHR vendors are increasing their R&D budgets to develop new features and meet meaningful use criteria. Their marketing colleagues are spending heavily on demand generation and brand building. These vendors have no choice but to win today’s market share battle.”

Fornes is primarily worried about what the mad dash for customers will mean for vendors; the weakest will be trampled underfoot. But he also worries about the customers faced with too many choices: “The EHR and practice management markets have always been highly fragmented into hundreds of software vendors, largely as a result of the need to service small and demanding local practices.  . . . It’s tough for providers to assess the financial viability of private EHR vendors. Software Advice offers our Guide to Assessing Medical Software Vendor Viability, but the industry really needs a trusted third-party to evaluate the 400 plus vendors.

“Organizations like CCHIT, InfoGard and ICSA Labs are all certifying EHRs against functional criteria. However, buyers also need the equivalent of an A.M. Best or Moody’s to rate the financial health of EHR vendors. .  . buyers must be careful not to become collateral damage as the fierce battle for market share plays out. It’s important to determine which vendors are closing business, growing their revenue and building a sustainable, profitable business. Providers should keep in mind that their success is tied to the success of the software vendor that will enhance and support their EHR system in years to come.”

Too Many Buyers, Too Many Sellers, Too Little Information

I am hardly an IT expert. But I have spent enough years observing markets—stock markets, real estate markets, and most recently, our health care market—to recognize a big, bright Bubble when I see one. Eager to take advantage of fat federal subsidies, too many buyers, with too little information, are scrambling to purchase health IT.  And, as is always the case, too many sellers are all too eager to satisfy the buyer’s desire to part with his money.

But many vendors won’t have the resources to follow through on the services and training that they promise. Or, they will be too busy chasing the next customer to meet their commitments. More importantly, the majority of HIT vendors cannot fathom what it’s like to work in an ER or a busy primary care office, and so they cannot begin to grasp precisely what doctors and nurses need.

Let me be clear. I understand that we need health care information technology. (I wrote about how important electronic health records can be to patients earlier this year.) Premiere health care organizations in the U.S.—including the VA, Kaiser and the Mayo Clinic—have demonstrated how valuable Health IT can be. But in each case, developing health care IT required fortitude, time, and top-down planning.  Even then, there were serious and sometimes hugely expensive glitches along the way.

Yet when it comes to spreading Health IT nationwide, we have decided to “let the market decide” which products doctors and hospitals should buy as we try to speed up the roll-out of healthcare IT nationwide. The result?  Laissez-faire chaos.

No doubt some physicians and hospitals are making wise decisions, but this is hardly a transparent market.  Those who support rapid conversion to electronic health records point out that the money in the HITECH Act “lit a fire” under health IT. This is precisely what worries me. In any market, a bonfire of cash creates a dangerous stimulus.

I think Fornes is on the right track when he suggests that “the industry really needs a trusted third-party to evaluate the 400 plus vendors.” But I have to object when he names Moody’s as a model. During recent bubbles, Moody’s has not covered itself with glory. We need a truly independent private sector or quasi government agency, a group like FASB (the Financial Accounting Standards Board) which has shown courage and integrity in a number of cases when the political pressure was intense. (I wrote about FASB in Bull).

Ideally, any third-party board sorting out health IT solutions would be made up of physicians and nurses who are IT experts. (They do exist.) Experienced professionals could then identify those products which would be most practical for a small physician’s practice, a large hospital, an ER . . . .   Interoperability is, of course, key.Yet vendors don’t always take that into account. I can think of at least one brand-name hospital in Manhattan that has IT in its ER that doesn’t talk to the IT in the rest of the hospital. How could a hospital possibly buy technology for the ER that isn’t compatible with the IT they’re using elsewhere?

They didn’t buy it. The system was “sold” to them. In theory, Health IT consultants steer providers away from impractical decisions. But even conscientious consultants add another layer of costs to health care. And, as any shrewd businessman will tell you, too often, the value that consultants bring to the table is not equal to the price that they charge. When it comes to healthcare reform, we just cannot afford to let middle-men boost costs.

                “Defunding” Electronic Health Records

Returning to Silverstein’s post, Friday he reported on  a new bill in the House of Representatives, the ‘‘Spending Reduction Act of 2011’’ that would call a halt to government subsidies for health care IT by “defunding” HITECH.   (Note: we’re not talking about defunding part of the Patient Protection and Affordable Care Act signed by President Obama last spring. The money for HIT is part of the financial stimulus package of 2009.)

“It looks like HITECH is one of a number of spending extravaganzas now on the proposed chopping block,” Silverstein wrote, adding: “I can't be too sorry about this.”

He argues that “this country cannot afford HITECH at this time. The money would be far better spent at this time on care of those who cannot afford it. HITECH appeared as if out of nowhere,” Silverstein observes, “with little to no input time from stakeholders. This suggests lobbying by those with conflicts of interest to push this bill onto the public, affecting their medical care without informed consent (see Silvestein’s March 2009 post "Draft Patient Rights Statement and Informed Consent on Use of HIT").

This is why Silverstein says “I would not weep for the HITECH act's passing. It would allow the restoration of health IT back to an unrushed and careful endeavor. It would also give time to work out the significant issues causing health IT difficulty (such as raised in 2009 by our National Research Council) before we embark on national diffusion.

“In other words, its passing would reduce risk and help restore an essential level of sanity and due diligence to the healthcare IT sector, now afflicted by irrational exuberance bordering on delirium.”

I greatly appreciate Silverstein’s unflagging commitment to warning us that Heath IT is not ready for prime-time. Yet, I wouldn’t want to see HITECH lose its funding. It would be too hard to get that money back, and ultimately health care providers will need subsidies in order to purchase this much-needed technology. More to the point, it is extremely unlikely that this House bill will ever become law. Even if it made it through the Senate, President Obama would veto it.

That said, I definitely would like to see the process of adopting HIT slow and perhaps the House bill will generate a conversation about the mad rush to fund EHRs.  Ideally, Congress would postpone the 2015 deadline when doctors and hospitals will  be required  to pay penalties if they don’t have electronic health records in place. This would give the government time to set up a third-party board made up of health care providers who are successfully using HIT, and have no financial stake in the industry. Meanwhile, buyers would have time to do due diligence before making decisions. At the same time, the government could stretch out EHR funding, distributing HITECH money over the next six to eight years.

“Free market competition” may have worked well when it came to bringing IT to banking. But medicine is far more complicated. And in the health care marketplace, most buyers are not IT experts. Even worse, the sellers themselves are often in over their heads; they truly don’t understand the needs of the health care marketplace, or the products that they are touting. They are surprised by the glitches that their customers experience.

The more I think about it, the more I am reminded me of the bull market of the 1990s. Then, as now, neither buyers nor the analysts, brokers and financial planners who sold them stocks possessed the knowledge that they needed. “Momentum” was all as the pace of investing quickened. As for the “collateral damage”—our economy is still recovering from the 1990s.

 

59 thoughts on “Electronic Health Records: Should Congress “Defund” the Stampede to Convert to EHRs? No, But . . .

  1. HIT cannot be looked at in a vacuum. HIT does not alone improve healthcare delivery in the areas of safety, quality, access, or cost. It is how the technology is deployed that matters. Vendors are not experts in this as their incentives are to deploy as quickly as possible to be able to recognize revenue for shareholders and investors. CIOs and other hospital senior staff often do not understand the nuances of healthcare delivery nor place CMOs, CMIOs, CNOs, CNIOs and others in positions of effective leadership to drive the innovations necessary for effective HIT deployment. Finally, the overarching problems inherent in our healthcare reimbursement system with its perverse incentives, often prevents HIT from being deployed in a way that can truly improve both clinical and financial outcomes. So, HITECH should not be defunded. Us leaders in HIT must expand our focus away from “meaningful use.” We must create a vision of what we want HIT to do in delivering healthcare, and put ,in place the delivery reforms, work toward the reimbursement reforms, and create the innovative clinical workflows that can achieve the benefits of HIT.

  2. Having worked with electronic record systems from two different vendors, I have to say that I think that electronic record systems are ready and able to be useful.
    There are two problems with electronic record systems, one real and one not.
    There needs to be a uniform national standard so that all EHR’s can exchange information transparently. This is by no means an insurmountable problem. The internet itself is an example of a system that allows transfer of information from many different source programs without any major glitches, and in health care the diagnostic radiology profession has been able to create an environment allowing different systems to communicate with each other, including systems with much greater information density than typical of EHR’s. This has been accomplished in the first case by creating an international standard that vendors had to comply with to be viable, and in the second case by fiat requiring that all vendors by able to comply with standards for communication.
    The second problem is imaginary — that doctors and other health professionals find EHR systems to be “too hard” to learn and comply with. Experience in many large health care systems has shown that doctors and others can learn to comply after a short learning curve and that after a little longer time — six months or so — people not only can comply with the requirments for operation but actually prefer the EHR to their old ways of doing things. As one resistor in my own old practice told me, “When this started I couldn’t imagine that I would ever be able to use the system comfortably and without a lot of lost time. Now I can’t imagine ever going back.”
    Someone, perhaps the government through Medicare, needs to force vendors into line in order to have uniform information exchange compatibility. Otherwise, the systems are ready to go. The benefits of being able to exchange and recover patient information wherever patients may go far outway the costs in the long run, both in terms of better quality of care and in terms of eventual savings due to information that prevents duplication of tests and procedures and costly injuries to patients due to lack of information about past history.

  3. I don’t take issue with this post, but I think it provides an opportunity for reflection.
    Here we have a lament about doctors and hospitals being thrown to the laissez-faire wolves of the free market.
    Surely some all wise, all knowing third party should step in to sort the wheat from the chaff and provide reliable advice to our health care professionals, so they won’t be burdened by having to choose for themselves among competing claims regarding a technology about which they know little or nothing. Why should they be required to educate themselves, so that they can become informed consumers?
    But I hear from doctors and hospitals and insurance companies all the time that patients should now consider themselves consumers, and educate themselves about the intricacies of medical science and technology, and drugs, so that they can make informed choices about their own health care. I don’t recall ever hearing a physician or a hospital administrator call for “a truly independent private sector or quasi government agency” to mediate between health care providers and health care consumers.
    I wonder, why not?

  4. As a small practice provider, I can tell you that it is indeed a daunting prospect to think about attemptiong to choose and implement this technology in its present state. While the idea of incentives in HITECH are enticing, they do not begin to cover the cost of implementation and initial loss of productivity. How does the goverment expect primary care docs living at the lower end of the physician food chain to give up 25% of their income while spending another 50K for the software and hardware, while hoping that your practice doesn’t go under during the transition?
    On top of this, we are starting to see studies being produced that suggest there is no effect on quality of care proven by any of these software packages! Is this not why our goverment has been pushing EMRs but to provide better quality care? Is it indeed better for me to invest untold hours learning to adapt to an EMR or to spend that time listening and caring for my patients?
    EMR producers have attempted to rush physicians into deals by claiming they need to get in line quickly to get installed and up and running. Otherwise, with the deadline on qualifying for HITECH dollars, they may have to take a number and may not get taken care of in time.
    Sounds like the used car dealer who tells you this is a once in a lifetime opportunity that won’t be availible tomorrow unless you sign on the dotted line today.
    We need to slow this process down, do some solid research on what these systems do and don’t do for our healthcare system, and let these products develop, and the market shake out those that will not survive for long. What is the big rush anyways? HITECH is distorting the market and may actually be adding to the cost of these systems by allowing EMR companies to price their product at a higher price, as long as the cost of software, hardware, and training is less than the 44 grand carrot per MD the goverment is dangling in front of us. The goverment needs to reassess what it is doing to the small practices in this country with all these regulations they are adding on, unless their goal is to make things so complicated that we need to join large healthcare systems. After all, we are small businesses that supposedly the goverment is trying to encourage to grow.

  5. I am NOT a health IT expert. But having read much by Dr. Scot Siverstein I would listen VERY carefully to what he has to say on the matter.
    Thanks,
    Dr. Rick Lippin
    Southampton,Pa

  6. I’m with Keith.
    I’ve used a variety of electronic documentations systems as I’ve worked all over the country. Each is different, each is proprietary, NONE impressed me.
    Some ask nurses to go through multiple screens just to document vital signs.
    The GUI’s on others are downright ugly, and hard to read.
    The printouts are very difficult to read. It is sometimes hard for key information to be conveyed in such a way that it is prominent and easy to find.
    I’d almost rather use Word and have providers type narrative notes.

  7. Dr. Siverstein is a HIT expert. I would take his suggestions over those who are not.
    If we are getting the money out of medicine, I think we’d best get the money out of HIT as well.
    Most of the large HIT providers, those who benefit the most from HITECH, provide ancient technology. In effect HITECH allows them to continue to profit from outdated stuff and by their size allows the large HIT vendors to stave off competition from innovative small business.
    So if the intent of the legislation was in part to spur development, it has had the opposite effect.
    I’d suggest that we should not stay with a bad thing just because it is already law. I do think that there is a place for government in HIT, and that is to set and enforce standards for interoperability and data transmission between HIT systems.
    This was the thrust of the most recent PCAST report on HIT. So apparently more experts than Scot believe the same thing.
    In a larger context, there is a rise, run and fall to almost every business application vendor. This has (and is) happening in manufacturing, banking, etc etc. and we shouldn’t try to change the natural progression of IT in healthcare because, simply, it will not work well.

  8. An additional consideration to ending the stampede is increased risk and patient harm from ill-designed and implemented health IT. Example, see here: http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html
    My own mother was nearly killed in May 2010 as a result of poor HIT.
    A short reading list for those so inclined:
    – Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Sharona Hoffman and Andy Podgurski. Harvard Journal of Law & Technology 2008 vol. 22, No. 1
    – E-Health Hazards: Provider Liability and Electronic Health Record Systems. Sharona Hoffman and Andy Podgurski. Berkeley Technology Law Journal (2010). Followup paper on EHR medical and legal risks. This article is a first of its kind, a comprehensive analysis of the liability risks associated with use of clinical IT. The authors point out that the potential benefits of computerization could be substantial, but EHR systems also give rise to new liability risks for health care providers that have received little attention in the legal literature.
    – Meaningful Use and Certification of Health Information Technology: What About Safety? Sharona Hoffman and Andy Podgurski. Case Research Paper Series in Legal Studies Working Paper 2010-34, October 2010.
    – Emerging Trends in Electronic Health Record Liability. Chad P. Brouillard. For the Defense, July 2010 (Defense Research Institute).
    – Electronic Health Records: Recognizing and Managing the Risks. ClaimsRx: Clinical and Risk Management Perspectives. NORCAL Mutual Insurance Company, Oct. 2009.
    – Litigation in the Decade of Electronic Health Records. Joel B. Korin and Madelyn S. Quattrone. New Jersey Law Journal, June 11, 2007.
    – Health information technology: fallacies and sober realities. Karsh et al. (Oct. 2010). JAMIA 2010 17: 617-623.
    – Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force. Goodman et al. JAMIA doi:10.1136/jamia.2010.008946. Nov. 2010.
    – Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties (educational website). Scot Silverstein, MD, Drexel University College of Information Science and Technology http://www.ischool.drexel.edu/faculty/ssilverstein/cases/
    – Healthcare Renewal blog: http://hcrenewal.blogspot.com. I write on healthcare IT issues at this multi author website.
    – Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop. Journal of the American Medical Informatics Association. Bonnie Kaplan and Kimberly D. Harris-Salamone.
    – Joint Commission: Sentinel Events Alert on HIT, Dec. 2008.
    – National Research Council report. Current Approaches to U.S. Healthcare Information Technology are Insufficient. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, Jan. 2009
    – The National Programme for IT in the NHS: Progress since 2006, Public Accounts Committee, January 2009. Summary points here.
    – Health Care Information Technology Vendors’ “Hold Harmless” Clause – Implications for Patients and Clinicians, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009; 301(12):1276-1278
    – Failure to Provide Clinicians Useful IT Systems: Opportunities to Leapfrog Current Technologies, Ball et al., Methods Inf Med 2008; 47: 4–7,
    – IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans’ Medical Centers, JAMA Mar. 4, 2009, p. 919-920.
    – Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System, Han et al., Pediatrics Vol. 116 No. 6 December 2005, pp. 1506-1512
    – Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Ross Koppel, PhD, et al, Journal of thae American Medical Association, 2005;293:1197-1203
    – Hiding in Plain SIght: What Koppel et al. tell us about healthcare IT. Christopher Nemeth, Richard Cook. Journal of Biomedical Informatics. 38 (4): 262-3.
    – Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes and Threats to Patient Safety, Koppel, Wetterneck, Telles & Karsh, JAMIA 2008;15:408-423
    – The Computer Will See You Now, New York Times, Armstrong-Coben, March 5, 2009,
    – Bad Health Informatics Can Kill. Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI).
    – Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167:1400-1405
    – “Dutch nationwide EHR postponed: Are they in good company?”, ICMCC.org, Jan. 24, 2009
    – “The failure rates of EMR implementations are also consistently high at close to 50%”, from Proceedings of the 11th International Symposium on Health Information Management Research – iSHIMR 2006
    – Adverse Effects of Information Technology in Healthcare. This knowledge center presents a collection of information on the adverse effects of information technology in its application to healthcare. It also references sources of information on information security, and related media reports.
    – Pessimism, Computer Failure, and Information Systems Development in the Public Sector. Shaun Goldfinch, University of Otago, New Zealand, Public Administration Review 67;5:917-929, Sept/Oct. 2007
    – Hospital Computing and the Costs and Quality of Care: A National Study. Himmelstein. Wright, Woolhandler. The American Journal of Medicine, Volume 123, Issue 1 , Pages 40-46, January 2010.
    – Information Technology: Not a Cure for the High Cost of Health Care: Knowledge@Wharton, June 10, 2009.

  9. Barry Chaiken, Pat S. Red Planet . .
    Barry C.– Yes, it’s all about how the technologoy is used. And perverse incentives can prevent it from begin deployed in a way that would truly improve both clinical and financial outcomes.
    As you say, we need to move beyond “meaingful use” to something subtler–that takes the nuances of health care delivery into account.
    Pat S.
    I agree that we must insist on interoperatiblity. (Unfortunately, this administration does not seem willing or ready to “force vendors into line.”
    So vendors are selling what is good for vendors (the most profitable systems.)
    But there are other problems.
    I know that you have worked at a large insitution that has one of the very best–if not the best– IT system in the coutry.
    That health center created its own system. They were not “sold” by a vendor. Their system was created by doctors for doctors. It is suited to the context where it is being used. It is user friendly.
    And yes, a doctor could easily learn it in six months.
    It is also totally atypical of much of the Health IT and EHRs out there.
    Most hospitals and doctors buy systems “sold” to them by a for-profit company and often the result is a system that does not fit their work-flow. Some of these EHRs actually increase errors, hurting and even killing patients.
    (See Scott Silverstein’s list of articles above.)
    Even Kaiser Permanente had to dump its IT system and start over because the original system was, in some ways, a lemon.
    Cedars Sinai had to scrap its hugely expensive system. (There, part of the problem is that doctors who had privileges at the hospital but didn’t work at the hospital were unwilling to learn the system. But I’m also told that it had serious flaws.)
    As for small and medium sized doctors’ practices– they are extremely vulnerable to being sold something that is extraordinairly difficult to use– and doesn’t meet their needs.
    You raise a very interesting point about the Internet. But it’s worth keeping in mind that the INternet was not created by for-profit companies trying to make as much money as possible while Competing with each other.
    It was created by people in the academic community Collaborating with each other so that they could share information with each other. They would not charge each other for that information. They just wanted a free flow of information. This is why, to this day, the web is seamless and most of the information free.
    I agree– is what HIT should be. If there was just one software vednor, and the CEO was Al Gore, it might be.
    But we are not going to get there as long as for-profit companies are competing for market share, and as long as some hospitals see Health IT as a way to hold onto “their” customers. (Some hosptials go so far as to refuse to share EHRs on their patients with other hospitals.)
    Red Planet–
    Those who refer to patients as “consumers” are doing patients–and medicine– a great disservice.
    As any good health care economist will tell you (going back to Kenneth Arrow, the father of health care eocnomics) health care is not a commodity that we consume, and the patient is not in a position to shop, compare and pick out the bset product (except in those cases where he is looking for something very simple–i.e. eyeglass frames.)
    Medicine is extremely complication,and as Arrow pointed out, the buyer (the patient) will never have the information that the seller (the docotr) possesses–not just by virtue of having gone to med school, but by virtue of the physicians’ experience in seeing many diffirent patients. Much of what an experienced doctor knows is hard to articulate–it’s intuitive knowledge . .
    This is why the doctor must be a professional who puts his patients’ interest ahead of his own. Otherwise, it would be too easy to “sell” the patient whatever would be most convenient or profitable for hte doctor.
    Patients need to be able to trust their doctors–this is a world where “caveat emptor” cannot apply.
    “Consumer-driven” medicine is a fiction. Consumers are not in a position to drive down costs or lift the quality of care. Most of our heatlh care dollars are spent when we are very sick, often suffering from more than one chronic disease.
    Patient-centered medicine is different– it calls for “shared decisoin-making” with doctor and patient, together, making decision, based on what the doctor knows and explains to the patient about the pluses and minuses of various treatments, and based on what the patient knows about himself, his fears and his desires.
    Shared decisioin-making does not assume that the patient becomes a medical expert.
    Similarly, we should not assume that doctors shoudl become IT experts.
    They,too need someone who they can trust, recommending the least expernsive product that will provide the greatest benefit to them and their patients.
    The whole notion that laymen should become “experts” in fields that they don’t know reminds me of the Big Lie of the 1990s–that we all could and should become our own money managers, picking stocks and mutual funds.
    Most people don’t have the time, the knowledge, the ewxperience or the native talents that great professional money managere possess. (The treat ones are those that survive and do well in bear markets as well as bull markets–who know how to invest, not just in stocks, but in bonds, commodities, foreign equities, real estate, as appropriate. They possess a world of knowledge that most of us aren’t going to obtain by spending 2 or 3 hours a week online.

  10. Maggie,
    The problem with national interoperable EMR’s may be that having them is incompatible with medical information privacy, security and confidentiality.
    The information is too potentially valuable to too many people, creating a monstrous temptation, at the same time the complexities and costs of the “little guy” dealing with breaches by the “big guys” creates a great moral hazard.
    See for instance:
    http://www.latimes.com/news/opinion/editorials/la-ed-prescriptions-20110131,0,277274.story
    The Supreme Court will hear whether states can ban selling prescription data. It is quite possible the Court will not permit bans.
    It is critical to understand the immutable principles (“laws”) of Social Informatics, a field that studies new information and communications technologies and their effects:
    a. IT is not value neutral: its use creates winners and losers.
    b. IT use leads to multiple, and often paradoxical, effects.
    c. IT use has moral, and ethical aspects and these have social consequences.
    d. IT is configurable – it is actually collections of distinct components (and mis-configurable as well)…
    e. IT follows trajectories and these trajectories often favor the status quo
    f. IT co-evolves during design/development/use (functionally, or dysfunctionally)…
    (based on Kling, Rosenbaum & Sawyer, “Understanding And Communicating Social Informatics”, Information Today, 2005 (Amazon link at http://www.amazon.com/Understanding-Communicating-Social-Informatics-Communication/dp/1573872288/ref=sr_1_1/102-9749119-8288920?ie=UTF8&s=books&qid=1174318804&sr=8-1 )
    It’s most difficult to legislate these principles away.
    — SS

  11. Hi Maggie,
    Before buying any system that has any of your data make sure you can get it back out. And test it. There are standards for formats et al today provided by NIH. The best are CDA formats in XML. Other computers can read that format and so can people.
    You want to talk about working with an EMR vendor, try doing something with Epic. They have a Vendor Relations group who won’t talk to vendors (they told me this) and won’t talk to their customers (that’s the job of the tech rep). So their job appears to be to enforce a proprietary data format and make it so that no one else can access it. But of course you can pay them big consulting bucks to make your data available to you, that you entered on the system you payed for. Hell of a business model, but it seems to be working for them.

  12. Maggie —
    The problem that both Kaiser and Cedars ran into was buying into a technology before it was mature — sort of like basing your entire office system on Atari computers. In addition to the positive experiences I discuss I did have an experience with a system that was purchased prematurely and had to be discarded.
    However, since then Kaiser has installed a new system that works very well. I assume Cedars has done the same.
    In addition to the locally grown program you describe, I myself have worked with two different commercial systems that were highly satisfactory, and have had some contact with a third one used by the system where my wife and I get our own health care. They are excellent systems for clinicians to use, and the system my doctors use has the added advantage of allowing me to sign on from home and view parts of my own record, including lab and other test results.
    One thing I would advise anyone is to avoid being the first to buy into any new technology — that role belongs to research institutions and other beta sites.
    A corollary is never to buy a major technical system without making a visit to a site that has had experience operating the system — ideally a site that is similar to your own in size and other characteristics and applies the system in the same way you intend to use yours. I learned that early in my career in radiology, and have since been involved in purchase of tens of millions of dollars worth of high tech systems without once ending up with a system that was unsatisfactory.
    The rule is still caveat emptor, and a large dose of healthy skepticism is always useful, but my experience leads me to believe that there are systems out there right now that can do what people expect EHR’s to do and do it well, EXCEPT for interoperability.
    The government, through Medicare, could do a lot to force interoperability, but if the government is too afraid of technological paranoia to do so, it is possible to attain it through private means. Radiology has been through the whole IT revolution about 10 years ahead of the curve, and by now almost all but the smallest radiology departments have both digital storage of images and radiology information systems that keep track of reports and other results as well as billing and records data. Those systems are virtually entirely interoperable for one reason — in the mid-90’s the American College of Radiology adopted a standard for interoperability which it publicizes widely and which was widely accepted by radiologists and radiology administrations. As a result it became impossible for vendors to sell systems that did not meet those standards. Consequently as early as the early oughts it was possible to perform radiologic studies in Duluth and have them available for interpretation in Australia. Radiology has crossed all the bridges that need to be crossed in this struggle, and crossed them with elephants — radiology data sets are much, much larger than those in any other branch of medicine and also involve highly protected proprietary processing algorithms worth billions of dollars as commercial properties and unique to each vendor.
    I don’t know if this means that radiologists are superior beings — we certainly like to think so 😉 — or if they are simply habitually used to dealing with high tech, but I remain certain that the rest of health care can make this transition too, without incurring either financial or patient care disasters. I would further point out that the paper systems that IT seeks to replace are even more vulnerable to theft, corruption, damage, loss, and misinterpretation than IT. Just try to locate, acquire, and read a five year old hospital paper chart on a complicated patient some time.

  13. Maggie, I commend you on this post, drawing attention to someone who has it right. The taxpayers are being taken for a ride with the handing out of greenbacks for devices that have no proof of safety and efficacy, and are, in fact, not fit for purpose. Support HR 408.

  14. Pat S wrote: “I would further point out that the paper systems that IT seeks to replace are even more vulnerable to theft, corruption, damage, loss, and misinterpretation than IT.”
    No. See my WSJ letter to the editor “Concern About Medical Records Is Not Misplaced” of April 3, 2010 here:
    http://hcrenewal.blogspot.com/2010/04/concern-about-medical-records-is-not.html
    Pat S wrote: “The problem that both Kaiser and Cedars ran into was buying into a technology before it was mature — sort of like basing your entire office system on Atari computers.”
    this is ALSO not a correct analogy. These failures were not a versioning problem. See my posts:
    Cedars Sinai: http://hcrenewal.blogspot.com/2005/03/wash-post-on-cedars-sinai-cpoe-failure.html
    Kaiser:
    http://hcrenewal.blogspot.com/2006/11/kaiser-healthcare-it-meltdown.html
    As I wrote at http://hcrenewal.blogspot.com/2011/01/more-on-electronic-health-records-and.html :
    … the refrain of “immature systems” or, expressed more colloquially, a “versioning problem” seems to come up when health IT is challenged … the fact that more fundamental issues of health IT fitness for purpose and usability are usually not mentioned is striking.
    Pat S wrote: “In addition to the locally grown program you describe, I myself have worked with two different commercial systems that were highly satisfactory, and have had some contact with a third one used by the system where my wife and I get our own health care. They are excellent systems for clinicians to use”
    What are the names of these systems?
    If what you say is true, recent surveys such as the one below would indicate these systems could have great promise:
    Survey: Docs Skeptical of EHRs, Hate Reform
    http://www.healthdatamanagement.com/news/survey-reform-ehr-physicians-41764-1.html

  15. Well, you know I would have to say something about this…
    The way I see it is that HIT has become something no other IT has ever been, or was ever supposed to be. HIT is a goal within itself, with government support and an elaborate program to “foster adoption”. So the first thing that needs to occur is to demote HIT back to where it belongs: a tool to accomplish whatever business goals the health care industry decides to undertake.
    This is the main reason why HIT “isn’t working”. HIT by itself cannot and will not improve quality of care or improve its cost effectiveness. It is insane to think that it could.
    The institution needs to decide that it wants to improve quality, for example, then make a plan, choose a method and then, and only then, shop around for IT tools to help it execute.
    Wrote about this very thing in detail a couple of days ago here:
    http://onhealthtech.blogspot.com/2011/01/timeout-for-measurement.html
    The recent HIT federal focus, or bubble if you wish, where medical care delivery is being redefined in committees, from a pure IT perspective, by IT folks, is mind boggling to me. What government should do is stick to defining standards and mandating that they are used for communications with all federal and state agencies. Period.
    Of course it is also government’s role to make sure that anything used in medical care is tested and safe, but I will leave that to Dr. Silverstein… 🙂
    Information is not shared between health care systems today not because the software is unable to do so – it is able and willing. Information is not shared because it does not fit the health system business model. If Kaiser decided tomorrow that it wants to share records with Sutter, the vendors would make it all work in a few short months, including testing and quality assurance. Lack of interoperability is not a technical problem. It is a business imperative for most hospitals and systems.
    Health IT, just like all other IT, will eagerly give the customer exactly what it demands. So far the customer demanded that HIT increases reimbursement, and that is exactly what the customer received.
    Now customers are demanding that HIT delivers Meaningful Use incentives, and this is exactly what the customer will be getting.
    From what I see in large systems who use one of two or three large vendors, physician utilization rates are surprisingly high and generally speaking in agreement with Pat S’s comments.
    The market for HIT is/was functioning well enough to satisfy customers’ expressed needs at customers chosen pace of consumption.
    It is the structure of our health care system that needs changing. The tool & die manufacturers will follow their customers.

  16. Margalit–
    I was hoping you would comment on this.
    I realize that this is your area of expertise, and I sincerely was hoping for your input.
    So when you write: “The way I see it is that HIT has become something no other IT has ever been, or was ever supposed to be. HIT is a goal within itself, with government support and an elaborate program to ‘foster adoption'”
    this strikes me as an extremely useful insight. And I totally agree.
    You also suggest that “HIT by itself cannot and will not improve quality of care or improve its cost effectiveness. It is insane to think that it could. The institution needs to decide that it wants to improve quality, for example, then make a plan, choose a method and then, and only then, shop around for IT tools to help it execute.”
    Yes, yes. Absolutely.
    But then why the push for eveyone to adopt HIT immediately?
    And I have to say that I don’t agree when you write that “the first thing that needs to occur is to demote HIT back to where it belongs: a tool to accomplish whatever business goals the health care industry decides to undertake,”
    I agree about demotig HIT to the status of a tool
    But I don’t think that Health IT should be designed ot meet the “business goals” of the health care “industry.”
    I realize that I may sound totaly naive, but I belive that Health care IT should be designed to meet the needs of patients and health care professionals who are trying to practice safe and effective patient-centered medicine,
    The people creating Heath IT are not designing and manufacutirng roller skates (or IT for casinos in Vegas.)
    They should understand this. Being involved in the “business” of health care is not like beingin other businesses. Lives are at stake.
    Margalit, I understand that you are expressing the reality of Wall Street and the for-profit business world when you write that “Health IT, just like all other IT, will eagerly give the customer exactly what it demands. So far the customer demanded that HIT increases reimbursement, and that is exactly what the customer received.
    Now customers are demanding that HIT delivers Meaningful Use incentives, and this is exactly what the customer will be getting.”
    But I have to say that the best busineeses ever created in this country don’t try to meet their own needs and the needs nees of their indusry. They dont’ even set out to meet the short-term needs of their customers.
    They strive to meet what they believe are (or will be ) the long-term needs of their customers. Here, I think of Apple– and the many excellent busineses that Warren Buffet has bought.They all have long-term goals that are aimed at meeting the needs of customers looking for Value for their dollars.

  17. Interesting statement from Margalit: “HIT back to where it belongs: a tool to accomplish whatever business goals the health care industry decides to undertake.”
    OK. Good concept. If it is a tool, why has it not been vetted for safety, efficacy, and usability by the FDA or any other organization/
    How is it that this tool has been allowed to be deployed in hospitals when there is not any proof it is safe?
    The reason why it is on the “spend cut” list is because certain congressman have been reading these blogs (especially the comments) and are now outing the truth.
    Rep. Jordan knows that most of the money will be wasted on tools not fit for purpose. The bill should be supported.

  18. Maggie,
    I completely agree with you that “Health care IT should be designed to meet the needs of patients and health care professionals who are trying to practice safe and effective patient-centered medicine,”. However, this must be driven/demanded by those providing health care. We should not expect HIT vendors to reform health care. They do not have the expertise to do that. When HIT customers start looking for what Apple’s and Mr. Buffet’s customers are looking for, HIT will deliver as well as Apple and Mr. Buffet. Not all HIT vendors, but enough of them.
    When Kaiser wanted to do well by its patients (and its own revenues) by reducing heart attacks and strokes, it somehow was able to find, or commission, the technology to do just that. When Dr. Fernandopulle wanted to innovate and improve quality and reduce costs, he was able to locate and undoubtedly customize the technology he needed. This same technology is available, or could be available, to everybody else. They just need to want to use it with patients and value in mind and they need to be willing to pay for it (just like Apple customers are). The HIT vendor needs to have a business, a socially responsible business, but a business nevertheless.
    [on this exact subject, you may want to look at my other recent rant http://onhealthtech.blogspot.com/2011/01/ehr-product-management.html%5D
    As to why push for everybody to adopt HIT immediately, I am going to be generous and assume that the those pushing are sincere and well intentioned. My guess would be that they are thinking that if we make everybody buy the tools, they will eventually use them “meaningfully”, particularly if we pay them a little to do so.
    The problem I have here is threefold. First and foremost, those defining meaningful use are by and large IT folks. What is meaningful to them is not usually meaningful to those delivering care. This is backwards. Second, this type of top down arrangement doesn’t usually work well for fiercely independent and extremely professional people. Last, unless we change the reimbursement system, particularly for primary care docs, who should be the chief coordinators and users of data, everything else we do is a waste of time.
    If I had my way, the driver would have been a national effort to improve a well defined set (exact numbers) of meaningful health and value measures by 2014, and let the technology be innovated, built, sold and bought to support those goals.
    Instead we have a goal of an EHR for every American by 2014, with a vague notion of improving quality and reducing costs, and federal committees searching for random clinical quality measures that can be measured by the current technology.
    Government shouldn’t worry about technology when setting national goals. We have plenty of private and academic talent still. Just tell people which moon we need to reach for now, and the technology will be created. And if the idealistic era of reaching for moons is over, then just pay people for what you want and let them figure out how to deliver, or else…

  19. One of the problems has been that CCHIT gave the impression to the POTUS and the Congress that certification assured that the devices (or “tools”) were safe. Congress was fooled by this and agreed to spend $ billions on devices that are certified by a for-profit non-profit pop-up created by HIMSS to legitamize devices that have no safety or efficacy as medical devices. As you read in the WAPO report, academic opinion was purchased by HIMSS and others in the industry, enabling the deception to go forward.
    I am glad to see that the HIT gig and the deception of Congress is being examined.

  20. Margalit stated that HIT is a tool for the business of health care. She is wrong because it is supposed to be used for medical care, not business. The problem is that the vendors have used business devices to treat patients and their illnesses.

  21. On Health IT.
    I believe a return to first principles would better ground the health IT effort.
    I remind readers of a paragraph from, of all places, a 1981 Radio Shack TRS-80 catalog (page 2 at this link- http://www.radioshackcatalogs.com/catalogs_extra/1981_rsc-04/ ):
    “What is a Computer?”
    “… A computer is an extension of the human brain. It is to the mind what the lever is to the arm – a machine capable of multiplying effectiveness. It can free you from tedious, repetitive work which does not require judgment. IT can provide facts and figures with lightning speed, giving you more time to exercise your judgment thoughtfully.”
    These microcomputer-pioneering Texans understood computing well. These words are just as valid today as three decades ago.
    I believe the understanding of the issue that computers free professionals from tedium, but only so that they may more freely exercise judgment, has been lost in the omnipotent marketing hype that’s taken over the IT world.
    That is what I refer to as the “syndrome of inappropriate overconfidence in computing” – a belief that expert judgment, arrived at after many years of grueling training and experience, can be duplicated or improved upon under real world conditions at our current understanding of information science (computers, of course, being simply a convenient vessel or vehicle for bringing forth information science to the applied setting).
    This overconfidence is a path straight to IT hell.

  22. I know most of the folks who posted here. I’ve sat with you in work groups or interacted with you and your communities in some fashion. You have earned my appreciation and consideration. It is here that a measure of caution is needed. We have a large population to provide care too. We need real tools that work right everytime , the same way everytime and made elegantly simple to operate. Complicated products are a distraction, this doesn’t work in the care environment. I understand some of you are only in it for the money, the digital divide enables the production of money. If you measure the value of your contribution as a medical professional by your earnings then you know in which quadrant your practice will be located ( dual axis model in development, 2011). Taxpayers are covering many of the costs associated with the mandate . Interesting material will certainly follow as knowledge is developed specifically in the area of medical economics and quality outcomes. I look forward to further inquiry while reserving the right to maintain standards of practice that exceed that which is promoted by the digital requirement – patients come first, making money is further down on the list of priorities. This is what I do and what I care about.

  23. Rus writes:
    “This Blog is for HIT Mobsters (EHRA) and not worth reading. My words will be found on the WSJ where HIMSS is not in charge. You have been dismissed.”
    Call me Dr. Nitti, Elliot.

  24. I have concern that nurses are devoting more time to these complicated user unfriendly EHRs than to the patients. Falls have increased on the othopaedic floors of the hospitals from nurses paying attention to the EHR rather than the patient.

  25. This is the best post I have ever read on this blog.
    I would just add that, from the point of view of a physician in a small practice, there is nothing about this process that could be called “letting the market decide.” The buyer, i.e. the docs, are being forced to purchase products that don’t work and that they don’t want, from sellers who have no interest/incentive to satisfy their customers.

  26. Let me start by saying that I am not professionally involved in IT and have no financial or professional stake either as a critic or supporter of EHR. I am a doctor with personal experience in HIT, and with a lot of friends who have personal experience.
    All of my experience with EHR and all the experience of people with whom I have discussed this issue has been in large organizations with hundreds or thousands of clinicians and with their own fairly large and sophisticated IT departments. They have also had large budgets to use in acquiring HIT and have had considerable market power and prestige in getting vendors to make modifications, if necessary, to meet their needs. As a result, they have arrived at positions that they are very satisfied with in terms of performance.
    This has not always been an easy road. A friend of mine worked through the Kaiser debacle — although he loves the system they use now; one of the organizations basically created their own program after being unhappy with what was offered; and another had to throw out the first system they bought but now has a system they are very happy with.
    I cannot address the position of small groups and individual practitioners since I have not worked in that setting. I can easily imagine that the products being marketed in cost ranges attractive to small groups are inferior to those bought by very large organizations, and that small groups lack the power to make vendors do their job well.
    I am not going to endorse particular products, since that is not my role, but would urge that anyone interested in this as a buyer reach out to large groups that they have contact with and ask them about their experiences as well as about the systems they now use.
    It is true without doubt that almost all large organizations have implemented EHR and that most, by now, are happy with the solutions they have found.
    I don’t know where Dr. Silverstein has practiced, but I can say that in my thirty years experience, and in the experience of everyone I have talked to, paper charts have resulted in serious problems. Charts and parts of charts are frequently lost, misplaced, accidentally destroyed, or damaged. I know of one institution that lost thousands of charts in one incident of water damage, and another where an error during a purging operation resulted in hundreds of active charts being shredded. Paper charts are very easily accessed by unauthorized people, and I know of incidents where friends, relatives, curious acquaintances, hospital employees from doctors to cleaning people, “scouts” for lawyers, insurance people, and reporters have illegally obtained access to paper charts and information in them. In the heyday of paper, paper charts were often left lying around unsecured on desks and counters, in cafeterias and locker rooms, and in cars and personal homes. I was at one institution where a former employee’s landlady called to ask if the hospital wanted a collection of hundreds of charts returned after she found them in a vacated apartment. I know of incidents where charts were strewn along highways and streets after boxes of charts were absentmindedly left on car roofs or in open trunks by doctors, and another where a doctor found several charts in his garage where he apparently had set them down months earlier. In some institutions the poor performance of chart tracking systems leads to people deliberately hiding charts so they can assure access to them. This does not even begin to address problems with misfiling leading to effective loss of all or parts of charts, or to discuss the problem of disorganization within charts, unreadable handwriting, and damage due to coffee spills and so on making parts of charts unreadable, all leading to loss of information or great difficulty in getting needed information.
    I would second Margalit’s comments that it is important that health professionals be very careful in buying and implementing EHR systems and that EHR should be driven by the needs of the health profession, not the vendors.
    I would also note that it is definitely true that almost everyone will go through a period — usually no more than the first hundred or so times they have to use it — when using an EHR system will be harder and more time consuming than what they are familiar with, and that first exposures will make everyone uncomfortable.
    However, I will also note that all the people I know who have worked through this process are now satisfied with the results, including me.
    Finally, I would urge anyone who is dreading this process to visit their local radiology department and ask them about their experience with PACS and RIS systems. As I have said, radiology went through this process five to ten years ahead of the rest of medicine, and has come out the other side with mature systems that perform well and make practice easier, save money, and benefit patients by easier and more reliable access to images and records, both within institutions and between institutions, even internationally.

  27. Maggie, How do you answer “no, but…” to that question. Would you want to be a patient in labor having a complicated delivery with fetal distress and have all records, labs, medications, orders, and fetal recordsvanish from sight concomitantly with 2000 other patients that occurred recently in Seattle?
    Your thinking is flawed, I must say, indeed.

  28. Seattle Slew —
    The first rule of IT is redundancy. In HIT you need redundancy in servers, computers, and in storage. Fortunately, with IT redundancy is very easy and pretty cheap. With paper redundancy is much more difficult, more expensive, and labor intensive. And you can lose those records in that complicated delivery if the intern accidently leaves them in the bathroom — that once actually happened to me during a procedure.
    The moral of Seattle Slew’s story — don’t buy an HIT system unless you are willing to buy the backup. If you can’t afford backup, you can’t afford HIT.

  29. Maggie, thank you for your eloquent reply to my somewhat snarky plaint earlier in this thread.
    A few years back I consulted with, and then worked for, a QIO that was being pushed by HHS to teach patients that they were, indeed, consumers. I’ve fought that characterization ever since, and couldn’t resist the opportunity to point out the parallel situation that physicians are facing with respect to HIT.
    AT that same time, QIOs were also being mandated to push EMR, which quickly became EHR, which was shortly dropped in favor of HIT. There was so much agenda driven policy coming at us so fast that nobody quite knew what to call it. The physicians we worked with wanted, needed, the kind of coordinated direction that Scot Silverstein calls for.
    I’ve been out of it for five years now, and am dismayed to see that so much confusion remains. Our private sector is an economic marvel, but not always the provider of the most useful answers. In HIT, physicians should not be left to the tender mercies of an IT marketplace driven primarily by profit.
    We know from experience with most every kind of software ever invented, that software developers are rarely in a position to fully understand how their software will be used. Too much software is designed to be engineer-friendly, rather than user-friendly, and in the case of HIT, there are many critical considerations going well beyond user-friendliness that software developers either haven’t the perspective to understand or haven’t the time to get right. Good software evolves with experience, feedback, iteration and time.
    Doctors should not have to become IT experts. The push for HIT, which does hold out the hope of improving health care outcomes as well as efficiency, is too much driven by politics and profits, looking for simple answers to complex questions.

  30. Keith,Dr.Rick, Panacea, Ed–
    Keith–
    Good to hear from you.
    You write: “EMR producers have attempted to rush physicians into deals by claiming they need to get in line quickly to get installed and up and running. Otherwise, with the deadline on qualifying for HITECH dollars, they may have to take a number and may not get taken care of in time.
    “Sounds like the used car dealer who tells you this is a once in a lifetime opportunity that won’t be availible tomorrow unless you sign on the dotted line today.
    “We need to slow this process down, do some solid research on what these systems do and don’t do for our healthcare system, and let these products develop, and the market shake out those that will not survive for long.”
    I totaly agree,
    ButI have to say that I don’t totally agree when you suggest that reform legislation contains too many regulations that might hamper medical practices that you decribe as “small businesses.”
    I don’t mean to focus too closely on your words, but I don’t think of a medical practice as a “business.”
    (For what it’s worth, I don’t think of my writing as a business either. I wouldn’t write advertorials; I’m focused on writing pieces that I hope will help readers.)
    Doctors are professionals, who put their patients’ interests ahead of their own intersts. In a business, “caveat emptor” (buyer beware) always applies. The customer should be wary that the seller is putting his (the sellers’s) financial interests first.
    But the doctor/patient relationship requires trust. The patient should feel certain that his doctor is a doctor–not a businessman.
    That’s why I don’t think you’re running a business. What you’ve said here and elsewhere suggests otherwise.
    Rick–
    Thank you. Yes, I, too, find Silverstein’s work compeling–as does Dr. Roy Poses, editor of Health Care Renewal. And Poses is one of the most honest and best heath care bloggers out there.
    Panacea–
    Thank you very much for your report from the field.
    Some very large institutions (the VA, Mayo, Kaiser, etc.) have very good EHRs that work well (some Very Well )internally, but what I’ve heard from doctors and many at smaller hospitals is not nearly as encouraging.
    Ed–
    Yes, yes.
    You write “If we are getting the money out of medicine, I think we’d best get the money out of HIT as well.”
    That pretty much sums it up.
    You add: “Most of the large HIT providers, those who benefit the most from HITECH, provide ancient technology. In effect HITECH allows them to continue to profit from outdated stuff and by their size allows the large HIT vendors to stave off competition from innovative small business.”
    I am afraid this is what I have heard and read in comments from doctors out there in the field–not to mention on this thread.
    You end your comment by saying: “I do think that there is a place for government in HIT, and that is to set and enforce standards for interoperability and data transmission between HIT systems.
    “This was the thrust of the most recent PCAST report on HIT. So apparently more experts than Scot believe the same thing.”
    I agree. HIT companies should be treated like utilites–and regulated accordingly.

  31. Bruce, Pat S.
    Bruce–
    You offer some very helpful advice:
    “Before buying any system that has any of your data make sure you can get it back out. And test it. There are standards for formats et al today provided by NIH. The best are CDA formats in XML. Other computers can read that format and so can people.
    “You want to talk about working with an EMR vendor, try doing something with Epic
    . . . course you can pay them big consulting bucks to make your data available to you, that you entered on the system you payed for. Hell of a business model, but it seems to be working for them. ”
    Yep. That pretty much sums up what I have heard and read about the business of IT consulting and service.
    Pat S.-
    Everyone should read your advice as well.
    “Never buy a major technical system without making a visit to a site that has had experience operating the system — ideally a site that is similar to your own in size and other characteristics and applies the system in the same way you intend to use yours. I learned that early in my career in radiology, and have since been involved in purchase of tens of millions of dollars worth of high tech systems without once ending up with a system that was unsatisfactory.
    “The rule is still caveat emptor, and a large dose of healthy skepticism is always useful, but my experience leads me to believe that there are systems out there right now that can do what people expect EHR’s to do and do it well, EXCEPT for interoperability.”
    Pat: I don’t doubt that there are good systems out there that knowledgable buyers could purchase.
    But I also think you’re onto something when you write:
    “Radiology has been through the whole IT revolution about 10 years ahead of the curve, and by now almost all but the smallest radiology departments have both digital storage of images and radiology information systems that keep track of reports and other results as well as billing and records data. . . I don’t know if this means that radiologists are superior beings — we certainly like to think so — or if they are simply habitually used to dealing with high tech, . . .
    Pat, I agree that other health care providers need to make the transition too. But it is going to be much more difficult for many small to medium sized practicies in specialites that are not habitually involved with hi-tech—and very complicated for many hospitals, particularly if the majority of doctors tending patients in the hospital are in private practice and don’t work for the hospital.
    Also, the transition is much more difficult for older physicians.
    A significant number of doctors over the age of 50-55 don’t even type, let alone use a computer. (Secretaries, wives, etc. have always typed for them.)
    Try to imagine using EHRs while hunting and pecking in a situation where you’re under some time pressure. . .

  32. Melanie G. M.D., Scott-
    Melanie G.– Welcome to HealthBeat.–and thank you.
    Yes, taxpayers are footing the bill while a great many software vendors are cleaning up. (Some may go under, but in most cases, the founder(s) and top executives will do nicel.y)
    Scott–
    Thanks much for all of the links, not to mention the reserach and writing that helped inspire this post.

  33. I find it very interesting that we often decry overtreatment with medicine or devices that have conflicting outcome research yet we do not do the same with HIT.
    Certainly there is equal potential for HIT to be overly done without supporting evidence, if not more potential for overuse or abuse due to the lack of FDA oversight and unbiased research on the topic.
    It is not right to think that commercial HIT vendors are not subject to the same conflict between their business and personal interests as are device and pharma companies.
    And it seems like a subject both the Democrat and Republican thinking sets can understand. HIT is not regulated, so it is outside of the net relied on by progressives. HIT incentives are contrary to conservative thinking.
    So this all seems unreal to me, everything seems to point opposite of the direction the government is taking, and that goes for both the Bush and Obama administrations. If you read even half of what Dr. Silverstein posted earlier, it is pretty obvious that some there are some serious questions on HIT, yet it seems anecdotes from non-experts (even those expressed by some in this thread) are often given equal (or more) credence as unbiased experts like Scot.
    Since I believe that people aren’t dumb, I think it has more to do with the money than the opportunity for better and more efficient healthcare.

  34. Maggie –
    Unlike some of the commenters on this thread, HIT is not my area of expertise so I don’t have a lot to say about it. Except for this. Doctors, unless they are both salaried and have no responsibility and risk related to hiring support staff, ARE running businesses. They have to hire people and then meet the payroll. They have to pay for office rent, equipment and supplies. They have to cover malpractice insurance. After paying for those expenses, what remains is their income / profit which support them and their families. Some may be more money driven than others but I suspect that most do a fine job of taking care of their patients and putting their patients’ interests first. However, their constraining resource is TIME. To the extent that regulations are put in place that consume time for which they don’t get paid and, in their opinion, do nothing positive for their patients, they view it, rightly I think, as a burden that hurts their ability to care for patients. As it relates to HIT specifically, the subsidies made available under PPACA may have the unintended consequence of driving doctors to purchase software and equipment that is either not ready for prime time or not appropriate for their particular needs.
    You, by contrast, as an employee of the Century Foundation, are NOT running a business. You are a salaried employee with no responsibility for meeting a payroll or for providing capital to ensure that TCF remains financially viable.

  35. I can not keep this to myself any longer. I have had 4 patients die because of the errors associated with the use of a CPOE system manufactured by a publicly traded vendor. Neither the vendor nor the hospital took any accountability at all. They blamed the nurses and the doctors for the deaths.
    These were complicated patients, but they were not ready to die.
    I am a mere internist. Multiply these deaths by the number of doctors using these systems that have been sold without regard to safety and efficacy.
    Government speaks with forked tongue.
    Our leaders want to know “what works”. Others pontificate about comparative effectiveness.
    Well, these systems have no track record of safety at all.
    The funding should be withdrawn.

  36. Pat S says:
    “Radiology has been through the whole IT revolution about 10 years ahead of the curve, and by now almost all but the smallest radiology departments have both digital storage of images and radiology information systems that keep track of reports and other results as well as billing and records data. . . I don’t know if this means that radiologists are superior beings — we certainly like to think so — or if they are simply habitually used to dealing with high tech, . . .”
    I think the point is that computerizing radiology systems (in essence, creating a digital Xray jacket with billing system on the side) is VERY different from creating an EMR (a billing system with patient care on the side?) that multiple people are interacting with on a minute-to-minute basis. The problem with EMRs is not that they can’t store data, it’s that the interface for using that data is so clumsy.
    To imply that radiologists are smarter than other docs, or that EMR use is an age-related issue does not improve the tone of this discussion.

  37. And, let me add, the advantages of going digital (both in terms of patient care and financial return) were so obvious and REAL for the radiologists, that the change-over was effected without one cent of ARRA funds. So far, the evidence shows that those advantages are not there with EMRs.

  38. I suggest you high and mighties stsnd up straight and take a derp breath then go look at the articles regarding chipset flaws published today on the WSJ.
    We all know that Doctors know everything so we just want to make sure you know the one size fits all approach with hardware is a myth.
    You guys need to get real and demand chipsets for medicine . This may come as a Duh moment to you but ah yes a lowly Nurse tild you so and has tild yiu thus on more tgen one occasion. Here’s the deal: DICOM is a suite of protocols for digital imaging and communications for medicine- it operates as a protocol and does this very well however that does change the way things are below the network layer. A solution set is needed for layers below – the Data link and physical layers . Consider the valur of consulting again with industry to create chip sets that are uniquely designed for medicine. Lets open it up for discussion. If necessary , get Dr Ness and Mr. Nitti to join in.

  39. Robert Watkins —
    What you are describing is a PACS – image archiving — system. Most radiology departments also operate RIS systems — registration, tracking, billing, report filing, etc. — along with the PACS systems. RIS systems date back to the late 80’s and have been ubiquitous since the mid-90’s, and are, in fact, almost identical to EHR sytems. As you say, they are “billing systems with record systems attached.” Labs have run similar systems about as long.
    Although labs and radiology departments are somewhat smaller than hospitals as a whole, and have somewhat fewer interactions, they are nonetheless very large generators of patient interactions and do involve multiple users — a medium sized radiology department may produce 300 exams a day and have fifty people working there during any 24 hour period — techs, doctors, administrators, clerks, typists, billing people, registrations people, transporters, nurses, etc., all interacting with the PACS and RIS systems.
    Radiology adopted RIS so early because of high volume of work and because of repeated studies showing high levels of loss of study results and of billing income (one department I worked at in the 70’s did a study that showed that 15% of data was lost under paper systems — and that was in an organization reknowned for its high level of organization and compulsive systems management.)
    As to complaints about the quality of EHR systems — I would fall back on the comment I made earlier and that Maggie quoted: never buy a system without thoroughly investigating and testing it, including site visits to places where the system is being used.
    One final point, which I will allow John Ruskin to make for me: “There is nothing in the world that some man cannot make a little worse and sell a little cheaper, and he who considers price only is that man’s natural prey.”

  40. Maggie —
    “Also, the transition is much more difficult for older physicians.”
    I was in my 50’s when HIT came to radiology, and I had partners in their 60’s — one was 68 when we bought our first system. And yes, several of my partners did not know how to type — at least one had his wife do all his e-mails — and several had never used computers. Everyone had reactions that ranged from anger to terror — mostly a bit of both — at the idea of having to learn this new way of doing things, but in a week the system was running smoothly and within six months everyone felt the systems were better than the old way.
    Then again, I have long suspected that radiologists are superior beings 😉

  41. Pat S:
    Thanks for the response. The quote from Ruskin is icing on the cake.
    I think the question here is why were radiologists such enthusiastic and early users of HIT, and why now are so many other doctors so reluctant to sign on.
    The implied answers that radiologists are smarter and many docs are too old aren’t satisfactory. As you state, there were many old radiologists back in the 80s, and every MD I know, regardless of age, uses a smart phone.
    I can come up with two partial answers:
    1. Radiologists benefitted from true efficiencies in using HIT, and were able to recoup their investments relatively easily. An internist who is paid only for face-to-face patient time and has a full patient panel has absolutely no ability to increase revenue and pay for an EMR. If an EMR is just slightly less efficient than paper (see #2), revenue and pay actually decrease;
    2. Radiology studies and interpretations seem quite suited to being digitalized. Compare that to an E&M visit with an 85 year old patient, 10 chronic problems, 4 new problems, 15 meds, 4 pages of nursing home orders, 3 calls from children, 18 prescriptions, 2 pharmacies, 3 referrals, 26 lab tests, and on and on. And then the doc is expected, with most EMR systems, to torture the summary of the encounter so that it fits a template, or else type the data in herself. It’s slow and hard going (as it is with paper, but in a different way). It just seems that certain types of medical work fits better with HIT than others.
    Maybe this starts to answer the question?

  42. I think PACS/RIS is a very good comparison to EHR. As Dr. Watkins astutely pointed out, radiology adopted PACS/RIS not because they were forced to do so, but because it made sense, both business and patient care sense. And lo and behold they figured it out all by themselves even though there are many vendors in this area as well.
    The other big difference is that from day one PACS were regulated by the FDA. Not that there are no adverse events due to PACS systems, but they are out there to be learned from and fixed.
    BTW, I don’t agree that HIT should become a utility, Maggie. You brought up Apple and I think that was a great example of what I would want HIT to model itself after. Physicians have very different needs and tastes, as you can see from this thread alone. HIT should be a thriving private market that is constantly innovating and competing to satisfy those needs. Utilities don’t do it, and government mandates don’t allow it to happen.
    There were very good reasons why physicians were not buying EHR before HITECH. Those reasons are still there. Without intervention, it would have taken longer perhaps, but the equivalent of PACS would have been created because vendors want to sell, and sooner or later somebody would have stumbled upon the right idea. No need to look for anything now because government dictates features/functionality/database-design, and everything sells like hot cakes anyway. Unintended consequences?

  43. Robert Watkins —
    I think you are right.
    Radiology was better suited to adapting to HIT changes than other fields of medicine (as was lab,) and the financial and systems benefits to radiology more obvious. Radiology departments also tend to be much more monolithic than clinical departments. However, radiologists also worried (me especially) that HIT would mean loss of efficiency and stretch what were, at that time, severely understaffed departments to the breaking point.
    Large group practices and HMO’s are better suited for making the transition as well. They have, as I said earlier, bigger budgets, large and relatively sophisticated IT departments, and unified leadership. They are used to implementing system wide changes.
    That is why these three areas have been early adopters. Smaller practices and individual practices have more trouble, and frequently do not have the budget to implement the changes. That may have led some to make poor purchases of systems selected largely on a price basis. They are also not in a position where they can eat the cost of a mistake, as several large systems have been forced to.
    However, I remain confident, based on the successes of implementation (including for internists seeing patients with complex medical problems and histories) in these places, that EHR will be implemented eventually throughout US health care, and that in ten years we will be all looking back and saying “remember how hard that seemed to be, but now I can’t imagine doing it any other way.”

  44. Pat, May I ask kindly that you stop reposting the same conjecture and anecdote? Clearly the experts here have a different view and I, for one, like to hear from them.

  45. Joe Says, Lucy, Barry
    ,Joe–your most recent commment
    Joe Says: Yes, there is great potential for conflict of interest in the HIT industry.
    I thiik that HIT shoud be regulated (to make sure that it is safe and fits the needs of the user–expecially since taxpayer money will contribute to buying it.
    Lucy–
    I agree that HIT should be approved by the FDA.
    But I don’t think we want to defund or repeal the bill. Docs and hospitals will need financial help to buy the software.
    At the same time,I don’t think they should receive the taxpayer dollars until someone checks whether the HIT they are planning on buying is indeed going to
    serve their work-flow and is not over-priced.
    In other words, I think
    that heatlh care providers should apply for the funding Before they sign a contract, and let an object 3rd party verify that they are not being ripped off.
    Barry– You are correct that doctors in small practices are running a business, and the time that it takes to implement, learn HIT,work out the glitches and train staff will cost them money.
    This is one reason why the government is providing subsidies, and not expecting them to pay for all of this out of pocket.
    And, if they wind up with good HIT that fits their needs, doctors report that afer losng some productivity in the first year, HIT becomes a real time-saver ,while also letting them improve the care that they are providing to patients.
    Pat S. is not the only satisfied customer out there.
    But inevitably some doctors are shrewder about picking HIT than others (and some are more easily “sold” than others. )Most need some help. Those who work for large organizations are more likely to have people in their organization who can help design or oversee HIT.
    Those working in small practices are more vulnerable to being “sold” .
    So I think the govenrment needs to give them some form of “consumer protection.” And I don’t think we should be putting pressure on them to rush into these decisions.
    In my view, the penalities definitely should be postponed.
    Joe,
    Regarding your most reacent comment, directed to another reader:
    On this blog we try to refrain from sniping at each other.
    Others readers are responding to Pat’s comments. Even though they may not agree with him, they don’t find seem his comments superflous.
    I realize that on a thread, peopled can become irritated with each other (Moi included.)
    But let’s stick to the subject at hand and try to avoid commenting on each other (except in a positive way.)
    So many blog-threads sink into attack, conunterattack, much of it personal . . No one learns anything.

  46. Maggie,
    What we are doing is running a rather unique buisiness, but it is nevertheless a buisiness that has to conform to common economic tenents, or it will quickly fail. And how this is run depends very much on what kind of employees I can hire to help care for my patients (after all, you have told me before that medicine is a team sport) and what tools I can afford to assist in their care, including EMR. Doctors, in my opinion, have long run their individual businiesses/practices, although the constraints of managed care and other regulatory pressures have made this ever more challenging.
    You are right that we are doing more than running a buisiness, but there are realities of family and other obligations that require us to manage our practices carefully and not squander health care resources, so as to deliver value to our patients in the form of cost effective care; yet still have money left over to support our families and send our kids to college.
    Choosing an EMR is a key example. It represents a major purchase that will have significant ongoing costs asosciated with the maintenance and support of the system. One has to decide if it will provide better care to our patients than the current methods of practice, and if it will do so without taking resources away from other parts of the practice. At this time, I am not sure that quality is improved by any measure, nor am I convinced that cost will be saved. If this was well proven, I think you would see a stampede of physicians signing up for these products. Intead we find the goverment needs to entice us with 44 grand to buy a product that has not been subject to FDA vetting as to its safety. Like any software purchase, I want to let it be beta tested on someone else before I risk a catastrophy with my patients, and the possible financial collapse of my livelihood.

  47. the idea of comparing radiology software to what has to be dealt with in a fully functional EMR system is not really fair. The compexity of a redundent action of viewing images and then dictating a reading is simplistic compared to what a multispecialty EMR system has to do.
    Secondly, digitizign films give an incredble cost savings over the old method of producing an actual film and storage cost and retreival are simplified. These types of cost savings are what made radiology the early adopters of this technology.
    If an EMR could be shown to do the same for an internal medicine practice, you would have them lining up out the door.
    IT needs to show improved value to patient care, a significant cost savings, or both. To date, I do not see that they have done either.

  48. Margalit, Scott, samir
    Margalit–
    You write: “I completely agree with you that ‘Health care IT should be designed to meet the needs of patients and health care professionals who are trying to practice safe and effective patient-centered medicine,’. However, this must be driven/demanded by those providing health care. We should not expect HIT vendors to reform health care. They do not have the expertise to do that. When HIT customers start looking for what Apple’s and Mr. Buffet’s customers are looking for, HIT will deliver as well as Apple and Mr. Buffet.”
    Margalit–
    I’m not expecting sortware vendors to reform healthcare.
    I would like to think that they would try very hard to figure out what would fit their cutomer’s workflow and then develop the least expensive product possible to meet that need.
    But for-profit software vendors, like all for-profit coporations are required, under U.S. law, to put their shareholders’ intersts first.
    This means charging as much as the market will bear for a product that won’t add too much to their costs. I’m not criticizing them– this is what a business is supposed to do.
    Some very, very intelligent businessmen, who have deep pockets, take a long-term view and put customers’ interests first, gambling that, in the long run,this will be better for cutomrs. But over the past 30 years, fewer and fewer U.S. companies have done businessses that way.
    As for Apple and Wareen Buffet —
    First,Apple’s customers were (and are) looking for a product that is much, much simpler than HIT–it’a consumer product made for individuals.
    And even then, Apple basically lost the war with the PC (IBM), not because the PC was a better product, but because the company had muchdeeper pcckets.
    That’s how capitalism works: money mamkes money. A company with less money is always the underdog, and often loses.
    As for Warren Buffet, he doesn’t have “customers” per se. Buffet has investors. And the companies he backs tend to be pretty simple companies that sell very simple products. Nothing nearly as complicated as Health IT. In these situations, the company’s customers do have some leverage: they can comparison shop, and the info is pretty transparent.
    Investors who send their money to Buffet understand that he is not taking risks on technologoy cmapanies (he has virtually never invested in technology.)
    Scott–Thanks for the many links in your comment on whether Kaiser and Cedars Sinai ran into problems because they tried to buy HIT before the industry and product was “mature.”
    I agree that the problems were more ocmplicated than that– and that there are many “immature” products still out there.
    samir–
    You are right– patients have been hurt by EHRS that are poorly designed. This has been well-documented.
    And typically, neither the software maker nor the hospital takes responsibility.

  49. Hands on Practitioner–
    Bravo!
    I hope that you continue to comment on HealthBeat–your measured, knowledgable and very candid comment contributes greatly to the discussion.
    You write: “I know most of the folks who posted here. I’ve sat with you in work groups or interacted with you and your communities in some fashion. You have earned my appreciation and considerationYou have earned my appreciation and consideration. It is here that a measure of caution is needed. We have a large population to provide care too. We need real tools that work right everytime , the same way everytime and made elegantly simple to operate. Complicated products are a distraction, this doesn’t work in the care environment.
    You add: “I understand some of you are only in it for the money, the digital divide enables the production of money. If you measure the value of your contribution as a medical professional by your earnings then you know in which quadrant your practice will be located ( dual axis model in development, 2011) . . .
    You conclude: ” I look forward to further inquiry while reserving the right to maintain standards of practice that exceed that which is promoted by the digital requirement – patients come first, making money is further down on the list of priorities. This is what I do and what I care about.”
    I have quoted you at length because I would like everyone on the thread to hear what you had to say.

  50. Robert Watkins–
    First, thanks much for the kind words.
    You go on to wirte: “there is nothing about this process that could be called ‘letting the market decide.’ The buyer, i.e. the docs, are being forced to purchase products that don’t work and that they don’t want, from sellers who have no interest/incentive to satisfy their customers.”
    I’m afraid that this the what “letting the market decide” means in many sedtors of our economy.
    Often, consuemrs, like doctors who are told that they must buy EHRS, have no choice.
    One exmple: You need a car to get to work, so you must buy a car. Unfortunately, over hte past 25 years or so, for most middle-class Americans this has meant buying a product that has ment buying a product that very well (needs many repairs, and isn’t very safe) from companies that have little interest/incentive to satisfy their customers (by providing an affordable, safe atuomobile that needs few repearirs.)
    There was a time whan Japanese automakers, who were new entrants to the market, and were working hard to gain market share, offered what middle-class Americans needed. ( I remember buying a brand-new Toyota in 1983 for aroughy $2,000. I sold it in 1989, after I moved to NY, and had never been forced to made a major repair. Even after adjusting for inflation,that price was a very, very good deal.
    I think that most middle- class buyers (people earning joint househod income of $50,000) would agree that the automobiles available in their price range just don’t offer good value for their money.
    The same could be said of health insurance, and some other products where consumrers form a capitve audience (if they possibly can, they have to buy the product.)
    This is why we need government regulation of products that are necessities; this is why, traditionally, we have regulated companies that sell heat and light.

  51. “The same could be said of health insurance, and some other products where consumrers form a capitve audience (if they possibly can, they have to buy the product.)”
    What about healthcare? People don’t “buy” healthcare because they want to. They buy it because they have to and, in some cases, may even die if they don’t buy it. Yet, we have precious little information and transparency regarding either prices (before services are rendered) or quality of care. For all the bashing of insurers that goes on, at least consumers can get a price quote before they decide whether or not to buy the policy.
    Underwriting and pre-existing conditions, of course, are separate issues that PPACA dealt with. However, if the individual mandate is ultimately ruled unconstitutional, guaranteed issue and limits on age banding will likely be struck down as well as they would not have passed but for the individual mandate.

  52. “This is why we need government regulation of products that are necessities; this is why, traditionally, we have regulated companies that sell heat and light. ”
    I would have to disagree at a certain level.
    Yes, we do need to regulate the safety of EHR products, just like we regulate the safety of cars. However, this doesn’t mean that EHRs, or cars for that matter, should be turned into utilities like electricity and gas.
    Utilities are pretty static in function and technology. The same outlets from 50 years ago work just fine today. This is not the case with technology, or cars, or even food stuff.
    I also want to have choices when it comes to cars because a perfectly safe car that satisfies the needs of my lumberjack neighbor is not what I need for commuting 10 miles to work on city streets. Same for EHRs. What works very well for a large practice of Cardiologists will not work at all for a solo primary care practitioner, and what works for a doctors that types a mile a minute will not work for one that types with two fingers, if at all. Electricity doesn’t have those nuances and doesn’t need to have them.
    So my suggestion would be to let technology companies compete for customers, which means that regulators should stick to safety and minimum network standards and NOT mandate that customer by “something”. Just like cars, they will buy when, and if, they find something that works for them. They may need to compromise on value, like cars, if there is a compelling reason to buy a product and the perfect one is not available, but that should be their individual choice.
    I think you will see much better quality this way, and if one product turns into a de-facto utility, like Microsoft Office has, so be it. Otherwise, let the best product(s) win.

  53. I agree with Margalit’s comment that HIT vendors do not need to be and should not be regulated like utilities. Electric (and gas) utilities are what economists call natural monopolies. They are hugely capital intensive. It wouldn’t make economic sense to have more than one set of power lines and poles and transformers to serve a given population. So, we only have one company provide this service in a territory but regulate its rates and limit its return to what regulators often refer to as a “zone of reasonableness” which is sufficient to cover its cost of capital and sufficiently attractive to induce investors to provide capital.
    Technology companies, by contrast, are nowhere near as capital intensive. They are also the sector of the economy where innovation is greatest, product life cycles are shortest and prices per unit of capability decline over time. So, settle on some standards, especially related to interoperability, and let the competitors compete. Smaller and less sophisticated medical practices could hire objective infomediaries who are paid for their time and expertise but have no financial stake in what product is ultimately chosen to help providers navigate the technology landscape. If they don’t want to buy anything at all and would prefer to stick with a paper based system, at least for now, they should be able to do so without being penalized financially.

  54. To all:
    I’ve updated a brief set of research/press articles on health IT to serve as a counterpoint to cavalier attitudes about the technology.
    I use this list in my teaching of Medical Informatics.
    The link is http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html
    or downloadable as a Word document from:
    http://www.ischool.drexel.edu/faculty/ssilverstein/hitreadinglist.doc
    Still others are available at the “Other resources” tab of my teaching site, reached by clicking on my name.
    S.

  55. Margalit–
    When writing about HIT, on HealthBeat, you should disclose that you have a financial interest in the subject.
    A reader raised a question which led me to Google you, and it was only then that I discovered that you are a partner in a company that helps docotors select EHR software, and services, and that you seem to have spent most of your career recommending and consulting on HIT after receiving a masters in aeronautical engineering in Israel.
    Normally, when debating an issue on the Internet, people disclose any financial stake as in “Admittedly, I have a financial interest in this subject, but . . .”
    You have been commenting on HealthBeat for a long time, but I don’t believe you have never made such a disclosure.
    Even on your own blog, you do not disclose who you work for, your background in business, or your education. Instead, your “profile” says only that you are in St. Louis and tells us what blog you follow. (See http://onhealthtech.blogspot.com/_
    I recall that when you first commented here we were talking about healthcare in Europe and you indicated that you had lived in Europe and knew quite a bit about how medicine is practiced there.
    I recall this because it sounded as if you had an interesting background.
    I assumed that you were a medical professional– perhaps a doctor.
    Subsequently, it became clear that you knew quite
    a bit about HIT. So I assumed you were a medical professional who is also a HIT expert.
    Someone who acts as a middle-man between software vendors and physicians is not an objective expert.
    As Barry Chaiken noted in the first comment on this thread: “Vendors are not experts in this as their incentives are to deploy as quickly as possible to be able to recognize revenue for shareholders and investors.”
    In your case, you have a vested interest in encouraging physicians to feel that they should buy HIT– otherwise, you have no customers.
    You company says it is “vendor neutral” but provides no disclosure on its website as to whether it receives any fees or money from vendors.
    Traditionally, in the health care industry, those who act as middlemen between hospitals and companies that sell equipment to health care providers take money from the companies that are selling the equipment!( No wonder hospitals pay such high prices for devices and equipiment.) See this Kaiser story on how “Hospital middlemen Waste Billions”http://www.kaiserhealthnews.org/Daily-Reports/2010/October/07/hospital-Buying-Coops.aspx
    I wonder if HIT consultants are paid, in any way, by vendors?
    Whether or not your company receives fees from vendors, you do a have a stake in downplaying the reasons why buyers should slow down before adopting HIT.
    Ideally, doctors and hospitals they would get advice from medical professionals who are also IT specialists– not engineers who are IT specialists. We know that adapting IT to work-flow is very difficult.
    Also, in New Jersey NJ-HiTech is a non-profit that offers IT consulting services for a very small fee ($500 a year.) I don’t know anything about its track record, but it certainly sounds like a promising idea.
    Having for-profits involved inevitably creates a conflict of interest .. . .
    In addition, on its website your company warns that doctors should never pay attention to the prices a software vendor quotes. It seems that only
    consultants can “bargain” vendors down to a true price.
    This sounds like the opposite of a transparent market. Why should we need a layer of middle-men (consultants) to get real prices from vendors? This will only add to the costs of health care reform. And how do we know that consultants are, in fact, getting the cheapest price possible?
    Certainly, your point of view is of interest in the debate over HIT–but it should be presented in context. As Dr. Chaiken indicates, your first allegiance is (quite propertly) to shareholders, not to patients.
    In that ocntext, your most recent comment makes sense: “So my suggestion would be to let technology companies compete for customers, which means that regulators should stick to safety and minimum network standards and NOT mandate that customer by “something”. Just like cars, they will buy when, and if, they find something that works for them. They may need to compromise on value, like cars, if there is a compelling reason to buy a product and the perfect one is not available, but that should be their individual choice.”
    The suggestion that regulators should stick to “minimum safety standards” ignores the fact that we are talking about medical equipment that could put a patient’s life at risk–if it is not well designed, not user friendly, or if the company does not do a good job of training a doctor and his staff in how to use it.
    You suggest that it’s up to the consumer to purchase “what’s right for himi” and that if he has to compromise on value “that’s okay.” This should be “their individual choice”
    Meanwhile, on your company’s website you acknowledge that physicians know little about HIT and really don’t have time to learn about it. “We know you are busy seeing patients and have no time or desire to research computer technologies and lengthy Government regulations. We can help…”
    This is why they should come to your company and rely on you to steer them to HIT which, as you put it may not be “perfect”. Presumably you will advise them when they may have to “compromise on value”
    No wonder you are opposed to gov’t regulation of HIT
    Meanwhile, there is growing cocern that when EHRS are not designed property, and staff are not trained properly patients are being hurt–
    see http://blog.americanehr.com/americanehr-partners/usability/

  56. Maggie,
    Where do I begin?
    Not only I am currently consulting in HIT, I also worked on the “evil” vendor side for many years and before that I worked for “evil” hospitals, as is posted on the bottom of every single post of mine over at THCB. At various times I did post disclaimers regarding my education http://bit.ly/gn3Db5 and any pertinent consulting I was involved with at the time http://bit.ly/91GqU It is not that difficult to find out who I am and what I do.
    It is also not very difficult to find out that I do support FDA regulation of EHRs http://bit.ly/9YXApp and http://bit.ly/bf28aN and I have no illusions regarding the quality of EHRs sold today, with this being the most recent of many links http://bit.ly/eWSTJY
    If you go about reading my blog entries at the link you mentioned, you will see that I am consistently advocating that we should slow down (significantly) over and over and over, but of course, nobody is listening. Nobody is listening to practicing docs either.
    I am also concerned with privacy issues and the predatory wholesale of “de-identified” patient data? What do you think “clouds” are for, Maggie? Why do you think everybody is hellbent to “get the data out” of the “paper silos”? Read some EHR vendor contracts and you will understand… And how about physicians’ privacy? Are they entitled to none? Perhaps you can browse a little on my humble little blog…
    Just like not every doctor is out there to rack up bills from unsuspecting patients, and not every attorney is out there to feast on people’s misfortunes, not every HIT person is out there to deceive doctors and make a quick buck.
    Most businesses contemplating large investments in software or real estate or whatever, employ expertise from outside. There is nothing strange or corrupted or morally bankrupt by definition with companies like Deloitte or Thomson Reuters or the AAFP’s TransforMed or even the ACP’s AmericanEHR you are linking to, and all of them do consult in the HIT industry. Sure there are corrupt consultants out there (lots and lots), but there are corrupt people in every profession.
    I have been advocating for primary care physicians, particularly those in small private practice for such long time that it seems forever. Here is calling for the Government to let docs decide how to fix medicine http://bit.ly/hrO2gU and here is lamenting the end of primary care http://bit.ly/16Bx1I and here is the story of one doc http://bit.ly/epgtde
    (I remember now that we had some disagreement regarding the cottage industry)
    So how about HIT? I believe that HIT is less than optimal right now, but unlike hospitals, which I don’t have much to do with anymore, EHRs in ambulatory settings are much more varied and although not perfect, one can find something that can work.
    Considering the current regulations, and considering what is being done to physicians in private practice right now, I strongly believe that the only way for a small practice to survive the coming changes is to get “on the network” somehow so they can be part of whatever payment arrangements will materialize, and still remain independent. The best way to get connected is to find the cheapest, workable solution and keep a watchful eye on it, as I wrote here http://bit.ly/aybyAg – with no illusions, but whether we like it or not, paper is indeed over, or will be so at very short notice.
    Most people have a favorite windmill to tilt at, and mine is the small independent doctors, because, contrary to current common wisdom, I think they are the only ones that can actually fix health care (see the latest from Dr. Gawande).
    I am saddened by the fact that you saw a need to challenge my integrity, but I guess I deserved it. I have a tendency to call it as I see it, and I often get in trouble for that.
    And no, Maggie, I don’t take money from vendors and I don’t “push” docs to buy EHRs, but I do try very hard to help them if they do want to buy one, and I have told more than one physician that he is better off to stay on paper right now.
    I don’t mention my company on my blog profile because I don’t want to use my writing, which I do for personal enjoyment, to promote business.
    I also don’t drink, don’t do drugs, have no police records and generally speaking am a law abiding citizen of this country.
    Somehow, Maggie, writing this is not making me feel less sad…

  57. Margalit–
    I simply suggested that on this blog, people are expected to (and nromally do) discose any financial interests in the topic at hand.
    I’m sorry that this upset you so much. But I didn’t call sofware vendors or IT consultants “evil.”
    I can’t help but think of the line from Hamlet: “The Lady doth protest too much.”

  58. Maggie,
    You will find the themes in your February 06, 2011 at 04:07 PM comment expressed in my Healthcare Renewal blog posts over the years.
    I entered the field of Medical Informatics via very hard work – medical school, internship, residency followed by a formal two year post doctoral fellowship (Yale) to improve healthcare. As a physician, seeing the information flows on paper were highly inefficient (e.g., as an intern in the early 1980’s at the Philadelphia VA hospital it took an hour+ just to fill out daily lab slips and paperwork, then another hour+ to gather the results in the afternoon (assuming they weren’t lost), I saw IT as a method to save wasted time. I never saw IT as a tool to “work miracles”, “save massive amounts of money”, “revolutionize medicine”, and/or replace critical, objective thinking and experience and expertise (gained only through medical training and practice) in patient care. I’ve documented such claims at HC Renewal, all the way up to the (past two) POTUS’s.
    Now, thanks to the “cross-disciplinary invasion of healthcare IT” by a myriad of “HIT specialist” amateurs, we have gone to the polar extreme of the IT burdening clincians, not really helping them, in its present “inventory system” form.
    Note that I use the “amateur” term in the sense that I am a radio amateur, Extra class (the highest) licensed by the government Federal Communications Commission after a series of exams, but I am not a telecommunications professional and would not deem to tell engineers their field. Physicians do not appreciate being dictated to by healthcare and health IT amateurs.
    There are those who believe in issues such as prevention of meaningful regulation, minimum safety requirements, adoption ASAP no matter the consequences, etc. out a naivete and wishful thinking despite the evidence (“irrationally exuberant” as I’ve written), but I believe the deeper one looks at the majority of them, one will find “rational exuberance”, i.e, one will find a financial or professional-advancement COI in espousing such views.
    The fact that patients might be harmed doesn’t seem to be a major concern.
    This is where these people (right up to the just-resigned ONC chair) and I diverge – WIDELY – in our views, esp. in the domain of ethics, and did so long before my mother’s injury in May 2010. Their view is little different than that of those who conducted, say, the Tuskeegee experiments. A harsh statement, but show me wrong … the (theoretical) betterment of the masses at the expense of the few who happen to suffer “for the good of all” (or, for the good of “my wallet.”)
    The ethical lapse is further compounded by cavalierly dismissing or simply ignoring accounts and literature such as I’ve compiled at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases and http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009 and http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html , and/or calling known issues such as at MAUDE that I documented at http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html “anecdotal” while full well knowing that in complex systems, “anecdotes” from reliable sources are often the first sign of potentially major problems.
    Hence my belief in regulation by neutral regulators with appropriate experience and expertise, informed patient consent for use of HIT, shared liability for harm where merited (i.e., no blanket “hold harmless” clauses for vendors), transparency about risks and patient harm caused by health IT, and a return to the stance that this technology remains experimental – and needs to be treated as such.
    Finally, if people want to play doctor, let them:
    1) go to medical school and
    2) play by the wise rules accumulated over the past several eons as in – the Hippocratic oath.
    S.