The Health IT Scandal the NY Times Didn’t Cover

The Health IT Scandal the NY Times Didn’t Cover

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In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in ­– well, actually, poured in not that much money at all when you think about it ­– lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.

Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.

The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.

That clinical evidence and the way in which the world outside medicine had been transformed by computers did almost nothing to change health care. Computerized medical records were available: before there was “Watson,” the IBM computer helping doctors make decisions, there was “Watson,” the IBM chairman, vainly trying to sell electronic records to doctors as early as 1965. But well into the 21st century, most providers only trusted computers to send out the bills.

Even those hospitals that adopted EHRs rarely bought, or bought and then didn’t turn on, clinical functions related to drug-drug interactions and infection prevention. “Computerized medical records” were used to better document all the small details of care that boosted payment in a fee-for-service world. Salt Lake City’s LDS Hospital used computerization to reduce the adverse drug reaction rate below the theoretical minimum of the Harvard Medical Practice Study and its innovation diffused precisely nowhere. One hindrance, some doctors whispered softly, was that infections resulted in more care, more revenue and more profit for the hospital.

To sum up: well before 2009, solid research and case studies showed that EHRs had the potential to save money and improve care, yet the pace of integrating them into practice was so tepid that HIMSS had to revise its original “Stage 1 to 7” EMR Adoption Model for hospitals to include a “Stage O.”

And then a wonderful thing happened that we, in our era of polarized politics and bizarre bursts of federal budget cuts, can only look back upon in nostalgia. Republican and Democrat, liberal and conservative, corporate executive and techno-geek all united to bribe doctors and hospitals to do what a minimally functioning free market would have prompted them to do years before. The point man was GOP House Speaker Newt Gingrich, whose cries of “Paper kills” accompanied rich speaking fees. Happily complicit Democrats (Hillary Clinton, Patrick Kennedy) and every health care trade group with a vowel in its name cheered him on.

This is also the time when think tanks, consultants and researchers ginned up studies showing that EHRs would save oodles of cash, improve care and shower jobs and prosperity on every Congressional district. (OK, I made that last one up; I think.)

Since this was a bribe rather than a gift, we taxpayers did demand something in return. When doctors and hospitals (“eligible professionals” and “eligible providers”) doled out the dough ­– and spending money was the point, since HITECH was part of an economic stimulus bill ­– they had to demonstrate they used what they bought to improve care. Wallets twitching, the professionals and providers agreed to “meaningful use.”

Now we come to the behavior that really should inspire the outrage. We as a nation paid out billions in bribes because so many physicians simply refused to believe they could benefit from an EHR that the hospitals dependent on those doctors for admissions refused to buy computerized records no matter what the evidence. The vendors, aiming to ease the transition when hospitals did buy, designed clumsy interfaces based on provider habits and inefficiencies from the paper world. When the market finally changed, all the bad stuff got baked in: difficult interfaces and missing functionality that frustrated physicians; poor customer service from vendors puffed up with profits; absurd flaws ­– a medical record less searchable than a ten-year-old PC – that were never corrected while piled-on new features created a kluge-job catastrophe.

Then there were the unintended consequences that occur when any innovation is taken to scale. Is it any surprise that academics focusing on efficiency and clinical improvement were blindsided by sharpies who focused, instead, on how EHRs could help game the reimbursement system to make more money? Is it a surprise that a new technology deployed in a hurry can be downright dangerous as well as helpful? Unfortunately, painting a picture of a panacea was useful for public relations purposes, but prompted a widespread backlash when reality set in.

Fortunately, it’s no longer 2009. “Meaningful use” requirements are gradually attaining real meaning. The rapid growth of high-speed cloud computing and specialized medical apps is starting to break the hold of the old-style EHR thinking. Even true interoperability continues to glitter on the horizon, even if that horizon seems sometimes to continually recede.

The problem with health IT isn’t the politicians and lobbyists, easy targets though they may be. It’s us, in health care. It’s the doctors, hospitals, vendors and researchers among us who are not held accountable when our behavior delays and distorts innovation, hurts patients, costs money and impugns our own industry’s credibility.

Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, IL; the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management; and a board member of the Society for Participatory Medicine. This post first appeared on Maggie Mahar’s blog, healthbeatblog.com.

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56 Comments on "The Health IT Scandal the NY Times Didn’t Cover"


Guest
Eric Page
Mar 3, 2013

Hi Michael,

You are claiming that millions and millions of highly educated, dedicated people are all, simultaneously, at fault. How can so many be so wrong?

At my last provider group, when we analyzed switching from our homegrown EMR to one that would allow us to receive the bribe money, we found that it would cost us an extra $50K/year/physician, net of bribe, to maintain. Not to mention the extra steps, reduction in automation and increased likelihood of error. We fought against all govt regulation and our data shows we were right to do so, both financially and in the eyes of our patients.

Saying all of us (“doctors, hospitals, vendors and researchers “) are at fault for not pursuing your objective is not helping your cause. Consider performing a root cause analysis of this behavior rather than chastising the symptoms.

Guest
TBMD
Mar 3, 2013

Eric Page: Right on, bro.

Guest
Craig "Quack" Vickstrom, M.D.
Mar 3, 2013

Mr. Millenson,

There, there, poor baby. Let me get you a hanky. Or maybe I should let you remain on the floor for your tantrum. That’s the best thing to do for toddlers.

EMRs are beautifully designed…for the billing department. For those of us who actually practice medicine, they are slow, error-prone and cumbersome. The designers forgot that I have patients to see and work to do. If I enjoyed doing data entry, I would have gone to business college.

Tantrum over now?

Guest
tcoyote
Mar 3, 2013

Mike,

I think it’s really hard to blame providers, particularly physicians, for not adopting crappy products that don’t return their investment other than thru upcoding. Physician offices added more than 160 thousand workers from 2007-2011 despite a 10% decline in volume, largely to manage the transition to clinical IT. Most of the docs I’ve talked to wouldn’t go back to paper, but spend less time with patients and more time coding. Name another industry where productivity actually suffered as a result of automation. I’ve spent a lot of time in this space. There’s plenty of blame to go around. . .

Guest
Pinak
Mar 3, 2013

Mike makes a good point that the technology to make EHR available has been around for a long time, it’s just that the implementation has been politicized and corrupted by a tangential need for profitability. I agree with Eric that there’s no call to blame one specific sector of health care for the failings of the tradecraft as a whole. We may have to come to terms with the fact that there may never be an EHR that everyone can agree with – and that’s ok.

Guest
Mar 3, 2013

Look, guys. The public already invested in health IT. It’s called the “VA’s VistA system.” Free for the asking, and the VA docs love it. BUT campaign bribes flowed from the private IT people to our trusted politicians and killed its use outside. Aren’t corrupt politicians great?

Guest
Kathy Wire
Mar 3, 2013

Word.

Guest
David Aylward
Mar 3, 2013

Excellent blog on getting the health industry to adopt computers like the rest of all our areas of economic activity. My non-health friends are dumb founded. You miss a key point: until the fundamental goal is changed from per service sick care to per person//per population wellness, then the wonders of modern ICT will mostly reinforce the current system. Too many organizations are making oodles of money on the current system. IT enables; it doesn’t change objectives and motivations.

Guest
Mar 3, 2013

Michael –

As you know, we are usually in violent agreement about this and so much else, but I have to say that you run off the rails a bit, hence the puerile personal ridicule from Dr. Quack.

While agreeing with your entire read of history and policy, I’d say in sharp contrast that no one is at fault, everyone is chasing their professional and economic rabbit as best they can, and it’s a long, slow, miserable process. EMRs today are Wangs, Commodores and Ataris. They’re miserably new and awkward creatures; they’re just getting going – relative to the complexity, density, and scope of the task at hand; and it will take many, many cycles until they hum like 486s once seemed to.

The messy and infuriating disruptions caused by ripping out paper process and jamming in EMRs are about on par with any automation disruption, when calibrated to the scale of the challenge. Bring this back down to the H-O scale of ordinary office tasks and desktop computing world, and I have to ask: how productive was anyone the first few weeks they switched from DOS to Windows, from a PC to a Mac, from voicemail to the 10 pound dial-up modem? Scale these little disruptions to the technical, operational and cultural revolutions required for computerizing medicine???

This is a 10-year challenge – and only 10 years BECAUSE of all those earlier breakthroughs with computers in the simpler world of office work – and most of health care started in on this challenge, in earnest, barely three years ago. The struggles everyone in health care faces as we embark on this jarring transformation is nobody’s fault but the size and complexity of the job itself…

Guest
Mar 3, 2013

JD, I’m with you, except that the “10 year challenge” was the cited figure at the onset of my medical informatics postdoc – and that began in 1992. Nobody knows how long it will take – but progress must be made with caution, due diligence and critical thinking.

Re: ” It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence.”

Mr, Millenson perhaps you should take a refresher course in research methodology and risk management, as well as literature retrieval. I’m not meaning this as an insult. Your statement, I will assume, was made in good faith.

It represents an erroneous view of a complex area, where in 2013 the literature is conflicting on benefits and harms. Cautious physicians and hospitals exercise due diligence as the liabilities for errors are theirs for adverse consequences of their decisions.

I suggest you review, as an example, a sampling of that literature here: http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist

Sincerely,

Scot Silverstein, MD
Drexel University
Philadelphia

Guest
J Harries
Mar 3, 2013

Mike you just don’t understand this issue. I quote from a recent Health Affairs Blog by Josh Archambault “A recent Wall Street Journal op-ed called into question the cost savings estimates of the EHR industry by highlighting work done at McMaster University and their review of 36,000 studies on EHR. The authors found that “the most rigorous studies to date contradict the widely broadcast claims that the national investment in health IT—some $1 trillion…will pay off in reducing medical costs.” Health IT is not inherently bad, but the research, once again, casts doubt on the promised savings.”

Guest
Mar 3, 2013

Generally, agree with your rant, Michael, in terms of the frustration in developing an EHR that adds value. Also think earlier respondents like Kleinke and Lohman offer some points worthy of reflection.

Putting this in context, while in grad school in the late 60’s I, together with classmates, spent a day at a medical center in NJ where we went to observe a Total Hospital Information System at work. It had been “operational” for five years, cost the hospital a fortune, and was the Beta site for one of the corporate giants in IT whose first initial begins with I. All we heard that day from the users (ward clerks) was how poorly it performed. BTW-the physicians refused to enter any information, it was all transcribed for them by these ward clerks.

Flash forward to today and know we are just on the cusp of beginning to see the potential with respect to improving care and safety as a result of some of the IT tools. Since it would not be appropriate to mention some tools/products here, I will not; however, I’m more positive than ever before that in two -five years we’ll see huge adoption of some tools, including many that are free, embraced by the health care community.

I can say that i believe much of the delay we’ve seen is caused by vendors who have been unwilling to collaborate because they’ve wanted to protect their space and clients who have not performed sufficient due diligence and educated themselves about the evolving market and the power of computing to improve health care.

Marty

Marty

Guest
TBMD
Mar 3, 2013

Marty: If by vendor collaboration your mean interoperability…I don’t see any progress on this at all. Since most of US medicine is not practiced in a “closed system” the various proprietary systems simply create less safe, more cumbersome, more expensive care.

Guest
Mar 3, 2013

No disagreement with you. For many years, I was involved in working with teams assessing what we needed to do to get a variety of stand alone systems linked. Vendors really wanted no part of this.

Marty

Guest
Whatsen Williams
Mar 3, 2013

These devices may cause more harm than good. No one knows, because there has not been any surveillance of the deaths, injuries, near misses, and other unintended consequences from CPOE and meaningfully useless clinical decision support. The scandal is that the HIMSS spawned the CCHIT certifying family that duped Congress and others into believing that certification meant that these new, untested devices were safe, when CCHIT ignored safety and was not interested in safety events in the market place. CCHIT was actually an empty office on So Wackers in Chicago. No one was ever home.

Are these new devices better than the systems they replaced? Most users do not believe that they come close.

If you want to run a ten year experiment, get the patients, doctors and other health care professionals to give informed consent, because, right here and now, they are all guinea pigs benefitting the HIT vendors and their trade groups.

About Intermountain, it made it in to one of Senator Eliz Warren’s speeches as having caused more personal bankruptcies than any other health organization, ever. Computerized debt collection, agressively.

Guest

JD: I’m not sure what the difference is between my saying EVERYONE is at fault for pursuing their own interest and your saying that NO ONE is at fault because they’re all pursuing their own interest. I certainly agree it’s the complexity of the job. My only point was that solving the complexity could have begun a lot earlier.

As for some of the commenters: again, I’m puzzled at saying “I don’ understand the issue” when, in fact, I explicitly agree that estimates of savings were overdone. Or that the systems were designed initially for billing.

But Mr. Coyote/Goldsmith, you of all people should not let the providers off the hook. Let’s do a little thought experiment, shall we? LDS Hospital proves it can reduce medical errors and save lives back in the mid-1990s. Remember, LDS was a community hospital, so its docs had to work with the interface. What was the reason that hospitals all over the country didn’t flock to Salt Lake City to adopt that innovation — maybe even make the interface better? What was the reason Intermountain didn’t even spread that innovation to other hospitals it owned?

The answer is that NOT harming patients (and reducing revenue along the way) was not an innovation that was going to spread at a time when doctors saw harm as inevitable and those who said otherwise as, literally, traitors to the profession (documented at length in my book, “Demanding Medical Excellence”) and when hospital administrators would watch their profits plunge.

Oh, and Elizabeth Warren’s piece about medical bankruptcies is total piffle, as I and David Dranove wrote in Health Affairs. It’s only virtue is that it shows both left- and right-wingers can utterly disregard academic rigor in pursuit of the truth they just KNOW is there. (Disclosure: that study we did was funded by the health insurance industry but they didn’t vet content. Just remember that Warren et al. classified drinking and gambling as medical problems and the cause of bankruptcy as what people said when asked in a survey.)

Meanwhile, why is that PCs for consumers started off with lousy interfaces and improved much more quickly than health IT interfaces did? Because of real competition (once it became practical for big computer buyers to escape the Wintel oligopoly) and real demand. Now that we have bribed docs and hospitals to use this stuff, their howls over the crummy interfaces will bring real competition. I agree it’s a long process.

Newt, God bless him, was right. We will save lives and money. It’s just not to going to be an instant process or an easy process or a cheap process to get to where we want to go.

Guest
tcoyote
Mar 3, 2013

The LDS/HELP system, which I site visited in 1984, was, sadly, a science project, which its co-developer 3M was never able successfully to commercialize. It certainly wasn’t clinical opposition to reducing harm to patients that resulted in the slow adoption. It was that no-one could reliably deliver a commercial product that didn’t cost a fortune to maintain, and cost clinicians huge chunks of their time documenting and retreiving key information.

Michael- go visit some real-life clinicians and look at their “records”.
It is a challenge to find the clinically relevant nuggets of vital information in page after page of excelsior. The major firms’ (Epic, Cerner) product platforms are fifteen years old. Their interfaces reek of Windows 95. Dozens of clicks are required to execute simple instructions, or to find vital information.

It isn’t the IDEA of IT based clinical quality improvement that isn’t working.
It’s the actual products. . .

Guest
Ron
Mar 3, 2013

Amen!

GE also has/had an unsuccessful joint venture with Intermountain.

There’s no reason that EHR products have to be shit… other than that the market – i.e. the healthcare organizations that buy them…the ONC that establishes the certification rules for them – tolerate and accept it. And that – in order to pocket the bribes – healthcare organizations needed to have bought yesterday.

Many of the products of today do not represent a foundation upon which can be built the systems that are needed to actually improve care, when (if) healthcare changes.

But forget the strategic and focus on the nitty-gritty: Most EHRs are bad software. There wasn’t a product on the market that University of Texas-Houston evaluated that wasn’t free on many, many gross usability issues… the kind of issues that anyone developing quality software product could and should have found. Bugs and glitches abound. Quality Management Systems and Usability Testing are new concepts in this industry. Kind of like before the FDA started regulating medical devices…

Guest
Mar 3, 2013

Many of you are correct except those who let providers off the hook and are being hostile to Mr. Millenson. The most correct, IMHO, is Mr. Aylward, who has nailed the core problem. We must FINALLY change system to value population health above corporate and other stakeholders’ agendas. All of us on this industry know we can do better and so many of us have allowed the carts (ins companies, etc) to lead the horses. We all know we should make sure patients discharged from the hospital should be evaluated for follow-up needs with info communicated to PCPs etc., as one example. We know that we make more effort providing care to BCBS patients than Medicaid patients, as another example, and we all know its wrong and too few of us have gone anything about it. Change the game/incentives and change the outcomes.

Guest
Mar 3, 2013

BTW, sorry about typos – darned cell phone…

Guest
Mar 3, 2013

Re Alan’s point: Change the game/incentives and change the outcomes. That’s precisely what the Accountable Care Act is all about. We’re a long way from the tipping point re shift in payment; however, it’s on the horizon and lead by physicians who are passionate about designing and EXECUTING systems that allow data mining and rapid intervention.

Marty

Guest
Curly Harrison, MD
Mar 3, 2013

OK Marty, Alan, and Ayward,

Hopefully not, but when you guys are suffering a massive gastrointestinal bleed, and you are in shock, and need immediate blood products, why not just lay there waiting for the doctor to log on, figure out the CPOE as to how to provide universal donee blood, and then hope that the CPOE device did not transform the order when received by the Blood Bank. That is great for the population.