Right now there’s a fierce debate going on for the hearts and minds of health IT. Finally American health care (well, half of it anyway) is using electronic medical records. But it’s not the panacea we were lead to believe. Costs haven’t gone down, health hasn’t markedly improved and the taxpayer/Chinese government is poorer. So too are many doctors and hospitals, and the main beneficiaries appear to be construction companies in Madison, Wisconsin.

Worse, those who promote the impact and importance of EMRs (Farzad MostashariAshish Jha) are being attacked by Ross Koppel, Steve SoumeraiScott SIlverstein and others who essentially say that EMRs are more dangerous and inefficient than paper.

This reminds me of the World War One British Army preparing to fight in the mud of Flanders with cavalry charges suited to the Boer War, the French Army in 1939 retreating to their WWI style trenches while the Germans flew over them, and (dare I say it) today’s TSA strip searching grandmothers looking for boxcutters.

Yes, we’re having the wrong fight by focusing on old problems. The EMRs that are producing the studies we’re fighting about are the current equivalent of 1990s EPR implementations. In general they’re hard to use and require lots of money and training to produce halfway decent results. The real improvements from IT came when user-centered tools came to consumers and then to business with Web 2.0 and new devices like the iPhone.

It may take months of training on Epic or Cerner to get a doctor or nurse to be three-quarters as productive as they used to be, but my two-year-old daughter can fire up an iPad and play games and watch videos with no training.What we’re seeing every day at Health 2.0 is a whole new generation of data-driven applications and devices that are going to make the health care user experience much more like the one my daughter has.

When we get there, the real improvements in both productivity and safety, as well as in quality and even cost, will emerge and we’ll wonder why we ever were having this fight.

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145 Responses for “The EHR Debate: Fighting the Last War?”

  1. S Silverstein MD says:

    Re: ” those who promote the impact and importance of EMRs (Farzad Mostashari, Ashish Jha) are being attacked by Ross Koppel, Steve Soumerai, Scott SIlverstein and others who essentially say that EMRs are more dangerous and inefficient than paper.”

    My actual position is that bad health IT (as defined at http://www.ischool.drexel.edu/faculty/ssilverstein/cases) is worse than paper.

    I find studies such as the ECRI Deep Dive (171 voluntarily reported HIT incidents from 36 ECRI PSO member hospitals over just nine weeks, with 8 incidents of patient harm and 3 possible deaths) alarming in that regard. See http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html

    • Bobby Gladd says:

      There’s a maxim among trial lawyers: “He With The Best Story, Wins.”

      “worse than paper.”

      Which paper? The worst, the most incomplete, illegible? The ones with coffee stain residues obscuring the lab results? The ones that get torn and taped over?

      Did the ECRI thing, being, well, “scientific”and all, provide a paper chart control group?

    • Steve Soumerai says:

      Who said that “EHRs are more dangerous and inefficient than paper?” Certainly not our blog. We have been talking about false claims of (debunked) cost savings, health gains and reductions in mortality from our trillion dollar investment in HIGHTECH. As Ashish charged in his post on our WSJ piece (it’s too late to go back to paper), this is just putting words in our mouths. A straw man? We are talking about the effect of a rushed and poorly managed nationwide boondoggle.

      There isn’t one piece of evidence in Matthew’s beautifully written! anecdote to justify his conclusions. Do we now want to throw more money after bad in the absence of decent data that new technologies will work? Or can we learn from our past mistakes and proceed incrementally with fully disclosed conflicts of interest once we know we have achieved something valuable. Or perhaps the term “evidence-based policy” is just a catchy phrase; certainly and sadly; it doesn’t happen all that much. Best, Steve S.

      • Steve Soumerai says:

        Sorry folks. Sitting in 95 degree heat and it’s HITECH.

        Supposed to reach 101 in Boston. How about others?

        • Matthew Holt says:

          Evidence Steve? My daughter’s room yesterday 8.15 am: a life & death struggle to get the iPad out of her hands so I could take her to day care. Luckily not recorded on video so that Child Protective Services may not be altered….(although if they’d offered to remove her during the incident, I’m not at liberty to say what my answer would have been!)

          And while I agree that HI(GH)TECH could have been done differently and that reliance on those old EPR style vendors (including the one that the major institution attached to your medical school just decided to spend over $1 billion on) is not something that we would want if we were starting from scratch, But we weren’t starting from scratch and this America where the job of Congress is to funnel money to already moneyed interests who want more money. Within that context I dont think HITECH was bad legislation and I do think ONC has done as good a job as possible making some stipulations for what the program has to do–which will get better with MU 2 & 3.

          The real question–the next war–is how do we make what another Harvard project (SMART) is trying to do happen very quickly. If we get a real market for user friendly end-user applications that can use data from the big ERP like systems, we’ll get to the point where clinicians and patients will have attitudes closer to my daughter, rather than to the 34% of users who are currently looking to de-install and start again.

          • Raj Sharma says:

            @Blogger_Holt,

            Do you use the EHR and CPOE systems that you defend?

            Easy for the arm chair lay people to think they understand what is involved with the care of sick patients.

            If you know so much, inform us of the incidence of crashes and outages and their duration.

            The truth would be shocking.

      • Al says:

        Steve S., you hit the right word, incremental steps, but when has the government ever been incremental permitting organic forces to create the EHR?

  2. Ashish Jha says:

    Excellent piece Matt. Yes there is bad health IT. I can even imagine how it could be worse than paper, though that’s a pretty tough. Bottom line is that we have to go digital. We can’t achieve any of the goals we have for a more efficient and effective healthcare system without health IT. The next war is about how to make health IT better — and have a healthcare delivery system that is flexible enough to exploit technology to deliver better care.

    • S Silverstein MD says:

      re: ” I can even imagine how it could be worse than paper, though that’s a pretty tough”

      Ashish,

      See http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html

      • Phil says:

        A press release from a nurse’s union that has been in a bitter labor dispute over the past 2 years with the hospital and has gone on strike 9 times….surely a questionable source.

        • S Silverstein MD says:

          Actually, I’d take the word of unionized nurses on risks to patients over the word of hospital and IT executives, and ‘egghead’ hyperenthusiast morals-are-relative academics lacking real-world experience anytime, based on experience as medical safety manager for a large highly unionized public transit agency many years ago. The unions had petty issues for sure, but they certainly did not want train wrecks.

  3. Craig "Quack" Vickstrom, M.D. says:

    Yeah, it didn’t work so well last time, but it’ll work next time. Yeah, that’s the ticket.

    • Bobby Gladd says:

      Paper is clearly better. After all, everything that COULD be invented has by now been invented.

      • 40yearold doc says:

        “Paper is clearly better.”

        Yes, for out-patient care, a well-organized paper chart and a highly trained staff IS better than current EMRs combined with MU.

        • SJ Motew, MD says:

          So how do you retrieve from your stack of paper charts the list of all patients with ASCVD who are not on ASA (and need to be) so that you can impact their health? Or how do you show the payers each year (in order to be paid fairly) that you can manage diabetes well in your patient panel by showing them that your average HBA1C is < 7 from your paper charts?

          Agreeably a long way to go and grand cluster without standardization but certainly not even comparable to paper.

          • S Silverstein MD says:

            How? Via data entered into registries by paid clerical data entry clerks, thus using clinician time appropriately and not wasting it on clerical duties. This comment is not theoretical as I designed an invasive cardiology information system for one state’s only tertiary care hospital in exactly that way, The hardest part of that project was steering around the IT leaders’ incompetence. http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story

          • 40yearold doc says:

            I don’t give a flying f*** about showing payers anything. That’s not what I consider my job as a physician.

            I tell patients with ASCVD to their faces when I see them in the office or hospital to take ASA. That’s how I “impact” their health.

          • SJ Motew, MD says:

            40yrold…I suspect you will care about showing payers when they reduce or stop paying you.

            SSilverstein…Interesting, I don’t use anyone to enter most of this data which is entered directly from the pharmacy and lab. Someone (i.e. you) is putting list of meds, allergies, past history into your paper chart, isn’t this clerical work??

          • 40yearold doc says:

            “40yrold…I suspect you will care about showing payers when they reduce or stop paying you.”

            So the whole point of EMRs is to enable physicians to jump through arbitrary payment hoops? Count me out.

      • Craig "Quack" Vickstrom, M.D. says:

        Actually, I’m all for the development of EMRs. I just don’t want them *deployed* until they are proven more effective, efficient and safer than paper. I use EPIC now, and I am not convinced.

        • BobbyG says:

          EPIC. Well…

          Condolences, bud.

          “just don’t want them *deployed* until they are proven more effective,”

          And, that “proof” would comprise precisely what?

          • Craig "Quack" Vickstrom, M.D. says:

            Probably an the EMR working in parallel to paper and Dictaphone, for at least a year. Showing me that I can see more patients, faster with fewer errors and better outcomes. AND with less time spent documenting.

          • BobbyG says:

            Craig “Quack” Vickstrom, M.D. says:
            July 20, 2013 at 7:28 pm

            Probably an the EMR working in parallel to paper and Dictaphone, for at least a year. Showing me that I can see more patients, faster with fewer errors and better outcomes. AND with less time spent documenting.
            __

            CHANGE.THE.PAYMENT.PARADIGM

            I know it escapes you, but I am on your side.

          • S Silverstein MD says:

            Bobby,

            If no such proof exists (or can exist?), as you seem to imply…than we are spending hundreds of billions of dollars on a technology of unknown risk (IOM’s words, not mine) to replace another technology, paper, based on “hope” that the latter is better and safer, and not on rigor and due diligence.

            My colleagues and I find such views disappointing and highly misaligned to the ethical concerns prevalent in western medicine.

        • Craig "Quack" Vickstrom, M.D. says:

          It does not escape me. I have no way of doing it.

  4. Ashish Jha says:

    By the way Matt — I wrote a similar piece (http://blogs.sph.harvard.edu/ashish-jha/the-wrong-question-on-electronic-health-records/) after Soumerai and Koppel wrote their critique of Health IT in WSJ.

    The question for Soumerai and Koppel is this — what’s the alternative? Keep the healthcare system we have? Its a mess. There’s much more evidence that Health IT, when done well, can improve care than for almost any other policy intervention.

    • S Silverstein MD says:

      the alternative is to treat health IT as any other medical device, and roll it out slowly, safely, with regulation of its quality, post marketing surveillance, and so forth – or, as you put it, the next war is to improve health IT.

      i agree, but it must not be done in situ while putting patients at risk, unless those patients are afforded meaningful informed consent.

      • Matthew Holt says:

        I’m going to upset Scott by saying again, “just like in the Vioxx case”

        • S Silverstein MD says:

          Matthew,

          Actually, just like NOT in the Vioxx case.

          See the piece I wrote on VIOXX and the potential use of EHR data (from good health IT, of course) written ca. 2004 or 5, “Reflections on the future of drug safety surveillance from the Medical Informatics perspective” at http://www.ischool.drexel.edu/faculty/ssilverstein/scotsilv/vioxx1.htm

          I presented on that topic to Merck Research Labs’ adverse events & drug surveillance dept. ca. 2006.

          IMO health IT should be subject to the same scrutiny that drugs are, or are supposed to be, before widespread deployment, and should be subject to post marketing surveillance as well. Yet there’s no database of EHR problems that can be mined to identify bad health IT.

          • Chris DeNoia says:

            That is abdicating the health IT revue process to government and stifling to advances for a product that can be improved in iteration, realtime. The alternative to IT is paper, which already is subject to errors, misfiling, poor hand writing, and time delays.

            One could imagine a doctor 20 years ago suggesting he could not use a fax machine without FDA approval to send a chart, an ambulance dispatch could not use the phone pending FDA approval of the use…

          • Al says:

            ” health IT should be subject to the same scrutiny that drugs are…”

            You hit the nail on the head. These guys professing to believe in science only seem to use science when it is convenient to promote their agenda’s. Thanks.

          • Al says:

            Let me revise my statement for Chris’s benefit. It need not require the review if government isn’t mandating it..

      • Matthew Holt says:

        Apparently Vioxx and other withdrawn drugs never went through the vaunted FDA approval process Scott prefers. The went through some other imaginary process.

        And BTW everyone serious (may even Scott) understands that the FDA approval process and that of clinical trials themselves is hopelessly unscientific (see Ben Goldacre’s work). And the “regulation of its quality, post marketing surveillance, etc” that Scott thinks Health IT should go just doesn’t exist in any practical sense for drugs or medical devices. But keep going down that delusional path, Scott and ignore the potential to improve what we have now but getting new technology into the system.

    • Al says:

      Ashish J., why do you say there are only two alternatives available? There are other ways and one of them is for EHR’s to grow organically while the government and the experts get out of the way.

      Do government or the experts know how to practice medicine outside of the laboratories of the Universities?

  5. Curly Harrison, MD says:

    There has been a strategy to avoid the evaluation for safety and efficacy of HIT that all other medical devices undergo.

    Jha states: “There’s much more evidence that Health IT, when done well, can improve care than for almost any other policy intervention.” What is the evidence exactly, and might it just be hearsay?

    Good doctors are impeded by HIT, and have been for about a decade. You do not hear about this because the doctors’ opinions are quashed by threat of retaliation and depreciation.

    The national HIT experiment is a failure so far: zero improvements in outcomes and costs, while innocent guinea pig patients have been killed.

  6. Dr. Mike says:

    Where is my ipad/android EHR? I want it and I want it now! If it also runs on a non-touch screen device I DO NOT WANT IT! It has been how many years since the Ipad hit the scene? Why isn’t it here yet????
    /tantrum off

  7. Whatsen Williams says:

    I like the report by the nurses exposing the nitty gritty on health IT, ie, that it endangersbthe care of the patients. Why is there a notion that if medical care requires a computer to guide it, that it will be safer and better than the system of care that was replaced? Paper as the medium for creating notes and the story of the patient is provocative. Computers are too rigid in what they allow the creative clinician to do.

    • Bobby Gladd says:

      Retire. If you are even a physician. A “report”? What “report”? What does it scientifically “prove” or, less dispositively “indicate”?

      Get serious here.

      Or not.

      • S Silverstein MD says:

        Bobby,

        Are you a physician or have any clinical training or experience? I know Matthew doesn’t, and I tolerate his antics because they amuse me, but you telling physicians to “retire” lacks any amusement value at all and is actually getting into the realm of needlessy rude.

        • BobbyG says:

          Ahhh…. the tried and true insinuation “if you’re not a physician, you have no right to any views on Health IT.”

          Notwithstanding, I in fact have been erring over into the “needlessly rude” of late. My apologies. I shall try to get a grip and do better.

          But, I note, you did not respond to the meat of my query. What “report”? What does it objective purport to “prove” that rises to encompass the broader HIT issue?

          • S Silverstein MD says:

            Actually, my view is that without medical training and experience, one’s views on health IT are those of an amateur. Everybody is entitled to an opinion, of course, it’s just that informed opinions have more credibility than those of amateurs. (Note – that is not a pejorative term. i am a radio amateur a.k.a. ham and although hold the Extra class – the highest licence – by exam, i am still a radio amateur and not a telecommunications professional).

            Case in point…you and Matthew would not be permitted to testify as expert witnesses in health-IT related cases, while I and similarly educated physician informaticists are, and do.

            Opine on, but show some humility based on lack of relevant education and experience.

          • S Silverstein MD says:

            and I was not responding to an issue about “reports”, merely your insensitivity and rudeness to the audience of this blog.

  8. ytisebo says:

    Holt says: “… others who essentially say that EMRs are more dangerous and inefficient than paper…”

    Not exactly from my read. The data to support the use of HIT other than digital labs and images is flimsy at best, yet the vendors and hIMSS convinced Congress to spend $ billions. The costs have gone up and outcomes have not improved. All the while, no one is recording the deaths and other adverse events from the errors cuased by the systems in question.

  9. Caregiver, MD PhD says:

    @Holt: “It may take months of training on Epic or Cerner to get a doctor or nurse to be three-quarters as productive as they used to be, but my two-year-old daughter can fire up an iPad and play games and watch videos with no training.”

    Read Foote in JAMA at Dartmouth. The systems are an insult to health care professionals who now must guard against errors faciliated by the complex ordering systems with idiosynchrasies worse than the disease being treated in the patient.

  10. Roger says:

    There should be a forensic study similar to thisin Australia: http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html

  11. LegacyFlyer says:

    So lets see:

    - EMRs slow down docs and nurses (which drives up costs)
    - They can’t talk to each other (fundamental design flaw – unlike DICOM)
    - No evidence they improve care
    - No evidence they save money

    But the government is mandating them and forcing their adoption. And some EMR vendors are making tons of money.

    And this is progress?
    Did someone make some big campaign contributions?

  12. As Matthew states, today’s EHR systems have their roots in the 1990s. Further, those systems were never designed to offer sophisticated decision support or to be responsive to clinical workflows. As a result, we have EHR systems that do not meet the needs or expectations of clinicians. The frustration that clinicians feel is understandable. However, exactly how one should go about building better EHR systems is not obvious.

    Building EHR systems with adjustable workflows, easy to use reporting and population management tools, and sophisticated decision support requires, among other things, the rendering of complex clinical concepts in a computable form. Obviously, this is much easier said than done. Research on EHR design and architecture has been left pretty much in the hands of vendors. Thus, while we have an open discourse on issues such as data exchange, terminologies and coding systems, there is very little formal research and open exchange of information regarding how to build EHR systems. As an example, the HL7 EHR functional model specifically disclaims any intention to say how proposed functions should be implemented in actual EHR systems.

    We have no idea of what the best EHR database schema is, or how to best represent clinical workflows, or the best way to incorporate workflow engines in EHRs, or the optimal user interface architecture/design. Most of today’s EHR systems were conceived at a time when LAN-based client/server was state-of-the-art and reliable relational databases were becoming affordable for small businesses.

    The cloud as a computing concept is really only about seven or so years old. The REST architecture, proposed in a PhD dissertation in 2000, is just now catching on. NoSQL data stores are now available that offer new data management capabilities. Finally, the iPhone was introduced in 2007 and the iPad in 2010 (to a mostly skeptical public). Moving software from a mouse-based interface to one based on touch is not trivial. Clinical software has a lot of catching up to do. This is neither a criticism nor an apology; it is simply a fact. Safety is critical and should be a component of any certification process.

    I am optimistic that EHR systems will improve. But, in order to do so, those on both sides of the issue must work together toward that goal.

    http://ehrscience.com/2013/04/22/ehr-design-and-personal-work-habits/

    Jerome Carter, MD

    • S Silverstein MD says:

      What about patients whose care is subject to these medical devices during the “improvement” phase? Or should the health IT and hospital industries be given carte blanche to get the bugs out on live patients?

      That has been the unprecedented special accommodation afforded the health care/health IT industry.

      The software in the 777 you travel in was not tested and debugged on the Washington-to-San Francisco run.

      • BobbyG says:

        “The software in the 777 you travel in was not tested and debugged on the Washington-to-San Francisco run.”
        ___

        Yeah, Scot, we all know that ALL avionics software works perfectly, first time, every time.

        What dod you want? A total HIT operations moratorium until ALL bugs and sub-optimal usability features are ID’s and removed to your satisfaction?

        Wish in one hand…

        • Craig "Quack" Vickstrom, M.D. says:

          That, is exactly what i want.

        • S Silverstein MD says:

          Bobby G, what you wrote is an example of an appeal to extremes.(Erroneously attempting to make a reasonable argument into an absurd one, by taking the argument to the extremes). Logically fallacious.

    • BobbyG says:

      “I am optimistic that EHR systems will improve. But, in order to do so, those on both sides of the issue must work together toward that goal.”
      __

      Tell it to the naysayers that overpopulate these comment threads. It must be PERFECTION out of the box in every way, or “paper is better” (which the latter is not)

    • Boris Katz says:

      I think that the major EHR problems are in a different area. Medicine is not a precise science and two physicians of the same specialty and even within the same practice work differently. The traditional software has their algorithms built-in to fulfill the current requirements. This approach works well in e.g. accounting where rules are all the same and do not change as often as in the healthcare. Also the software designers are more concentrated to fully address the formal requirements (to get all the required certifications) than on making their product convenient and efficient to use. The above is not as much dependant on technology achievements as on the way of how people think. The software intelligence solutions I have developed may work equally well within the old client/server and cloud based technologies. One of the main problems I have encountered is deficiency of physicians who want to contribute time and efforts to tweak the system to work well in their specific environments. There are way more doctors who like to whine and complain than those who want to make an effort to change both – the software and their habits.

  13. Boris Katz says:

    As presumptuously it may sound, but I have an answer to all of you. And the answer is software intelligence. Here is what one of my customers said: “Having evaluated numerous EMR products and platforms over the years, I was consistently promised by almost every EMR company I looked at that I would save time, get home quicker and reduce my overhead compared to working on a paper chart. Having been an EMR user since 2001, despite my efficiency as a typist (I can type 100 wpm) and my proclivity towards computers and technology, I was never able to personally realize any of the above promises. The only thing my EMR did for me was create a neat looking document that I could conveniently reference from home. With every 15-30 minute patient encounter I am allotted, I found myself spending at least half of each encounter entering data, struggling to find test results and fumbling with orders rather than directly interacting with my patients. On top of that, I found myself often staying in the office late to finish my electronic charting. Having shared my frustration with numerous colleagues across the country, I found that I was not alone with regards to dissatisfaction with my EMR and eventually resigned myself to the idea that EMRs could only do so much.
    That opinion changed when I was introduced to EMA in January of 2012. After viewing a demo and a brief chat with EMA’s creator, Boris Katz, I found, for the first time, a product that had the potential of legitimately fulfilling everything my EMR company had promised me years ago. I can honestly say today that compared to working on a paper chart (or anything else I have tried), I am now able to save time and get home earlier while improving the quality of my face time encounters with my patients. This applies to both patients with simple as well as challenging diagnoses. Equally important, especially during these challenging times of dropping reimbursement, our single specialty practice of 5 gastroenterologists has been able to reduce our medical assistant staff by a full FTE (a savings of about $50,000 per year) which we attribute almost exclusively to EMA. The exciting prospect for us moving forward is that as Boris continues to refine EMA for our practice, we expect our efficiency to grow further!

    Roy L. Foliente, M.D., AGAF”

  14. Whatsen Williams says:

    I ponder why patients are subjected to medical care run by software driven systems that not only have not been tested for safety, but have no accountability to any agency when they cause serious adverse events and facilitate errors. I smell a dead rat.

    • BobbyG says:

      Specify quantitatively the “safety” errors or STFU.

      • legacyflyer says:

        BobbyG,

        Top of the morning to you sir. Your style of debate is sure to win friends and influence people – NOT.

        Generally in Medicine, when one moves from the traditional way of doing something to a new way, one is required to demonstrate that the new way is superior. We don’t adopt something that someone THINKS is great and then demand that others prove that it is not.

        It seems that you have turned this principle on its head. Now the EMR skeptics need to quantify the errors or STFU? Really?? How about a demonstration of safety and efficacy from the proponents before we adopt it?

        The traditional way of keeping medical records was on paper. Then (quite reasonably) it was proposed that we should move from paper to electronic documents.. In principal I also believe that medical records should be electronic. However, in practice it has not worked out so well. At present, there appears to be no demonstrable benefit to and EMR. Yet we are spending tons of money and coercing people to buy systems that they will soon have to replace.

        Years from now, I believe we will all be using well designed electronic medical records. The journey from where we are now to there will be difficult and expensive.

        It is too bad that the Feds decided to proceed by : 1) Ready, 2) Fire, 3) Aim.

        • BobbyG says:

          Yeah, that was over the top. Agreed. Very poor taste

          “How about a demonstration of safety and efficacy from the proponents before we adopt it?”
          __

          What would comprise such a “demonstration”? It’ll never suffice for you guys.

          • Craig "Quack" Vickstrom, M.D. says:

            It’s going to be a challenge to satisfy us, I assume. Doctors are very hard to please.

        • BobbyG says:

          Craig “Quack” Vickstrom, M.D. says:
          July 20, 2013 at 7:23 pm

          “It’s going to be a challenge to satisfy us, I assume. Doctors are very hard to please.”
          ___

          And they make a lot of mistakes not attributable to HIT.

          But, you are correct. Want at least 12 opinions? Gather 10 MDs in a conference room.

          • Dr. Mike says:

            Do I remember correctly that you are a healthcare consultant? I would never, ever, hire a consultant who posted a statement such as this.

          • BobbyG says:

            “Do I remember correctly that you are a healthcare consultant? I would never, ever, hire a consultant who posted a statement such as this.”
            ___

            Dude, I have been working around healthcare for 20 years. I am a statistical analyst by training and long experience, as well as an applications developer (Oak Ridge, radiation lab) back in the days prior to indoor plumbing. I am not a “healthcare consultant.” Health IT? Yes. Quantitative analysis? Yes. I cut my white collar teeth in a forensic environment — meaning you actually had to PROVE your assertions to an endless horde of hostile counterparties and regulators.

            bgladd.com/papers

            Part of my early QC training involved adversarial mock depositions conducted by our lawyers. And, I’ve been on the butt-end of some hostile audits that would make you yearn for a root canal without anesthesia.

            What is your point? Docs DON’T err, independent of IT? See Groopman, Jerome, to cite one respected contrary source.

            Docs are not hyper-opinionated? Right. It’s the unremarkable product of the Iron Man training paradigm. See “Medicine in Denial” by Messrs Weed, MD and PhD.

            You just prove my point.

            I’m plenty busy, my friend. There’s more than enough work to go around. I don’t sing in anyone’s choir.

            Last year I got a 3 site, 14 doc Internal Med practice to Meaningful Use Year 1 Stage 1. It was not like herding cats, it was like herding cheetahs.

      • S Silverstein MD says:

        Again, a fallacious argument showing no understanding of risk management principles.

  15. Doctor Mawrdough says:

    Epiphany! Blogger Holt has seen the light when stating:

    “But it’s not the panacea we were lead to believe. Costs haven’t gone down, health hasn’t markedly improved and the taxpayer/Chinese government is poorer. So too are many doctors and hospitals, and the main beneficiaries appear to be construction companies in Madison, Wisconsin.”

    “Not the panacea. ” Exactly. You would never know that from hearing Mostasavy brag to the Senate and how the Senators sucked up his convoluted unsubstantiated conclusions with a “good work” sign off.

    Scandalous, but Blogger Holt has finally come around to acknowledge that the Truth in HIT followers know what they are talking about.

  16. ross koppel says:

    Irony of unwarranted conclusions & distortions–repeated in arguments.

    Stephen Soumerai and I wrote a blog post about poor research methods and unwarranted conclusions used to support HIT. In the comments by Matt Holt and Dr. Ashish Jha, they distort our statements in an effort to create a false dichotomy. Is this an attempt at irony?

    We wrote (verbatim quote): “We agree with Dr. Jha that HIT offers many and significant advantages over paper.” Elsewhere I’ve repeatedly said that HIT is far better and safer than paper. I’m quoted repeatedly as saying I would inevitably pick a hospital (for myself and my family) with and EHR over one without an EHR. We have never said we should revert to paper. Never! What Steve and I repeatedly say is that we should rely on valid research and we should focus on improving data standards, interoperability and usability. We also call for disclosure of conflicts of interest. That’s not saying we should give up on HIT. Such distortions of our statements are unfortunate and deflect our effort to improve HIT, not kill it. But far worse than they false attack is the false dichotomy offered by Mr. Holt and Dr. Jha. They present us as saying it’s between HIT vs. reverting to paper. Matt’s quote: [Steve and I]…. essentially say that EMRs are more dangerous and inefficient than paper.
    No! That’s absurd.
    The real dichotomy is between working toward better HIT vs. continuing the efforts at aggressive marketing of clunky, non-responsive, non-interoperable HIT — assisted often by research and research conclusions that reflect methods or logic that fail to achieve the quality we should demand from such important scholars and on such an essential topic.
    It’s a cheap shot to distort our position and to suggest we are demanding a reversion to cavalry in the face of modern warfare, as Mr. Holt suggested. In contrast, to keep the metaphor consistent, we are demanding better tanks for our side.

    • Dr. Koppel,
      Surely you must understand that what you are asking for (i.e. FDA oversight over HIT products) is no longer possible. It is certainly impossible to pull out all HIT software until FDA approval is obtained, but even if the FDA would devise a way to review these products, while allowing them to remain in use for the duration of its testing processes, the following will occur:

      1) No new developments will be allowed, including those “required” by Meaningful Use, until the FDA process is complete ( a couple of years at the very least?)
      2) Vendors would have to devote significant resources to the FDA approval process, again shortchanging the HIE/MU directives
      3) The vast majority of products currently deployed will most likely fail the FDA process and be unable to bear the costs of rectifications, particularly the multitude of small products proliferating in the ambulatory sector.
      4) The above would increase the costs of those EHRs that manage to obtain FDA approval to levels beyond the reach of anyone but large systems, thus accelerating the extermination of small independent practice.
      5) The Meaningful Use program will be effectively dismantled.

      There are large fortunes, illustrious careers ant political interests at stake here, and those who benefited the most are the ones calling (or heavily influencing) the shots. So I would venture a guess that FDA oversight is not in the cards for HIT. Since we are now establishing a new (and I think peculiar) consensus that the benefits of HIT will not become evident for decades to come, efficacy studies with unfavorable results are all going to be dismissed as premature, while studies showing some marginal association with benefits will be hailed as harbingers of things to come. This war has been lost.

      • ross koppel says:

        Interesting and important points. But a very slight mis-reading.
        We were not actually calling for FDA oversight. We simply noted the efforts by the vendors and their federal friends were seeking to avoid FDA oversight. Certainly I share everyone’s concern about the prospect of clumsy regulation, or toothless regulation, or co-opted regulation, or innovation-restricting regulation. On the other hand, sometimes regulation is very well done, enhances efficiency dramatically (as in useful data standards) and is just what’s needed. I’m agnostic.

      • Whatsen Williams says:

        So what!

  17. MD as HELL says:

    Bobby. It is for the advocates to prove superior performance. The traditionalists are not on trial.

    With EMR the tendency is to try to fit patients into templates in the system.

    Patients never fit templates.

    The pretty record that eschews is full of errors. It looks like good care was provided. In fact it represents fiction laced with grains of truth.

    Bad care.

    • BobbyG says:

      Here’s the problem: As with any deployment of any technology, there is a DISTRIBUTION of performance efficacy, from significantly better to demonstrably worse. Cherry-pick away at your Horror Stories. For every one you can cite, i can cite at least one countervailing anecdote in refutation.

      “Patients never fit templates.”

      Except on those swell paper templates.

      • MD as HELL says:

        Do not twist my words. Patients fit no templates of any kind. I am citing no anecdotes.

        The burden of proof is on the techno-geeks. We who have done it for a long time do it better without the meddling of the EMR. Not perfect, but better and cheaper.

        I do not need EMR for paitent care. It is an intrusion of privacy,. It is a barrier to quality. It is detrimental to doctor-patient relationships. It is a means of transferring the role of the physician to the bureaucracy of managed care.

        Patient beware.

        • BobbyG says:

          ” We who have done it for a long time do it better without the meddling of the EMR. Not perfect, but better and cheaper.”
          __

          The “scientist” in you should be able to quantify that. Otherwise you’re just blowing the usual smoke.

          • sleuth says:

            Bobby G seems to be s shill for the vendors; or a vendor himself, desperate to maintain the facade that HIT needs no regulation for safety, efficacy, and usability.

      • S Silverstein MD says:

        re: “Here’s the problem: As with any deployment of any technology, there is a DISTRIBUTION of performance efficacyy, from significantly better to demonstrably worse”

        That is true, especially with experimental technologies or technologies not yet perfected.

        The problem is, patients are not given the opportunity to provide informed consent to the use of such new technologies in their care, and a chance to opt out.

        • Chris DeNoia says:

          When doctors started writing things on paper, where the patients given the choice to decide how the doctor wrote those down? Did patients have the choice to opt out of a dictaphone?

          Is your position that a) government (FDA) should regulate and approve of all health IT and b) patients consent to opt-in/opt-out of any health IT/workflow decisions?

  18. Meaningless Clicks says:

    Read Ytisebo:

    ytisebo says:
    July 19, 2013 at 3:48 am Holt says: “… others who essentially say that EMRs are more dangerous and inefficient than paper…”
    Not exactly from my read…

    Koppel notes, as Ytisebo did a few days ago, that Holt misrperesented the issues and facts.

    A well organized paper record is more conducive to intellectual thought than are multiple screens of meaningfully useless billing documentation. The progress note by EHR has become the bill. If a patient with multisystem disease and failure has been in the hospital for a week or more, the consultants coming in late have a futile experience in trying to figure out how the patient and the disease got to the current state.

    The EHR with its CPOE has become the disease requiring intellectual energy to diagnose and work around. There is widespread iatrogenic illness because of this.

    Gag clauses keep doctors from speaking out.

  19. nurse mary says:

    EHR v Paper is not the debate. Simply get the EHR systems evaluated for the usual criteria for medical devices, revalidate the systems after an upgrade

  20. nurse mary says:

    And seek feedback from the nurses and doctors on the problems and adverse events and errors from using the system.

  21. Chris DeNoia says:

    Anecdotes of agreement, two issues with EHRs:
    1) in a fee for service model, the real last war, EHRs do not get patients in and out of rooms faster than the 15 minute doctors are reimbursements for (in general). Doctors capacity to see patients (revenue) remains unchanged, unless the EHR facilitates upcoding (another topic) The efficiencies promised from EHRs benefit the revenue cycle management side more than the patient workflow and outcomes.
    2) in a fee for value model, the new war, e.g.: DPC, PCMH, ACO, the EHRs/and practice management systems do not the proper workflow to manage patient outcomes. The workflow focus on the patient visit and typically lack monitoring adherence, follow up appointments, and incorporating virtual clinic utilization.

    • Boris Katz says:

      Chris
      1.Even if a doctor still spends 15 min per patient visit good EHR makes a big difference how this time is spent. Specific example from one of my OB/GYN customers: before he would spend 3-4 min working with the computer – making necessary records, orders, charges, etc. Now he spends only 20-30 seconds working with the computer leaving more time for the pure clinical interaction with the patient. This fact alone greatly improves the level of patient care.
      2.Most of my customers see 1-2 more patients a day.
      3.All of my customers almost never have to work after hours finishing their documentation.
      4.Some of my customers reduced their staff.
      5.All of the customers improved accuracy of billing and therefore, their reimbursement also improved.

  22. Know it all says:

    You can do it in less than 15 minutes and bill the max by using the vendors’ H and P templates that are pre populated with normal findings. Click in a few abnormals and yiou have whipped up a level 5. Now that is efficient and no one seems to care.

  23. BobbyG says:

    sleuth says:
    July 21, 2013 at 4:03 am
    Bobby G seems to be s shill for the vendors; or a vendor himself, desperate to maintain the facade that HIT needs no regulation for safety, efficacy, and usability.
    __

    That is completely stupid. A Clue awaits you at my REC blog:

    Google “REC blog”

    I’m the 1st result.

    Search on “FDA”.

  24. Mighty Casey says:

    I’m (maybe) going to take this in another direction by observing that the current status of EMR tech does exactly what it was designed to do: make getting paid easier. What’s called medical-record tech is really medical-billing tech, since all those lovely ICD-9/soon-to-be-ICD-10 codes have little to do with dx/tx, and everything to do with GETTING REIMBURSED FOR CARE.

    Cherchez l’argent, tout le temps.

    EMR tech will, over time, shift into actual meaningful use. However, it will take herculean effort on the part of both clinicians AND patients to get to that useful point. The time between here and there will be rife with gnashing of teeth and rending of garments … and, unfortunately, more than one tech-enabled medical error. However, given that it’s likely that close to 100K patients die every year due to medical error, who’s gonna notice?

    • BobbyG says:

      Good comment.

        • BobbyG says:

          I have long argued CHANGE.THE.PAYMENT.PARADIGM.

          The totemic 15 minute office visit has everything to do with keeping the doors open, and much, much less to do with providing quality care.

          • Mighty Casey says:

            Why I registered the hashtag #howmuchisthat with Symplur, and have been pressing cost/price transparency for … ever. Patients can be massive change agents, if only we wake up and start asking that question: how much IS that?

    • Boris Katz says:

      You may be right in most of the cases but certainly not in all because my software (and despite the fact that I do not try to sell it to anybody – just share the idea) is not only about “getting reimbursed” but rather about automation of the workflow – clinical in the first place, but everything else as well. And taking everything else equal it improves the quality of care because the more time is left for a doctor to spend on talking and examining the patient, test results and other clinical information – the better it is. Of course, the software will not make one a better clinician, but one will perform better if the stress level is reduced and more time is left for the pure clinical work. Automation my software does improves the billing as well but this improvement does not come at expense of reduced clinical quality – right opposite.
      But from the whole discussion I do not see anybody to care. Most posts are nothing more but complains and whining.

      • Whatsen Williams says:

        The progress note is a misnomer. Call it the bill. Meaningful use requirements do not improve outcomes or reduce costs, but the gig of doing them nets $ millions for the hospital that beats on the doctors to abide ( or suffer the consequences).

        • BobbyG says:

          A longer assessment timeline is required to determine whether any of this MU stuff will bear clinical or financial fruits (and I am rather dubious on the latter).

    • Al says:

      Mighty Casey: “given that it’s likely that close to 100K patients die every year due to medical error, ”

      Firstly correct your data for the year we are in. Secondly, do you know the difference between malpractice and preventable deaths? A little extra morphine to a patient with metastatic cancer to the bone might kill him several hours earlier than letting him stay in pain and not trying to alleviate it. That death may have been preventable, but it was the appropriate thing to do.

      You should check out your slogans before using them.

      • Mighty Casey says:

        I didn’t name a year, because there is no hard data attached to any year. There’s only the extrapolated data from sources like “To Err Is Human” [1999, IoM, http://www.nap.edu/openbook.php?record_id=9728; ‘Epidemiology of Medical Error” [2000, BMJ, based on IoM report, http://www.bmj.com/content/320/7237/774?view=long&pmid=10720365; the 2005 followup “5 Years After … What Have We Learned?” [2005, JAMA, their site’s squiffy right now but article is linked inside this one, http://www.commonwealthfund.org/Publications/In-the-Literature/2005/May/Five-Years-After–To-Err-Is-Human—What-Have-We-Learned.aspx; the most recent, and best, assessment in recent memory is “The Toll of Preventable Errors: How Many Dead Patients” [2012, Health Affairs, http://healthaffairs.org/blog/2012/03/09/the-toll-of-preventable-errors-how-many-dead-patients/.

        I don’t know why you bring up giving extra morphine to a terminal cancer patient as any kind of medical error. It’s not anywhere near “preventable death” or even “preventable error,” like, say, the surgical errors that I have personally witnessed the aftermath of.

        So don’t accuse me of sloganeering, and I won’t accuse you of paternalism.

        • Al says:

          Casey, Maybe you should learn a bit more about the IOM report and what it means. You should also quit with the secondary and tertiary sources that don’t know any more than you do. You should also learn the terms that were used and what they mean. You were sloganeering based upon insufficient information.

          I will quote from a senior researcher with the Harvard group ”

          “I have cautioned against drawing conclusions about the numbers of deaths in these studies. The reliability of identifying errors is
          methodologically suspect.In both studies (New York and Utah/Colorado) we agreed among ourselves about whether events should be classified as preventable . . . these decisions do not necessarily reflect the views of the average physician, and certainly don’t mean that all preventable adverse events were blunders (12).”

          You are sloganeering. By the way the year is 2013 and I won’t get into the political nature of the report. Some of your citations are merely quoting other citations that do not know what the report says or how it was gathered. Others make mistakes in the terms they use.

          To Err is human is based upon two!!! studies in localized areas and extrapolating from there. The 98,000 study was based upon ***173*** patients that died “at least in part because of an adverse event”. I didn’t use the term medical error, you did because of your lack of familiarity with the study. I brought up preventable deaths. Thus a person dying of metastatic cancer (who will be dead in a day or so) might be given morphine to relieve pain. The adverse effect is a respiratory arrest and death. That type of death was included in the study because they were looking for preventable deaths to see if some of them ought to have a change in medical practice not to calculate the number of erroneous deaths. Preventable deaths are different than deaths from error.

          I think you either ought to skip talking about the To Err Is Human or spend a good deal of time learning what you are talking about.

        • pmanner says:

          “To Err Is Human,” used studies of errors during hospitalization in New York State in 1984, and in Colorado and Utah in 1992. The results of these studies were then extrapolated to the entire nation, which is where the 100,000/year number comes from.

          In essence, the data is 30 years out of date.

          • Mighty Casey says:

            But where IS the hard data? Were are the aggregated M&M stats? That’s the issue, AFAIC.

          • pmanner says:

            The short answer is that we have no idea. Standards of reporting are different, metrics are different, and there is no good evidence that EMRs are responsible one way or the other.

            http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap3.html

            The only data I see that is possibly relevant is “Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue)”, which went from 160 events to 120 during the period of 1994 to 2005. Which was before the big push for EHRs.

            (These are hospitalizations complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, gastrointestinal bleeding or acute ulcer, shock, or cardiac arrest. Many of which occur regardless of how good care might be.)

            The fundamental problem being that we have committed ourselves to an extremely expensive, disruptive, and hard-to-use kludge at the behest of the Federal Government. Because when it comes to streamlined, efficient, consumer-friendly service, there’s nothing like the Feds!

            My opinion, as an orthopaedist: I like electronic imaging and charting (I use EPIC) and want EMRs to work. For a complicated patient within my institution, EMRs are great. And I think they probably allow for better care. BUT – as with any therapy/medication/intervention, you gotta have proof.

  25. Boris Katz says:

    I agree that there is nothing meanigful for patients and doctors within the MU requirements – only for the bureaucracy. But my post above was not about MU but rather about medical software concepts (EMR/EHR) which are not all about MU.

  26. Al says:

    One of the good things about health IT and the logging of all information on a computer is that one always knows where all the nurses are.

  27. Al says:

    Bobby G., If your technology is better then the alternative physicians will adopt it just like they adopt new ways of doing things all the time.

    It is you that has to prove your value and not the other way around. If you can’t prove your value then work harder on the programs and stop complaining.

    • BobbyG says:

      It has proven worthy for many, many actual physicians. The Great Unwashed non-MD me tends to side with them.

      • Al says:

        No one doubts that there is variation in how physicians benefit from different things. That is fine. However, if you are in this sort of technology it is up to you to prove your value to the other physicians who will adapt when you make such adaptation worthwhile.

        I am one who likes the idea, but finds it distressing how you react to criticism. Understand, the primary reason for the physician record is for physician use. Therefore you have to appeal to his needs and his fears, not to the government or the insurer or even to your own preferences. You also have to recognize how computerized records can make physicians records into a sham.

        • BobbyG says:

          “the primary reason for the physician record is for physician use”
          ___

          “primary” perhaps, but not “exclusive.” What do you imply by “primary”? 51%? 95%?

          e.g., in the much maligned “meaningful use” program, when assisting with workflow adjustments, we have always taken pains to point out, for example, that 11 of the 15 core measures involve data capture that don’t require physician EHR interaction at all. With respect to those measures that DO need provider interaction, we try to make it seamlessly part of normal workflow — albeit, with uneven success, to be fair (e.g., eClinicalWorks: FIVE different workflows for CPOE, ranging from 3 to 8 clicks? Seriously?). Google “ClinicMonkey EHR”

          I disagree with this vestigial Iron Man paradigm wherein effectively the only material consideration is the “needs” of the physician. That’s the paper chart world we are inexorably exiting, where the doc can leave behind whatever illegible and/or incomplete mess he likes (emphasis “he”), for others to have to rectify later, at great expense.

          To be sure, I realize that a lot of docs bristle at this emerging notion of the MD as a “mere” member of a health care “team.”
          __

          Coda: you (and Scot) are correct, I have in fact been overly and counterproductively combative of late in light of the continuing bait-rich environment. I shall try to do better.

          • Al says:

            BobbyG, did you ever think of why it has been called the physician record? Do you realize the courts recognize the physician record as the physician’s work product and therefore the physician has the right of primary ownership? Have you looked historically at physician notes and records? If not, I think you should do so.

            Do your own manipulation of data on your own dime and your own time or prove to me that you will aid me in my task so that I will use your service. Years ago the pen and paper manufacturers hawked their wares as well and in order to sell me a pen they had to satisfy my needs. You are nothing different from an advanced form of pen and paper along with certain new functions that I may or may not want. If the patient wants things differently they have a right to tell me what they want and they always have a right to go to another doctor. You are not their agent.

            As far as your idea of a health care “team” remember that if you and I are dealing with the same patient you are part of my team.

            Understand though I am one that has been around computers and have great fondness for them everywhere including medicine if a salesperson came with your attitude he would be shown the door.

          • BobbyG says:

            @Al says: July 22, 2013 at 4:01 pm
            “BobbyG, did you ever think of why it has been called the physician record? Do you realize the courts recognize the physician record as the physician’s work product and therefore the physician has the right of primary ownership? Have you looked historically at physician notes and records? If not, I think you should do so.”
            __

            I’m really not that interested in this “history.” That’s a forensic thing more than a clinical one. States increasingly also recognize the data comprising the “physician record” as the property of the patient (I have the 2-binder set of each state’s medical record / privacy rights info). Yes, there is indeed a “work product” aspect to it, but it is no longer viewed as a priori “confidential” from the physicians’ POV. I’m sure you are aware of the pressure to make the entire patient record, including subjective impressions and progress narrative notes, available on demand to patients.

            I’m not advocating that that is wholly a good thing, btw. I know it’s gotta chafe.

            It’s gonna get worse: Forensic data mining auditing of the now-HIPAA requisite 24/7/365 access logs. To me, the access/event/audit logs essentially comprise a “workflow record” insofar as they pertain to HIT use (the other two aspects being physical motion / “spaghetti map” stuff and the purely cognitive/thinking/decisionmaking elements). I can see who “touched” what (created, merely viewed, updated, transmitted, deleted) pertaining to which patient, and when (datetime stamp). I can sort and tracked who did what every day from login to logout.

            Just curious: what exactly is my “attitude”, beyond my curt show-me-the-door style? Do you even know what it is, as it goes to Health IT? Doesn’t seem to be the case. Though, I am glad to know you regard health care as “team work.” And, in fairness, teams have to have actual “leaders” everywhere outside the Dilbert Zone.

          • Al says:

            BobbyG: “I’m really not that interested in this “history.” ”

            That sounds about right. You are so ultra focused on what you want and what you think your abilities are that you have developed tunnel vision. I look at you as an accessory much like I look at the MRI or any other piece of equipment available for me to use. I have no problem with my work product being shared with my patient or others that I or my patient feel add to his care, but I do have a problem sharing it with you or anyone else especially when you wish me to convert it to your form from mine.

            ‘blah , blah and blah’

            You don’t have to brag about what you can do. We are all reasonably familiar with what computers are capable of.

            “Though, I am glad to know you regard health care as “team work.””

            I am a very reasonable and egalitarian fellow. I consider those that mop the floors as part of a baseball team. When you are on my team we will have no problems as long as you recognize it’s my team. There is only one person higher than me in the team and that is the patient.

            “Just curious: what exactly is my “attitude””

            You want to know about your attitude? If you have to be told what is wrong then you are in more serious trouble than I imagined.

            “Do you even know what it is, as it goes to Health IT? ”

            If you are asking me if I know about health IT or computers the answer is yes. I also understand how IT interacts with my patients and my treatments and above all I know how to practice medicine. That is one thing you lack. The second thing you lack is understanding how I think and what I need to do my job properly. When IT accomplishes that I will say job well done, but right now you are overreaching so I consider you dangerous.

          • Bobby G says:

            “Do you even know what it is, as it goes to Health IT? ”
            If you are asking me if I know about health IT or computers the answer is yes. I also understand how IT interacts with my patients and my treatments and above all I know how to practice medicine. That is one thing you lack. The second thing you lack is understanding how I think and what I need to do my job properly. When IT accomplishes that I will say job well done, but right now you are overreaching so I consider you dangerous.
            __

            You missed the point. I wasn’t asking what YOUR views are. You really don’t know what mine are. You’ve just jumped right off to erroneous conclusions.

            Whatever.

            I’m not “overreaching” anything (nor do I have such power).

          • Al says:

            You are right. I don’t know what your views are. I only know what I read here on the blog and nothing you say here has changed my views.

        • BobbyG says:

          “distressing how you react to criticism.”
          __

          Being called a “shill” or a “HIE vendor” or an “amateur” who doesn’t show the proper humility is gonna get pushback every time. Those are not criticisms of my ideas. Sorry.

        • BobbyG says:

          @Al says:
          July 22, 2013 at 7:49 pm
          You are right. I don’t know what your views are. I only know what I read here on the blog and nothing you say here has changed my views.
          __

          Fine. End of debate. The feeling is mutual. I won’t trouble you again. Good luck to you.

  28. BobbyG says:

    apropos of Anger Management:
    __

    EHRs ‘transforming’ care, says Tavenner

    Providers are increasingly using electronic health records, both to manage their patients’ care and to provide more information to those patients, according to new data published Wednesday by the Centers for Medicare & Medicaid Services…

    By meaningfully using EHRs, physicians and care providers have shown increased efficiencies while safeguarding privacy and improving care for millions of patients nationwide, the data show.

    “Electronic health records are transforming relationships between patients and their health care providers,” said CMS Administrator Marilyn Tavenner, in a press statement. “EHRs improve care coordination, reduce duplicative tests and procedures, help patients take more control of their health and result in better overall health outcomes.”

    According to CMS, since the EHR Incentive Programs began in 2011:

    - More than 190 million electronic prescriptions have been sent by doctors, physician’s assistants and other health care providers using EHRs.

    - Healthcare professionals sent 4.6 million patients an electronic copy of their health information from their EHRs.

    - More than 13 million reminders about appointments, required tests, or check-ups were sent to patients using EHRs.

    - Providers have checked drug and medication interactions to ensure patient safety more than 40 million times through the use of EHRs.

    - Providers shared more than 4.3 million care summaries with other providers when patients moved between care settings resulting in better outcomes for their patients.

    “More patients than ever before are seeing the benefits of their providers using electronic health records to help better coordinate and manage their care,” said National Coordinator Farzad Mostashari, MD, in a statement. “These data show that health care professionals are not only adopting electronic health records rapidly, they’re also using them to improve care.”

  29. 40yearold doc says:

    Beautiful collection of meaningless endpoints.

    Tavenner and Mostashari are both moronic self-righteous bureaucrats who have never used an EHR.

    I don’t ask for advice on buying a new car from someone who has never driven one.

    • BobbyG says:

      “moronic self-righteous bureaucrats”
      __

      The Usual Libel.

      “…Dr. Mostashari served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project, where he facilitated the adoption of prevention-oriented health information technology by more than 1,500 providers in underserved communities. Dr. Mostashari also led the Centers for Disease Control and Prevention-funded NYC Center of Excellence in Public Health Informatics and an Agency for Healthcare Research and Quality-funded project focused on quality measurement at the point of care.

      He conducted graduate training at the Harvard School of Public Health and Yale Medical School, served his internal medicine residency at Massachusetts General Hospital, and completed the CDC’s Epidemic Intelligence Service program. He was a lead investigator in the outbreaks of West Nile Virus, and anthrax in New York City, and among the first developers of real-time nationwide electronic disease surveillance systems.”

      I’ll stick this THIS “moron” any day.

      And I get accused of rudeness. LOL.

      • 40yearold doc says:

        Read any interview with Mostashari: he seems incapable of understanding simple English.

        He is asked about A, B, and C, and responds by talking about X, Y, and Z.

        If he’s not a moron, he should stop talking like one.

        • BobbyG says:

          That’s complete crap. I know the man personally. I have heard him speak in person on multiple occasions. And I am no reflexive cheerleader for all of his views (as he well knows).

          But, y’all keep it up. Wasting bandwidth.

          • 40yearold doc says:

            Maybe.

            But the real miracle that should make us drop to our knees is that EHRs have sent out over 13 million appointment reminders, right?

          • BobbyG says:

            “But the real miracle that should make us drop to our knees is that EHRs have sent out over 13 million appointment reminders, right?”
            ___

            LOL. Yeah, and they overtly touted it as a “miracle.”

            Take any one required reporting measure in isolation and mock it. Lather, rinse, repeat. A fun time.

  30. BobbyG says:

    “you and Matthew would not be permitted to testify as expert witnesses in health-IT related cases, while I and similarly educated physician informaticists are, and do.”
    __

    And, we can assume you have an empirical case outcomes track record? Are you exclusively an anti-HIT witness? What’s your batting average?

  31. Roger Collier says:

    Matt’s analogy with World War One tactics is interesting but incomplete. Cavalry charges were superseded by defensive barbed wire and trench warfare (which resulted in millions of casualties with no perceptible progress by either side) and finally in turn by tank assaults (which made the previous strategies instantly obsolete).

    So far as healthcare IT is concerned, it does sometimes seem as if we’re stuck in the second phase of the analogy – a grinding costly effort that has yielded very limited achievements. Unfortunately, Matt’s post provides no convincing proof that we’re on the verge of a third phase: a vastly more effective and less costly approach to the war on ill health. Yes, we’re seeing some incremental improvements, but not a game-changer like tanks in warfare (or Matt’s iPhone in entertainment for two-year-olds).

    • This is not a “normal” war, Roger. It’s a Holy War. The outcomes are irrelevant. The only important benefit accrues to the powers to be from maintaining a perpetual state of war.
      Full opinion here: http://onhealthtech.blogspot.com/2013/07/the-holy-ehr-wars.html

      • BobbyG says:

        Now, THERE’S a worthy blogger!
        __

        “The non-believers come in many flavors and as always in history, are disorganized, fearful, delusional and in violent disagreement with each other. There are those who question only the particulars of the Technology, but basically believe in the Promise, and very carefully profess their deep belief in magic in every article or opinion piece criticizing the current state of Technology…”

        Sorta like pols who have to preface EVERY gun control advocacy with their “unwavering support for the 2nd Amendment” — an Amendment I would repeal. (While we seem hell-bent on effectively repealing the 4th and the 14th).

  32. Bubbles says:

    Nonsense above. Patients are not safer with HIT infrastructure in hospitals. Collect the data and get the systems validated and proven safe by organizational surveillance. The number of errors due to flawed drop down menues and tiny fonts are staggering.

  33. One very interesting thing I have noticed in reading about MU and HIT on the web is how quickly the discussions devolve. The fact is that no technology is ever neutral in its impact—there are always good and bad consequences. Antibiotics save lives and create super bugs. With any technology, prudence requires that one study the effects and attempt to maximize the good and minimize the bad.

    Looking at user surveys such as the one conducted by the Medical Group Management Association, reveals that some say they are better off after implementing an EHR, some say they are worse, and many state there is no significant difference. When, it comes to implementation outcomes, it seems to me that the most prudent path is determining the factors that best predict who will be in each group.

    http://ehrscience.com/2013/03/18/ehr-implementation-where-are-we/

    My concern in reading this thread is that the potential of clinical information systems as adjuncts to clinical care is being lost in the debate over the MU program as public policy. Electronic health records are neither good nor evil; they are neither a panacea nor a blight. Obviously, current systems can be improved—user interfaces are often problematic, and workflows are usually hard-coded. Building better systems requires objective research, testing, and an open discussion of design flaws. Overstating the case for or against EHR systems leads to arguments, not progress.

    http://ehrscience.com/2012/07/23/universal-implications-external-validity-and-thomas-kuhn/

    • Boris Katz says:

      I would suggest that the main goals of a good medical software (routinely called EHR even it does not reflect the goal) is to help (faster and withh less mistakes) physicians and their staff to get from point A (when a patient makes an initial problem related appointment) to point B (when problem as completely cured or – in case of a chronic desease, patient dies). That is it!. Everything else – MU specifically, is nothing more than intermediate goals, correctly or in case of MU incorrectly set.

    • BobbyG says:

      “Overstating the case for or against EHR systems leads to arguments, not progress.”
      __

      That has always been my position. Great comment.

  34. Bimbo says:

    @Carter “Overstating the case for or against EHR systems leads to arguments, not progress.”

    I would not want my records on an EMR. Whenever money is involved, the cas is overstated, though the case against EMR is issued because it is a known fact that they cause errors, injuries, and deaths and no one is making a profit from insisting that the truth be known.

    • Bobby Gladd says:

      ” it is a known fact that they cause errors, injuries, and deaths”
      __

      And, you can document this precisely how? With legal specificity? A comparative specificity scientifically, forensically proving that Health IT is worse than paper overall?

      “known fact” LOL.

  35. It is 2013, I’m shocked that this debate is even going on. Emrs have been around since the late 1980s. How many of you are driving cars that old or cars that have technology, software and hardware that old? Having watched this industry since the early 1990s I can honestly say what we have in 2013 for the most part is far advanced from that time. The pen & paper vs electron debate has been going on way too long. There is way much more you can do with computers than pen and paper. There really is no comparison. Though it has to be planned and implemented correctly.

  36. Ross Koppel, Ph.D., FACMI says:

    Matthew Holt made the debate about HIT vs. pencil and paper. That’s not what anyone is talking about. HIT offers thousands of advantages over pencil and paper. Mr. Holt made that straw man argument for his post, and then won the debate with himself. But it never part of anything Steve or I ever said or contemplated.
    The issue is not about going back to paper or even going back to wet clay tablets and cuneiform. The issues is what can we do to make HIT better than it is? Than the clunky, non-user-friendly systems we currently have. But no one ever talked about dumping HIT or going back to 1953 Fords or 1853 buggies.

    • Matthew Holt says:

      Not sure why you’re responding today Ross, nearly a year later. But we agree! Need better technology, not pen & paper.

      One good piece of news. We had 4 biggies in the world of EMRs (Cerner, Allscripts, athenahealth Practice Fusion) on stage our HxRefactored last week in NYC. All 4 have gone from 1-2 in their human/UI design depts 3-4 years ago to over 20 now. So your messages are resonating….slowly

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