The HIT Job

The HIT Job

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I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).

Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”

Moreover, in the last few years we’ve gained a deeper understanding of the hazards of HIT, including new kinds of errors created by the stormy marriage of imperfect computer systems and fallible humans. We’re also becoming familiar with subtler problems, such as the copy and paste phenomenon now plaguing progress notes and the degree to which computers can distance us from our patients (Abraham Verghese’s “iPatient”). These problems are all-the-more irritating since IT was hyped – overhyped – as the solution to so many of healthcare’s woes.

So it’s natural to be disappointed in the present state of HIT, and even to wonder whether HITECH is on target. But overall, I believe that we are on the right track, that there is no better way to get to an HIT Promised Land than the path we are taking, and that the Federal government should be commended for getting involved in a reasonable way.

In the February 19th issue of The New York Times, one of the most off-base, unbalanced articles in my recent memory paints a very different picture.The paper’s lead article – yes, Page 1, Column 1, above the fold, called, “A Digital Shift on Health Data Swells Profits in an Industry,” focuses particularly on the consequences of HITECH. The reporter, Julie Creswell, does raise some new and legitimate concerns, such as the degree to which HIT vendors have jumped into Washington’s toxic swamp of money and politics.

Yet the tone of the article is inordinately conspiratorial about HITECH, and downright dismissive regarding the overall value of HIT. Creswell’s sources are disproportionally slanted to HIT skeptics, including her choice to quote my UCSF colleague Mike Callaham, who pronounced our Epic system “lousy.” (I’d venture to say that most people at UCSF – including me – find the system imperfect but pretty good. Moreover, we switched to Epic, a company that Creswell paints as a Goliath, only after a dismal experience with a different system built by GE, a $240 billion behemoth of a company whose electronic health record product is foundering in the HITECH world.) After reading the Times piece, I found myself in full agreement with Mark Hagland, editor of Healthcare Informatics magazine, who wrote,

The opening one-sentence paragraph says it all. Creswell writes, of a presentation by the Chicago-based Allscripts to physicians in 2009, “It was a tantalizing pitch: come get a piece of a $19 billion government ‘giveaway.’” First of all, characterizing HITECH as a “giveaway,” without in any way mentioning the penalties embedded in the law for providers who haven’t implemented electronic records (EHRs) by the end of 2015, is simply irresponsible journalism….

Ms. Creswell could easily have noted that no other large industry in the United States remains even remotely as paper-based as healthcare… or that study after study has confirmed the benefits to patient safety, care coordination, and cost-effectiveness of the automation of patient records. [The story] will undoubtedly be read by many thousands of laypeople who may or may not have any sense of how misguided and distorted its core thesis is.

The Times article ends as skewed as it begins: with a backhanded reference to the “gold-rush mentality” of today’s HIT players.

Let’s pause to ask a few questions: Does anyone honestly believe that computerizing American healthcare is wrongheaded? Or that the correct strategy was to continue toe-tapping, waiting for “the market” to promote IT adoption when, in 2009, only 16 percent of both US hospitals and doctors’ offices had functioning clinical IT systems? Or that they would like to be a patient, or a clinician, in a paper-and-pencil hospital?

I didn’t think so.

In 2004, then-president George W. Bush asked David Brailer – a brilliant MD and PhD in economics – to direct a new federal office of healthcare information technology, whose primary goal was to promote IT adoption. Brailer and his staff realized that a top-down program that had Washington forcing computer purchases on doctors and hospitals would be a disaster. (In fact, such a strategy was adopted by the UK’s National Health Service – a centralized, command-and-control initiative that, in 2011, was deemed a fiasco and junked, at a cost to British taxpayers of $19 billion.)

Instead, Brailer began planning a program consistent with American values, one that would allow physicians and hospital leaders to choose their own vendors, and encourage market competition. The plan that he and subsequent heads of the Office of the National Coordinator for Health Information Technology (ONCHIT) developed was to fashion a set of standards – relatively easy to reach at first and progressively more ambitious over time – and then to find the cash to fuel a national incentive program. They found the booty (about $20 billion worth) in 2009 when Congress and the president were seeking “shovel-ready” projects to include in the $700 billion federal stimulus package.

That, my friends, is the crux of the story. The meaningful use standards were developed and disseminated after extensive public comment. The IT vendors, a sleepy industry of true survivors (many of them barely maintained their pulses for over a decade, just hoping that the day would come when HIT adoption finally tipped to their side), did what all U.S. businesses would do when the feds were considering tossing money in their direction: they hired lobbyists and made campaign contributions. I don’t love this (and there is a risk that the Epics of the world will succeed in thwarting competition by scrappy upstarts), but that is our system, and any responsible business would have done the same thing – in fact, they’d be stupid not to.

It’s not a conspiracy. It’s America.

And trumping everything, the program has worked. The HIT adoption curve, previously stuck on flat, is now extraordinarily brisk: by 2011, 35 percent of US hospitals had functioning electronic health records, more than double the percentage of 2009; a similar surge has been seen in outpatient practices. The literature continues to demonstrate that, overall, these systems do reduce medical errors and harm. The promise of easier data collection to fuel transparency, pay for performance, and quality improvement activities will soon be realized, and we will ultimately enter the long-awaited world of “Big Data” in healthcare – one in which we can aggregate patient-level data on millions of patients, paving the way for more efficient methods of determining best practices and risk factors.

There have been problems. The systems are not great, and the vendors – including Epic – are putting most of their energy into keeping up with the insatiable demand for installations, and relatively little into improvements. Studies have demonstrated that the promised productivity gains have been weak to nonexistent. We have the aforementioned problems with IT-based errors and new challenges to clinician-patient communication. But the history of IT innovation is one in which systems become optimized only after many cycles of user feedback and vendor improvements. That cycle is beginning to play out, and the result is sure to be better, more mature HIT over time. There is no shortcut.

The Times (full disclosure, my wife Katie Hafner, writes about healthcare and technology for the newspaper) has covered HIT, including its glacial pace of adoption, responsibly, up to now. The Creswell piece, by failing to acknowledge the value of healthcare IT, the absolute necessity of wiring our healthcare system, and the fact that a federal program to kick start this process was a perfectly reasonable policy approach, was unbalanced and unfair. While a cautionary note is welcome, one could come out of reading this article clamoring for a Congressional investigation of the HITECH program and of the activities of Epic, Cerner, and Allscripts. If our goal is to find ways to create an improved, and ultimately less expensive, healthcare system, such a response would be unwise, even counterproductive.

The HIT industry, and those who regulate it, don’t need any special favors, and the Fourth Estate should keep a close eye on things, particularly now that there is gold in them thar hills. But as journalists are drawn to the increasingly vibrant world of healthcare information technology, it will be important that they do their homework and strike a balanced tone. The Times piece, I’m afraid, was a HIT job.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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44 Comments on "The HIT Job"


Guest
Dr. Rick Lippin
Feb 26, 2013

” I don’t love this (and there is a risk that the Epics of the world will succeed in thwarting competition by scrappy upstarts), but that is our system, and any responsible business would have done the same thing – in fact, they’d be stupid not to”

No Dr. Wachter- America is NOT only about the free market and paid lobbyists

Dr. Rick Lippin
Southampton, Pa

Member
Feb 26, 2013

Dr. Lippin, you are correct, I know several physicians in the Chicago area that use an EMR system that one of their techie buddies made as a hobby. They’ve been using the system for a few years now and for the most part they’re happy about it.

However, I agree with Dr. Wachter that giant EMR companies can easily thwart competition. Going head to head with Epic, a company with their long contractual buying cycles, aggressive marketing team, and product that many docs say is “pretty good,” would be hell on earth.

Maybe the next big thing in EMR won’t come from these industry monstrosities, but rather from a handful of people who know how to do it right. Perhaps that’s what the free market is about in the first place.

Guest
Feb 26, 2013

In liked my tweet the best– Dogs licking sores all over again bit.ly/Y8SD8T #newyorktimes

Guest
southern doc
Feb 26, 2013

Terrible, terrible post.

The NYT article was about the financial wheeling and dealing that were necessary to get doctors to buy a product that wasn’t selling on the open market. The author states briefly and correctly that some like EMRs, some don’t. She does not address the clinical benefits of HIT.

But Dr. Wachter, posting from inside the bubble, finds any article that is less than 100% positive regarding EMRs to be “off-based and unbalanced.”

Pathetic.

Guest
Feb 26, 2013

I don’t agree that the NYT piece was that far off the mark. However, I do agree that wiring healthcare is deeply necessary, and the current path is the best one we’ve got to achieve that … until a better approach comes along.

The part in the Times piece that I thought hit the nail squarely on the head, and that Doc Wachter doesn’t give enough shrift to, is the risk that big players like Epic will literally squash open-source development in HIT like a bug. (Note: the NYT and Wachter did not use those words. They’re all mine.)

’70s “vendor lock-in” IT thinking is what’s driving a lot of EHR technology development, and sales. That’s the infection that’s gotta be cured. Until that happens – and with the big players throwing money at regulators via K Street, the infection remains untreated – the frustration with what’s implemented will remain, and accelerated development won’t be as possible.

HIT’s goal is purportedly to break data silos, and enable better care across the system. Unfortunately, right now we have 700+ new, smaller silos, with little to no wiring created to share the data effectively outside the EHR bubbles. When that starts to happen – really, not just in someone’s project outline – then I’ll start cheering.

Guest
Feb 26, 2013

Whatever the intent, and I believe it was mostly good, I’m not sure that the “American way” has always been to hand out cash for doing the right thing. Traditionally, we handed out tax deductions to encourage spending on goods and services, thought to be beneficial (e.g. energy efficient appliances, education, charity, etc.).

I don’t see why we had to hand out cash here, most of it to large corporations that don’t really need it. Of course, if this was a tax based incentive, all those “charitable” non-profits that are now raking in most of the HITECH money (for something that they were doing anyway), wouldn’t have gotten as much taxpayer support in a recession….

Member
Feb 26, 2013

If Creswell’s article is irresponsible journalism for showing how government spending can be bad for health care, is it irresponsible doctoring for telling a patient that smoking may lead to lung cancer? Allocation of federal funds have the power to transform the ecosystem of medicine from the inside out. Although Creswell’s article may have had a toe outside the line, we’re better off knowing the failures of EMR policy, lest we have to eternally settle for “cream of the crap.”

Guest

RE “In 2004, then-president George W. Bush asked David Brailer – a brilliant MD and PhD in economics – to direct a new federal office of healthcare information technology…”

What does Brailer think of the result? A “colossal strategic error.”

What do I think?

“By the way, to just to be clear, I am much in favor of digitizing health data. The problem is that we digitized the “Data-at-Rest” but not “Data-in-Motion” or “Data-in-Use.” Between an unequal playing field created by Meaningful Use and inadequate technology (see My Fixing Our Health IT Mess), we precipitated a “colossal strategic error” (in the words of the our first health information czar).”

From:

Wordle Based on 40,000 Words in 500 Comments to NYT’s “Digital Shift on Health Data Swells Profits”

http://chuckwebster.com/2013/02/social-media/wordle-based-on-40000-words-in-500-comments-to-nyts-digital-shift-on-health-data-swells-profits

Referenced:

Fixing Our Health IT Mess: Are Business Models or Technology Models to Blame?

http://chuckwebster.com/2013/01/healthcare-bpm/fixing-our-health-it-mess-are-business-models-or-technology-models-to-blame

Guest
Feb 26, 2013

I don’t believe that anyone doubts that information technology can and will have profoundly positive impacts on healthcare quality, safety and efficiency.

Reasonable people can question whether the HITECH program’s structure and execution have been successful: The real question is: Have HITECH and its execution by ONC been successful or failed policy?

The role of ONC, as Dr. Wachter correctly notes, is to “promote IT adoption.” That means that the Office of the National Coordinator’s role is to cheerlead and promote adoption of certified EHR systems and its performance is measured by the number of eligible providers that adopt and “meaningfully use” certified EHR systems. Part and parcel in ONC achieving “success” in this role is to remove any barriers to adoption and to discredit and discount concerns or issues, legitimate or otherwise, that could slow adoption (of commercial systems).

HITECH injected a massive amount of money into an industry with products that its customers largely hadn’t wanted to buy or go through the trouble of implementing. The timeline and structure of HITECH necessitate that healthcare organizations buy and implement what is/was on the market and not what is/will be needed to support the models of care envisioned in health reform and to move us away from the FFS hamster wheel. To really get to the triple aim…to coordinate care…to unlock the value of big data, will health systems have to rip and replace the systems that HITECH funded?

HITECH failed to spur real innovation in health IT. Meaningful Use, as it has been structured, has driven some incremental improvements and evolution in systems but the systems of today are largely the systems of yesterday. Same heterogeneous data models that ensure that quality reporting is cumbersome and problematic. Same problems with usability. Same problems with interoperability. Same bugs, legacy platforms and shoddy development that reflect the EHR industry’s heritage as a cottage industry of piece-part acquisitions and insular cults of personalities.

Because ONC views it as counter to its mission, it has largely ignored and overlooked establishment of an oversight framework to learn from HITECH and has failed to drive the EHR industry to collaborate on foundational issues and to police itself. There is currently vague talk of an industry code of conduct…but will it materialize and amount to anything in a way that ensures that there is transparency in the EHR marketplace, that health IT-contributed errors are known and acted upon?

This has also been a failure of healthcare organizations to demand more of the EHR industry and to demonstrate how they’re going to turn the taxpayers’ investment in HITECH into better care.

And a failure of Congress to ask hard questions.

Guest
Lynn in SC
Feb 26, 2013

Reading through this discussion, I’m reminded of the early days of electronic billing. At least with the electronic bill there was an agreed format and a single purpose to collect data to get reimbursed. It wasn’t pretty and many physicians spent thousands and thousands of dollars on hardware and software not to mention coding clerks and other administrative staffs.
These memories were so painful that when faced with EHR and meaningful use, many physicians ran to their hospitals and said, “please employ me. I promise I’ll be good. ”
HIT is the right direction but I see a journey undertaken with only a compass…no map…no GPS but the persistence that we need to do this. But like everything in health care today….someone’s cost is another person’s profits.
As long as the health care remains mired in an information imbalanced between providers, insurance, and patients, it will behave as an unregulated monopoly or oligopoly.

Guest
Feb 26, 2013

My 2 cents:
HIT is designed to make the health care system work better. This sounds like an innocent statement of fact that could not possibly be a bad thing, except when you consider what the “health care system” is: the payment system. HIT has been shaped by the payment system and is an enabling tool to allow increased complexity (i.e. more data faster). This is, again, possibly not a bad thing, except when you consider what gets left out: patient care.

As a doctor who used to be in the forefront of HIT, even talking at NIH alongside the national coordinator of HIT, I used to agree with the “good direction” theory. Then I left our health care system to practice care that was centered on the patient, not documentation or payment and discovered something: peel away the HITECH, E/M, and other “Health Care System” parts of an EMR and you don’t have much. Patient care is buried in the detritus of the payment system. I didn’t see this as a doctor in the system because my main task was to deal with the system; now my main task is to give care and communicate with patients and the IT is woefully deficient in this.

I challenge the defenders of HIT and the use of programs like ACO’s, PCMH and others to see if the emperor is really wearing clothes. What of the physician-patient encounter? Lost in all of this are the two entities who the whole system is supposed to be about: the one providing the care and the one getting care. Neither seems to gain much by any of these initiatives.

Guest
Feb 26, 2013

I always take your admonitions seriously, giving that you are actually walking the talk.

I hear such vastly varied pro- and con opinions about Epic, I can’t tell if it’s “The Cream of the Crap” or “The Turd That Just Won’t Flush.”

Be interesting to see what throwing ICD-10 into this sHITstorm will end up doing.

Guest
Feb 26, 2013

You got it all wrong, Rob. The system is supposed to be about consumers, providers, margins, expenditures, capital investments, risk and speculation, market-share, campaign financing, dividends, etc. Those two entities you mention are incidental to the above.

Guest
J. Stefan Walker, M.D.
Feb 26, 2013

Rob,
Good points from the real world, and good posts; however on this, I have a different conclusion: the need for accountability (MU, Hedis, PQRS, better coding systems) and more granular data are absolute necessities in any attempt at a new healthcare model that unleashes the powers of automation and maximizes technology for optimal patient care. Yet there is just no way to help patients without the fiduciary, trust-based dyad of doctor and patient. Our path forward is both-and, not either-or. When the two methods conflict, we must choose the latter, but I think the next step lies in standardization of the data elements and even in the how-to of incorporating the EMR into the actual patient interview. We need to create the standardized passenger jet and its cockpit so we can retrain us biplane pilots to fly such jets, and teach the new docs how and when to use autopilot and other assisted in flight controls…and when not to. To the point of this article here, I agree with the author that HITECH and the current incentives did better than expected, and are cause to celebrate – as well as continue moving this forward. For all the imperfections (no interoperability yet?!?; lack of safety and usability testing; etc), there are for many, still ways to make the new systems work; although at a considerable toll on many (financial; stress). However, I really believe there is room in the emerging system for alternative models such as your own; indeed, for all my support of a new system, I remain fairly dogmatic about the doctor autonomy thing and keeping care fairly legacy-like in my biplane practice…until it is clear patients will be served better by the new jets we will someday fly.

Guest
bev M.D.
Feb 26, 2013

Criticism of HITECH has been unrelenting, some of it accurate. However, let’s not forget there is only one way out of this mess – forward. We cannot go backward. Therefore, the only solution is to incentivize better EHR systems by exerting all the pressure we can bring to bear on both the government and the industry to provide a better product. If that means anti-trust action against EPIC or others, so be it. But users, never forget – you can criticize and Monday morning QB all you want, but the only way out is ahead, not back.

Guest
Feb 26, 2013

Howdy Bev, sometimes when you walk in circles, it seems like you are moving ahead, and even ahead still has 180 degrees of choices…. We will get there sooner or later, but this is not the optimal road for patients, doctors and taxpayers in general. And, this is not Epic’s fault either…..

Guest
bev M.D.
Feb 26, 2013

Margalit, good to talk with you; it’s been awhile. The only reason I mention Epic is because others have cited them as a threat to innovation – and innovation is the only thing that will help us out of these clunky products. I don’t see any of the existing companies ever able to change their mindset enough to produce something that meets the needs of both clinicians and patients.
I think we all agree this is not the optimal road, but we are too far down it to turn back now.

Guest
Feb 26, 2013

We don’t need to turn back. We just need to turn right :-)

Guest
southern doc
Feb 26, 2013

“the needs of both clinicians and patients”

Completely irrelevant to those calling the shots these days.

Guest
Feb 26, 2013

Not that Congress will give ONC another however-many-billion dollars to do HITECH II (Electric Boogaloo) but forward shouldn’t mean more of the same.

ONC is vigorously executing a flawed plan.

Guest
Jay
Feb 26, 2013

I think your right on the money, Bob. You can’t stop progress, but rational and thinking people can shape it. You seem to be a little of both.

I think that the medical industry crying foul that EMR vendors went to washington is hypocracy at its finest, but thats a topic for another discussion.

Guest
TBMD
Feb 26, 2013

If Epic is the best there is, we are in big trouble. I think it is a bit of “the emperor has no clothes”. Large systems spend $millions (billions!) on the system and cannot go back. It is the end users that suffer because the user interfaces are not build for clinicians and the system is clunky and cumbersome. Is this the best we can do? I agree with Bev that we must go forward but if we can’t be honest about the mess HIT is in, we can’t crawl out.

So far I do not see “better,safer care” with Epic ehr. It impacts productivity, safety and patient satisfaction. When the experts tell us “you will never get back to 100% productivity with ehr” one has to wonder who it is really serving.

Epic is neither innovative nor intuitive and was not developed for good clinical care. Period!

Guest
Feb 26, 2013

Thanks for all the thoughtful comments on my post – this is understandably an issue that people are passionate about. While I appreciate the concerns about the existing HIT systems and federal policies, I believe that we need a strategy that will get us to a new place in our healthcare system in the next 5-7 years: interoperable electronic health records, accessible to both clinicians and patients, that can serve as a scaffolding for levels of decision support, advanced analytics, patient engagement, trainee education, and quality improvement that we can only dream about today.

If you accept that as a goal, then the question is not whether Epic is perfect (it’s not) or HITECH is flawless (it’s not), but rather: What is the set of policies that are most likely to get us to that place, with the least pain and cost? I believe that the present strategy is about right. (Of course, like any policy, it’ll have to be tweaked over time as we get smarter, as will the HIT systems themselves, but that would be true of any path that we might choose).

For those who disagree, I’m looking forward to hearing alternatives that aren’t a blend of status quo and wishful thinking. Remember what they say about insanity and doing the same thing… We’ve tried the same thing in healthcare for 20 years – while every other industry computerized, to great effect – and we see where it has gotten us: low quality, insufficient safety, poor reliability, confused patients, massive waste, and backbreaking cost. I, for one, am ready to try something new.

Thanks again.