AMA says EHRs create 'appalling Catch-22' for docs - And just how many experts does it take to screw in a light bulb, anyway?

(NOTE:  this post, being about minor matters like death and financial mayhem, is particularly and unusually [even for me] biting and lacking in euphemisms and political correctness.  If you are easily offended and want the latter, and/or believe we all need to be 'nice' about banal issues like patient injury and death, fraud, and other minor matters, click here:  <b><a href="http://www.disney.com/">http://www.disney.com</a></b> and skip the post below.) <br /><br />You were warned.<br /><br />--------------------------------------- <br /><br />At some point, so-called EHR "experts" and pundits need to stop being accommodated for their having ignored years of warnings, complaints, "anecdotes" -a particularly egregious term that comes from those who don't understand risk management, especially academics of the echo chamber-egghead subspecies (<a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">link</a>) - and other signs that health IT is not a beneficent, omniscient gift from the <a href="http://en.wikipedia.org/wiki/Lords_of_Kobol">Lords of Kobol.</a> (The latter is a pun on the business-IT programming language Cobol, of course.)<br /><br />Instead, they simply need to be ridiculed for being stupid.<br /><br />I will do so:  folks, you have been, and remain, stupid:<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZE95zecrMVRB1bq9q2g01AUsab2c67jIhlE-ARIcXChO_6KSU5IP-c2sQpFyO-MiKOXWOOrpyAZAeWR-1L3VIpsiYWG_2dldo8bUN1af4BuG8p24xo2u2V_pTviw9_w3ZMLvXbAvwG9Zo/s1600/cow3.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZE95zecrMVRB1bq9q2g01AUsab2c67jIhlE-ARIcXChO_6KSU5IP-c2sQpFyO-MiKOXWOOrpyAZAeWR-1L3VIpsiYWG_2dldo8bUN1af4BuG8p24xo2u2V_pTviw9_w3ZMLvXbAvwG9Zo/s200/cow3.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">The Bovine Stare of Incomprehension (click to enlarge)</td></tr></tbody></table><br />The Bovine Stare of Incomprehension describes the reactions I've gotten over the years to many warnings about health IT.  It was like talking to a cow.<br /><br />So now there's this: <br /><br /><blockquote class="tr_bq"><a href="http://www.govhealthit.com/news/ama-says-ehrs-create-appalling-catch-22-docs">AMA says EHRs create 'appalling Catch-22' for docs</a><br />May 03, 2013 | Tom Sullivan, Editor<br /><br />As the healthcare industry moves to EHRs, t<b>he medical record has essentially been reduced to a tool for billing, compliance, and litigation that also has a sustained negative impact on doctors' productivity,</b> according to Steven J. Stack, MD, chair of the American Medical Association’s board of trustees. </blockquote><br />Gee, they're only realizing and complaining about that <b>- now?</b>  <b>In 2013?</b><br /><br /><blockquote class="tr_bq">“Documenting a full clinical encounter in an EHR is <b>pure tormen</b>t,” Stack said during the CMS Listening Session: Billing and Coding with Electronic Health Records on Friday. </blockquote><br />(What, the "pure torment" in such a mission-critical function only started with the most recent patches installed last month on the nation's EHRs?  EHRs were just dandy until then?)<br /><br />It's nice to know in May 2013 that “documenting a full clinical encounter <span style="color: red;"><i><b>[essential to avoid injurious and even lethal mistakes, I anecdotally note - ed.]</b></i></span> in an EHR is <b>"pure torment”</b>, several years into an accelerated "National Program for HIT in the HHS" costing hundreds of billions of dollars.<br /><br />I guess sites like this blog, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">this site</a> extant since 1998, and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist">other materials</a> written over the years by backwards stubborn health IT iconoclast fear-mongering Luddites were beyond the comprehension level of - t<i>hose now proffering the exact same pronouncements.</i><br /><br /><blockquote class="tr_bq">EHRs are also driving the industry toward charts that look remarkably similar because they’re based on templates created by the technology vendors — that includes often using the same words. <b>And that threatens to make doctors appear to be committing fraud by the practice of record cloning, or cutting and pasting from one record to another, when they are not, in fact, acting fraudulently</b>. </blockquote><br />I guess putting patients in mortal danger from note cloning (and to those too stupid to understand why that is, get off your rear end and look it up, I'm not going to spoon-feed you) is a step better than acting fraudulently...<br /><br /><blockquote class="tr_bq">Alongside the federal mandate to implement an EHR under threat of a monetary fine, that creates what Stack called “an appalling Catch-22 for physicians.”<br /><br />Put another way: The government mandates that doctors use an EHR, the EHR vendors’ templates can <b>sometimes create an appearance of fraud</b> and that, in turn, opens the door for payers to decline reimbursement or, even worse, the government to prosecute doctors for the crime.</blockquote><br />I guess actual fraud is just anecdotal.<br /><br /><blockquote class="tr_bq">As dire as that sounds, it's an exception that belies the unproven perception that EHRs perpetuate fraud. “<b>Upcoding does not necessarily equate to fraud and abuse,”</b> said Sue Bowman, AHIMA’s senior director of coding and compliance at the same event<b>. “This is an area where more study is needed. We really need to know the causes</b>. Further research is needed on the fraud risk of using EHRs.”</blockquote><br />Sure, let's study while rolling this stuff out as frantically as we can.  We'll fix it later -- and Jesus, I guess, will heal and reanimate any patients actually harmed by the technology (<a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">link</a> to <b>ECRI Institute Deep Dive Study</b>: 36 hospitals!  Nine weeks!  171 health information technology-related problems voluntarily reported!  Eight injuries!  Three possible deaths!  <b>All mere "anecdotes", of course</b>).<br /><br /><blockquote class="tr_bq">Indeed, Jacob Reider, MD, CMO of ONC, explained that the government and industry d<b>o not have good data right now proving whether or not EHRs trigger fraud and abuse</b>.</blockquote><br />Per the IOM, the same industry does not have good data on harms levels.  (The previous link to a recent small ECRI "Deep Dive" study's probably the most robust we've got on that score, and the figures are not encouraging).<br /><br />So - let's review -<br /><ul><li>poor data on harms, </li><li>poor data on benefits, </li><li>poor data on fraud and abuse.</li></ul><br /><b> The logical, ethical course of action thus is:</b><br /><b><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzFC_WsPusjorZPhSFY5JNJs4lrt-V5x8PZiENWJVqP7gPQUwxbtq0bhjwtsjUvHuXdwrMUrEOAhghWrHjEV5pRduQIHRcyj9uMkKL4OC1x87NkSBUQTkZ2MFlroX8uK0YIz8pxcKCC1jP/s1600/homer-simpson.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzFC_WsPusjorZPhSFY5JNJs4lrt-V5x8PZiENWJVqP7gPQUwxbtq0bhjwtsjUvHuXdwrMUrEOAhghWrHjEV5pRduQIHRcyj9uMkKL4OC1x87NkSBUQTkZ2MFlroX8uK0YIz8pxcKCC1jP/s200/homer-simpson.gif" width="165" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><b>D'OH!  LET'S ROLL THE TECHNOLOGY OUT AS FAST AS WE CAN, AND PENALIZE NON-ADOPTERS BESIDES!</b></td></tr></tbody></table></b><br /><br /><br />See how simple logic, ethics and clear thinking can be?<br /><br /><blockquote class="tr_bq">“There is concern that some doctors are using the EHR to obtain payments to which they are not entitled,” said Mickey McGlynn of Siemens Medical Solutions and HIMSS EHR Association. <b>“Any fraud is an important issue and we, as the vendor community, take that very seriously.”</b></blockquote><br />Only after independent whistleblower investigations by <a href="http://www.publicintegrity.org/health/medicare/cracking-codes">Fred Schulte of the Center for Public Integrity ("Cracking the Codes")</a>, and by <a href="http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?_r=0">New York Times reporters Reed Abelson and Julie Creswell</a>, that is...<br /><blockquote class="tr_bq"><br />AMA’s Stack offered a triptych of suggestions to CMS and ONC: address EHR usability concerns, provide guidance on EHR use for coding and billing, and make meaningful use stage 2 more flexible for providers.<br /><br /><b>“My purpose is not to denigrate EHRs</b>,” Stack said, explaining that he believes CMS and ONC are genuinely trying to better the current situation.</blockquote><br />Nice to have <a href="http://en.wikipedia.org/wiki/Caspar_Milquetoast">Caspar Milquetoast </a> on the side of EHR criticism.<br /><br />Knock knock, anyone home, McFly? <br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtRtjpOxhXTclN2k84gzTCHH0QfGVK4EArboCbP3IGByDNyfeuK8KnsHHBwxufCjhZMfBaX_fi2c3IJcMZ0Ld8LH_e9O9fNum3CO4Vrr-U1ZhuGyPRyBVFK3qZ_kYUNFkVGqyPAHOgcBZO/s1600/hello-mcfly1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="177" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtRtjpOxhXTclN2k84gzTCHH0QfGVK4EArboCbP3IGByDNyfeuK8KnsHHBwxufCjhZMfBaX_fi2c3IJcMZ0Ld8LH_e9O9fNum3CO4Vrr-U1ZhuGyPRyBVFK3qZ_kYUNFkVGqyPAHOgcBZO/s320/hello-mcfly1.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Knock knock, anyone home, McFly?</td></tr></tbody></table><br /><br />Today's EHR systems, for the aforementioned reasons above and more, <b>deserve denigration for patients' sake.</b><br /><blockquote class="tr_bq"><br />There are efforts underway, within the government and industry, <b>to more comprehensively understand the unintended consequences of EHR implementation.</b></blockquote><br />But let's keep rollin' em out, anyway.  Wheeee!  What fun!<br /><br />Class action attorneys, are you listening?<br /><br />-- SS<br /><br />

AMA says EHRs create 'appalling Catch-22' for docs - And just how many experts does it take to screw in a light bulb, anyway?

(NOTE:  this post, being about minor matters like death and financial mayhem, is particularly and unusually [even for me] biting and lacking...

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Michael Millenson and "the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence"

Over at <i>Health Beat</i> by Maggie Mahar appears a piece critical of NYT reporter Julie Creswell's Feb. 20, 2013 article "<a href="http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html" target="_blank">A Digital Shift on Health Data Swells Profits in an Industry</a>."  (The piece was also cross-posted at The Health Care Blog.)  There have been several responses highly critical of the NYT article recently in various venues.<br /><br />The Health Beat piece <b>"<a href="http://www.healthbeatblog.com/2013/03/the-health-it-scandal-the-ny-times-didnt-cover/" target="_blank">The Health IT Scandal the NY Times Didn’t Cover</a></b>" is by Michael L. Millenson, president of Health Quality Advisors LLC in Highland Park, IL, and the author of the critically acclaimed book, <a href="http://www.amazon.com/Demanding-Medical-Excellence-Accountability-Information/dp/0226525880" target="_blank"><i>Demanding Medical Excellence: Doctors and Accountability in the Information Age</i></a> published in 2000.<br /><br />I bought and read that book at the time.<br /><br />The posting at Health Beat contains the following statement:<br /><br /><blockquote class="tr_bq">The actual scandal is more complicated and scary. <b>It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence.  </b></blockquote><br />I am profoundly disappointed by this statement in view of issues (frequently written about here and elsewhere) such as: <br /><br /><ul><li>The <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist" target="_blank">conflicting literature</a> by credible and responsible parties on health IT's real-world value and risks as it exists today;  </li><li>Fiduciary obligations of hospital executives to maintain safe operating conditions; </li><li>Legal and ethical obligations of physicians to resist technology they find or believe harmful without rigorous proof of its beneficence and efficacy (which includes the absence of major evidence conflicts); </li><li>The evidence of major and frequent <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">flaws, bugs</a> and "<a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">glitches</a>", some of which are alarming; </li></ul>not to mention: <br /><ul><li>The 500+ reader comments in response to Creswell's article, many by clinicians describing why they don't like today's health IT; </li><li>Examples of unintended adverse consequences such as <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html" target="_blank">here</a> (plus at least 5 other IT-related crippling injuries and/or deaths of infants I know of but cannot speak about), and <a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" target="_blank">here</a>, and <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">here</a>; </li><li>Other factors as at this blog and at my teaching site <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">here</a>.</li></ul><br />I am trying to find a polite term for the statement, and struggling to do so in view of the author's prior work, which I admired.<br /><br />The statement really is saying:<br /><br /><blockquote class="tr_bq">... It [the "scandal"] has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence<i><b> ... </b></i><b><i>which is all exceptionally robust and positive, leaving no room whatsoever for reasonable doubt or caution.</i></b> </blockquote><br />Regrettably, here is the most polite term I can come up with describing the statement:<br /><br /><a href="http://thesaurus.com/browse/preposterous" target="_blank">Preposterous</a>.<br /><br />If anyone takes offense to that term, please suggest a more precise one.<br /><br />Perhaps a book needs to be written entitled "<i>Demanding Information Technology Excellence: Health IT and Accountability in the Information Age</i>." <br /><br />-- SS<br /><br /><b>Mar. 4, 2013 addendum:</b><br /><br />In a response to a reader's comment to the cross-posting of this piece at The Health Care Blog (<a href="http://thehealthcareblog.com/blog/2013/03/03/the-health-it-scandal-the-ny-times-didnt-cover/" target="_blank">link</a>), Millenson responds:<br /><br /><blockquote class="tr_bq">"platon20: my point, <b>that EMRs were available in the 1970s but never changed their interface because doctors never cared enough to demand it</b>, is not refuted by your argument, but confirmed."</blockquote><br />This is bizarre and inconsistent with my experience and that of other Chief Medical Informatics Officers I've mentored or spoken with.  Since my entry into the domain of Medical Informatics 21 years ago I've heard many physicians, myself included [1], demand that health IT sellers and/or hospital IT departments "improve the user interface", among other areas for improvement.  <br /><br />Based on my own observations and that of others (e.g., via reader <span style="font-size: small;">comments at my</span> teaching site dating to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/opinions1.htm" target="_blank">at least 1999</a>), these pleas have often fallen on the deaf - and in some cases ill-informed and/or incompetent - ears of hospital senior and IT executives and industry pundits.  The latter have often responded by accusing the physicians of being "Luddites" or technophobes, and the advocates for change such as myself "anti-health IT."<br /><br />The most stunning example regarding this phenomenon is the industry pushback against Prof. Jon Patrick at U. Sydney, and the ignoring of his work (on both the user experience and the fundamental software engineering quality) sitting on a University server for several years now, regarding a major U.S. ED EHR <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">slated for rollout in an entire state of Australia</a>.   <br /><br />With usability issues now being forced of the industry for reconsideration by HHS via NIST, the industry response has been to claim that "<a href="http://ehrdecisions.com/2011/05/11/from-the-chair-usability-still-in-the-eye-of-the-beholder/" target="_blank">usability is in the eye of the beholder</a>" and other frivolous claims, up to and including <a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html" target="_blank">interference in the the public comments period on Meaningful Use via ghostwriting</a>, and possibly <a href="http://hcrenewal.blogspot.com/2010/05/did-epic-ceo-judy-faulkner-of-epic.html" target="_blank">outrageous statements</a> (although that issue became anechoic), to get their way, which is to do little or nothing on that score.<br /><br />I remind Millenson that "improving the user experience" of health IT cuts into the bottom line.<br /><span style="font-size: x-small;"><br /></span><span style="font-size: x-small;">[1] e.g.,  in a project initiated 20 years ago <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story" target="_blank">by the clinicians themselves</a> - in a critical care area no less - in which I had to take over through force of will from the hospital's own IT department and COO and  re-engineer not just the commercial user interface but the <i>entire dataset itself.</i>  The project ultimately proved successful after my intervention, but the mid-level executive who facilitated my takeover to do that, and I, were punished by our superiors for our efforts<span style="font-size: x-small;">.</span> </span><br /><br />-- SS <br /><br /><br />

Michael Millenson and "the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence"

Over at Health Beat by Maggie Mahar appears a piece critical of NYT reporter Julie Creswell's Feb. 20, 2013 article " A Digital Sh...

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New York Times: "A Digital Shift on Health Data Swells Profits in an Industry"

The New York Times has published an article today by Julie Creswell entitled "<b>A Digital Shift on Health Data Swells Profits in an Industry.</b>"  It is available <a href="http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html" target="_blank">at this link</a>.<br /><br /><blockquote class="tr_bq"><div itemprop="articleBody">... While proponents say new record-keeping technologies will one day reduce costs and improve care <i><b><span style="color: red;">[only when today's bad health IT is abolished - see</span> <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">here</a> <span style="color: red;">- ed.]</span></b></i>, profits and sales are soaring now across the records industry. At Allscripts, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry. At the <a class="meta-org" href="http://topics.nytimes.com/top/news/business/companies/cerner-corporation/index.html?inline=nyt-org" title="More information about Cerner Corporation">Cerner Corporation</a> of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays. </div><div itemprop="articleBody"><br /></div><div itemprop="articleBody">None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records. </div></blockquote><br />The article does not reveal anything that readers of this blog did not know already.<br /><br />The push for the financial incentives and profits were also written about at the The Huffington Post Investigative Fund by investigative reporter <b>Fred Schulte</b>, now at the Center for Public Integrity ("<a href="http://www.huffingtonpost.com/2009/11/05/stimulus-fuels-gold-rush_n_347311.html" target="_blank">Stimulus Fuels Gold Rush For Electronic Health Systems</a>"), and in the Washington Post by <b>Robert O'Harrow Jr</b>. (which I wrote about at this post:  <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html" target="_blank">The Machinery Behind Healthcare Reform: How the HIT Lobby is Pushing Experimental and Unsafe Technology on Unconsented Patients and Clinicians</a>). <br /><br />Rather than re-hash the issues, I wanted to focus on some of the current NYT reader comments:<br /><br /><br /><blockquote class="tr_bq">... After a visit to a Florida hospital for suspicion of heart attack, I asked for a copy of my records to give my home (IL) physician. I was shocked to read that I had had "anal surgery." When I reviewed these records with my doctor, she told me that I had probably told the admitting ER nurse I had recently had a colonoscopy, so the closest coding information their electronic system allowed was anal surgery. So, how can these inaccuracies which will live on forever electronically be helpful toward patient care? The old acronym GIGO certainly applies here--garbage in; garbage out.<br /><br />... This article highlights only one aspect of the "Failed Promise of Electronic Health Records". Through lobbying but also supported by a study from the RAND organization, the three final 2008 presidential candidates, Hillary Clinton, John McCain, and Barack Obama outbid each other with promises to spend billions to entice doctors to use electronic record systems. Unfortunately, because of unsolved documentation problems, such systems are often disliked and slow the process. Instead of creating interoperability, electronic medical record systems (EMRs) with limited functionality and benefits were created. In particular, true interoperability has been neglected and attempts to create it through networks in the form of CHINs, RHIOs, and HIEs have failed. <br /><br />... Mr. Tullman's comment is priceless. “I think it’s very common with every administration that when they want to talk about the automotive industry, they convene automotive executives, and when they want to talk about the Internet, they convene Internet executives." Of course, when "they" want to radically alter the way doctors do their jobs, "they" talk to academics, lawyers, publicly traded insurance CEOs and internet executives. Today's diatribe about quality care being more important than quantity care is laugh out loud funny. Unless you're a physician. Only in America does getting paid less and less, with more clerical data entry record-keeping at every step just to get paid and protect against lawsuit, translate into an incentive to provide quality care. Somebody prescribe a dose of common sense. Oops. Too late.<br /><br />... Every person needs a national health ID with up to date health information. To say that the current EMR systems are problematic would be an understatement. They take away face time with patients, the M.D.'s talents and time are wasted doing data entry and worst of all ,they are potentially dangerously flawed. An example is a recent patient I saw who was treated by a number of physicians. His medications had required significant changes which were done by 2 different M.D.'s from his main doctor. Both gave him computer generated lists from the same system. Both had a mixture of unmatching generic and proprietary names, the patient's actual medicines from the pharmacy had a mixture and different doses from the Dr.'s orders. He was trying to set up his week's supply. But didn't know which proprietary name went with which medicine. These systems should have been tried out on a small scale and approved by M.D.'s before this became law. The VA system which is time tested, physician friendly and free only the VA is using. These other systems are set up to maximize profits for the IT companies, cost the physicians huge amounts to install, cost the hospitals huge amounts esp when they are changing from one system to another due to problems when they were advertised to maximize hospital billing. This another example of our distorted legislative process where profits and politics take precedence over people.<br /><br />... I am a dermatologist in private practice who teaches at a local medical school part time. Electronic records are problematic. Every doctor I know feels they take time away from being a doctor. I literally don't know a single colleague who feels their benefits are worth the extra time involved. In medical school, we learned how to record notes in medical records so that patient care is improved from visit to visit. In short, we use notes from the previous visits to assist in our decisions in subsequent examinations. In today's digital world, most doctors I know are forced to change their notation style to justify payments from insurance companies. The more detailed the note in the medical record, the lower the chance that an insurance company downgrades the fee charged to the patient. Thus, notes are now longer and more detailed than they were ten years ago. The problem with such notes is that they are filled with detritus geared to prevent payment reduction rather than aimed at improving continuity of patient care from visit to visit. The impact of this adoption of electronic medical records is that insurance company computer systems can easily sift through notes to reduce compensation to doctors who spend more time with patients and who write cleaner, more efficient notes.<br /><br />... I still use pen and paper.  One requirement would fix this mess: interoperability No, NOT the "industry supported" standard. Thats a joke. Industry wants NO inter-operability because they want to lock us in to a an individual product, The government has a great EMR (the VA system). All commercial ones should be forced to be able to export data in a way that is 100% compatible with that. As such, they would then be 100% compatible with each other. Some of my colleagues are now on their third EMR product in 7 years. Why? Big company buys company B and then stops supporting it. The doctor is forced to switch to Big Company's new product. Of course the data does not transfer over so the doctor has to go through the crude data-entry mess all over.<br /><br />... The folly of relying only on digital records. Without constant and costly software and hardware upgrades, your digital medical records will be rendered obsolete. Could be a matter of years or decades, but it will happen. Not only that, digital proprietary systems are at huge risk if the private for-profit company goes bankrupt. Paper records can last 1000 years.<br /><br />... Another scam. Very expensive and involved for end user:ie doctor. Have had to hire an IT company to assist, have to pay annually for service contract, upgrades and what the article didn't mention was the "meaningful use" criteria that all doctors have to comply with in order to pass government inspection for a rebate. The software vendors, labs, and others are charging doctors extra for software upgrades and abilities to comply with each "meaningful use" component . This is already costing more money and aggravation than the worth of the government rebate. Who will subsidize this? Doctors are starting to lose interest. We know this is another corrupt government sponsored ploy and only the tip of the iceberg. If the government were to have spent the 19 billion with a consortium of vendors such as google apple and microsoft, the goal of free software provision capable of interexchangeable data would likely have been completed with all providers on board.<br /><br />... Common sense can tell you that the real value of these systems is marginal. Much of medical treatment is "incident specific" where history is not necessary. Most PCP's already have a system that works. In larger systems and for complex diseases, perhaps EMR are beneficial but not for routine care. As has been noted, all sorts of problems arise with EMR's: destruction of MD-pt relationship, incorrect data being entered and never removed, cumbersome and expensive requirements of instituting and maintaining the system, etc. It is awful that physicians and patients are "used" in the service of politicians and EMR execs.<br /><br />... As a practicing physician I have to struggle everyday with the Citrix and Quickbase electronic records. The Electronics Medical Records industry has been getting the gold promised by the government in exchange of a very poor and deficient product. The EMR industry has been selling to the healthcare providers, in need of electronic records, the equivalent of the Formaldehyde-contaminated trailer homes sold to FEMA for the Katrina homeless.</blockquote><br />These are just from the first page of comments.  Read the article and the comments at the link above.<br /><br />My observation is that it seems that as transparency increases, the public "gets it" that these systems are not the panacea the industry wants us to believe, and may impede the clinicians trying to treat them.<br /><br />Now, when will the government "get it" that they've been had?<br /><br />-- SS<br /><br />Addendum:  another "anecdote" just caught my eye because it sings an unfortunate familiar tune to me:<br /><br /><blockquote class="tr_bq">So much data, so little knowledge. <b>My best friend's father just died because none of his who-knows-how-many physicians took the time to actually read and anaylze the reams of info they were dutifully inputting. They killed him with an overdose of one drug and not enough of another.  </b>Useful data collection and analysis is one thing, but what we seem to have now is just institutionalized hoarding. More data doesn't make anyone safer (except the data companies), just like stacks of old magazines or cans of beans makes one safer. More is NOT better; it is just more. More time and more expense wasted on stuff and less spent on actual health care. You've got to USE anything or it is just more useless and potentially dangerous stuff. </blockquote><br />-- SS

New York Times: "A Digital Shift on Health Data Swells Profits in an Industry"

The New York Times has published an article today by Julie Creswell entitled " A Digital Shift on Health Data Swells Profits in an Indu...

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New York Times: "In Second Look, Few Savings From Digital Health Records", and AMA Med News on EHR Harms

This post should perhaps be entitled <i>"I told you so."</i><br /><br />A letter I wrote in response to the Wall Street Journal's "<a class="" href="http://online.wsj.com/article/SB123431432273870909.html">A Health-Tech Monopoly</a>", Feb. 11, 2009 was <a href="http://online.wsj.com/article/SB123492035330205101.html">published</a> Feb. 18, 2009 under the header <span style="font-weight: bold;">Digitizing Medical Records May Help, but It's Complex</span>.<br /><br />I wrote:<br /><br /><blockquote class="tr_bq">Dear Wall Street Journal,<br /><br />You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.<br /><br />I have a different view on who is deceiving whom. In fact, <b>it is the government that has been deceived by the HIT industry and its pundits.</b> Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. <b>The beneficiaries will largely be the IT industry and IT management consultants.</b><br /><br />For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors.<br /><br />HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine.<br /><br />The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. <b>The government has bought the IT magic bullet exuberance hook, line and sinker.</b><br /><br /><b>I can only hope patients get something worthwhile for the $20 billion.</b><br /><br />Scot Silverstein, M.D.<br /><i>Faculty, Biomedical Informatics</i><br /><i>Drexel University Institute for Healthcare Informatics</i><br /><i>Philadelphia</i></blockquote><br />I also had penned essays on the need for a moratorium on HITECH (Nov. 2008, "<a href="http://hcrenewal.blogspot.com/2008/11/should-us-call-moratorium-on-ambitious.html" target="_blank">Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?</a>" and Jan. 2009, "<a href="http://hcrenewal.blogspot.com/2009/01/i-ask-again-should-us-call-moratorium.html" target="_blank">I Ask Again: Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?</a>").  My theme was that the issues with implementation of good health IT and elimination of bad health IT, and the issue of how to implement most efficiently, needed to be better understood before a national rollout.  Hold off multi-billion dollar national initiatives "<span style="font-weight: bold;">until we know how to get HIT right</span>", I wrote.<br /><br />Now the New York Times has this, citing a new RAND paper:<br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><b><a href="http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html" target="_blank">In Second Look, Few Savings From Digital Health Records</a></b></span><br />By REED ABELSON and JULIE CRESWELL<br /><br />January 10, 2013<br /><br />The conversion to electronic health records <b>has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care,</b> according to a new analysis by the influential RAND Corporation.<br /><br />Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.<br /><br />“We’ve not achieved the productivity and quality benefits that are unquestionably <span style="color: red;"><i><b>["unquestionably?" why?- ed.] </b></i></span> there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.</blockquote><br />Noted is the provenance of the 2005 report that created the windfall for the electronic records industry:<br /><br /><blockquote class="tr_bq">RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.</blockquote><br />A retraction: <br /><br /><blockquote class="tr_bq">The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure <b>RAND now says was overstated.</b> The study was widely praised within the technology industry and <b>helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems ... </b>But evidence of significant savings is scant, and there is increasing concern that electronic records <b>have actually added to costs</b> by making it easier to bill more for some services.</blockquote><br />In my Feb. 2009 WSJ letter, I'd written that "<i>it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.</i>"  It appears I was correct. <br /><blockquote class="tr_bq"><br />Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.</blockquote><br />Not mentioned are harms that bad health IT is creating.<br /><br /><blockquote class="tr_bq">The recent analysis was sharply critical of the commercial systems now in place, many of which are hard to use and do not allow doctors and patients to share medical information across systems. “<b>We could be getting much more if we could take the time to do a little more planning</b> and to set more standards,” said Marc Probst, chief information officer for Intermountain Healthcare, a large health system in Salt Lake City that developed its own electronic records system </blockquote><br />A "little more" planning?  How about several years' worth, to ensure the technologies are safe, effective and properly vetted, along with a system for post-market surveillance as exists in other healthcare sectors?<br /><br /><blockquote class="tr_bq">Technology “is only a tool,” said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. “Like any tool, it can be used well or poorly.” While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.</blockquote><br />Dr. Blumenthal seems to be triangulating from his <a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html" target="_blank">earlier 2010 NEJM statement that</a>:<br /><br /><blockquote class="tr_bq">... <span style="font-size: 100%;">The widespread use of electronic health records (EHRs) in the United States <span style="font-weight: bold;">is inevitable</span>. EHRs <b>will</b> improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they <b>will demand</b> nothing less from their providers. Hundreds of thousands of physicians have <b>already seen these benefits</b> in their clinical practice.</span></blockquote><br />Meantime, in the real world signs of my expressed concerns about a quagmire are appearing:<br /><br /><blockquote class="tr_bq">... Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously.</blockquote><br />A clue as to the candidness of the new report: <br /><br /><blockquote class="tr_bq">... The new analysis was not sponsored by any corporations, said Dr. Kellermann, who added that some members of RAND’s health advisory board wanted to revisit the earlier analysis.</blockquote><br />Finally, this from the horse's mouth:<br /><br /><blockquote class="tr_bq">Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. <b>In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.</b></blockquote><br />I repeat my admonition from 2009 that <i>I can only hope patients get something worthwhile for the $20 billion</i>, which by now is probably many times that amount.<br /><br />Finally, I note the American Medical News cites me in a <a href="http://www.ama-assn.org/amednews/2013/01/14/prsa0114.htm" target="_blank">Jan. 14, 2013 article</a> as follows:<br /><br /><blockquote class="tr_bq">... Other experts on health IT said the Pennsylvania [PA Patient Safety Authority] study probably underestimates the extent of health IT safety problems. They say that is because the research is based on voluntary reports and that health professionals are unaware that a patient safety incident was caused by an EHR failure.<br /><br />“These systems are incredibly complex,” said Scot M. Silverstein, MD, a consultant in medical informatics at Drexel University in Philadelphia. “They’re not just huge filing cabinets, they are enterprise resource management systems. There are many ways that things can go wrong that may not be seen as the computer having caused the mess-up in the first place.”<br /><br />For example, he said, it would be difficult for a practicing physician to detect when data are missing from a record or that an alert failed to pop up.</blockquote><br />Yet the title of the article is "<a href="http://www.ama-assn.org/amednews/2013/01/14/prsa0114.htm" target="_blank"><b>EHR-related errors soar, but few harm patients</b></a>" with a table at the bottom labeled "<b>How rarely EHR problems harm patients</b>." More evidence that EHRs always receive special accommodation.  <br /><br />I was an invited reviewer of the PA Patient Safety Authority report, and wrote about the major deficiencies of its dataset at my posts Dec. 13, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/12/pennsylvania-patient-safety-authority.html" target="_blank">Pennsylvania Patient Safety Authority: The Role of the Electronic Health Record in Patient Safety Events</a>" and a follow-up Dec. 19 post "<a href="http://hcrenewal.blogspot.com/2012/12/a-very-signifcant-additonal-observation.html" target="_blank">A Significant Additional Observation on the PA Patient Safety Authority Report -- Risk</a>."<br /><br />My major point was that one simply cannot know what one cannot know, when using a very incomplete dataset gathered in a setting of <b>systematic impediments to accuracy and completeness</b>.  For instance, as I wrote in those earlier posts, through my work I personally know of cases of harms up to and including death that should have been in the PA database, but apparently are not - and I'm just one person.<br /><br />We simply don't know in 2013 how many EHR errors harm patients, and the effects of increasing adoption by organizations and physicians less technology-able than current adopters.  I hope the magnitude of harms is truly small, but hope is not enough; this study and report was just a 'dipping of the toes into the water' towards understanding the realities.<br /><br />Incidentally, we also don't know how severely the known toxic effects of bad health IT might affect care in times of duress, e.g., an epidemic.  However, I am certainly not sanguine about EHRs in their present state as robustly facilitating national emergency preparedness.<br /><br />My dreaded prediction for the future?  A 2016 AMA News story entitled "<b>Known EHR-related harms soar</b>."<br /><br />-- SS

New York Times: "In Second Look, Few Savings From Digital Health Records", and AMA Med News on EHR Harms

This post should perhaps be entitled "I told you so." A letter I wrote in response to the Wall Street Journal's " A Healt...

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