Keep Calm and Interoperate On

Keep Calm and Interoperate On

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Digital DoctorFollowing the recession, the Obama administration sought shovel-ready projects.

One unlikely shovel wielding aggregate demand was health information technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the stimulus towards digitizing medical records.

Computerization of medical records doesn’t induce the images of public works as building freeways during the Great Depression does, but the freeway is a metaphor for exchange of information between electronic health records with the implication that such an exchange is a public good and so government intervention is justified.

Robert Wachter, voted the most influential physician by Modern Healthcare, sums the optimism and frustration with the electronic health record (EHR) in Digital Doctor – which stands to be a classic.

It was Bush Jr., not Obama, who started the digitization. Seeking bipartisanship after the war in Iraq, Bush was inspired by his closest ally, Tony Blair, who was wiring the National Health Service (NHS) – a $16 billion initiative which has since failed, spectacularly.

Bush founded the Office of National Coordinator of Health Information Technology (ONC) and appointed David Brailer – a physician, quant and entrepreneur – as head. Brailer wanted interoperability so that hospitals shared information. It is because of interoperability that we can use our debit cards in New York and Singapore. The market must agree on a common language, such as the TCP/ IP for the internet, to achieve interoperability.

Patients suffer when systems can’t talk. Were patients, not a third party, bearing the full costs of care – a free market – they might have forced hospital information systems to talk. Rightly or not, healthcare is not a free market and hospitals have little motivation in making cross-talking simpler.

Brailer wanted the ONC to be an enabler not dictator of common standards. Fearing that market innovation would be ruined by regulatory over reach, he drew a fine line. A budget of $42 million suited his libertarian ethos. Following the HITECH Act, the budget for ONC increased to $30 billion and Brailer’s line was wiped.

With unabashed Keynesianism, the government subsidized the purchase of EHRs by physician practices from certified vendors. The logic was sound. Expecting practices to digitize voluntarily is like expecting people to buy roads to make Interstate-95. The cost of digitization is high, yet all will, one day, benefit from the wiring, not just practices which choose to be wired.

The reformers wanted a Goldilocks system in which doctors delivered neither too much nor too little care. To pay doctors for doing the right thing, not just for doing, an electronic repository was necessary, so that payers knew which doctors followed guidelines, encouraged prevention and practiced high value care.

If only payers could measure doctors they could reward the good and punish the bad. EHRs would be the treasure trove of that information. If mandating health insurance was crucial to reforming insurance, the EHR was essential to reforming physician payment. Thus, the EHR transmogrified into an electronic version of Bentham’s panopticon.

The government could not subsidize physicians unconditionally. The conditions were named, with unintended irony, “Meaningful Use.” Regulators no longer were concerned just with interoperability but how the technology was being used. It was like Steve Jobs and Bill Gates selling computers only if used for activities they both approved.

In a dialectic not odd in healthcare, HITECH is a success and disaster. The adoption of EHR, which increased from 10 % to 70 % of practices, would not have happened so quickly without the subsidies. The Blitzkrieg has consequences – many physicians loathe EHRs, viscerally.

The paradox of automation is at once diminution and magnification – fewer but more catastrophic errors. Wachter narrates how a young male received an obscenely high dose of an antibiotic because of a user-unfriendly prescription interface. The bad tool might blame the workman. Whether the tool or the workman is at fault is a distinction without a difference.

Why are doctors deskilled by EHRs when they use I-pads, power point and Yelp? EHR is like a library which throws all books all at once at you when all you wish to read are books by Herman Melville. The information overload fatigues.

EHRs serve many masters including administrators, payers, risk managers and researchers. EHRs must also capture the nuances of a doctor-patient interaction. By bloviating the EHR with information rather than trimming the interface with context, the vendors have pledged their servitude to the comptroller not the foot soldier; which would be fine but it is the foot soldier who uses the EHR predominantly.

Wachter is no Luddite. He speaks in measured tones with subtle angst and his sharp analysis will please Luddites as well as Futurists. He occasionally invites the reader to disagree. Wachter believes EHRs, though flawed, have improved healthcare delivery. I might argue with that. The loss of clinical context is tangible. But would I return to paper records? Truthfully, probably not.

Computerization of records was inevitable. Had it emerged organically, through dispersed agents and trial and error, the way advised by Friederich Hayek in his landmark essay “Use of Knowledge in Society”, arguably we might have interoperability. The precocious adoption of EHR may have stunted its growth.

Imagine if the government had subsidized the purchase of cars in 1896. Perhaps all Americans would have owned cars before the twentieth century, and horse buggies would have disappeared sooner. But would Henry Ford have innovated beyond the Quadricycle?

Mr. Ford might have envied the EHR-vendors. I do. They enjoy a rare carapace which shields them from unhappy customers. Disgruntled doctors are summarily dismissed as change-phobic dinosaurs. Hospital administrators don’t admit that they have misjudged costly technology. Some contracts forbid doctors from shaming vendors openly, even as taxpayer’s money flows to the vendors. Free market advocates will protest that this is not capitalism. To be fair, neither is this socialism. Whatever this innominate political economy will be named, it seems quite unique to US healthcare.

John Maynard Keynes famously said that in a recession there was value even in the government burying bottles with bank notes and luring private enterprise in to retrieving them. HITECH didn’t exactly bury the bottles but handed them out, with $30 billion in them. In return for the bottles we have strategic plans, shared goals, pages and pages of rules but no interoperability. Instead, the ONC is remonstrating with hospitals not to block information. Might the stimulus have been better spent on tinkerers? Brailer believes so.

To quote Seneca: to be everywhere is to be nowhere. The reformers may have asked too much, too soon of electronic health records, which may deliver too little, too late. Time will tell, of course, and in twenty years either the tinkerer or the central planner will have the satisfaction of “I told you so.” But both will applaud Wachter’s tome.

Saurabh Jha, MD is a radiologist at the University of Pennsylvania. His views do not represent those of his employer.

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34 Comments on "Keep Calm and Interoperate On"


Member
May 21, 2015

Nice and informative post Dr.Jha..

Source: http://www.tariqdrabu.co.uk/

Guest
May 7, 2015

I’m actually willing to read it because i already boat it

Guest
May 3, 2015

Saurabh — thanks so much for this extraordinarily thoughtful, erudite review of my book. You not only “got it” but took some of my ideas a step further.

I just loved some of the concepts and turns of phrase: the “dialectic not odd in healthcare;” the image of Steve Jobs and Bill Gates approving of computer uses; the thought experiment of what would have happened had the first cars been subsidized with tax dollars; and the line: “whether the tool or the workman is at fault is a distinction without a difference.”

I particularly like your ending — I agree that we’ll have to see, over the course of time, whether our initial steps, and missteps, will ultimately take us to a better place. I tried my best to understand this remarkable moment, as healthcare rapidly, reluctantly goes from an analog business to a digital one. But even after a year of thinking about nothing but this question — and interviewing nearly 100 experts with a variety of points of view — I came to realize that one can paint a future that proves the skeptics right (including some of the commentators in this chain), and an equally plausible one that vindicates the optimists.

Guest
May 3, 2015

Saurabh — thanks so much for this extraordinarily thoughtful, erudite review of my book. You not only “got it” but took some of my ideas a step further.

I just loved some of the concepts and turns of phrase: the “dialectic not odd in healthcare;” the image of Steve Jobs and Bill Gates approving of computer uses; the thought experiment of what would have happened had the first cars been subsidized with tax dollars; and the line: “whether the tool or the workman is at fault is a distinction without a difference.”

I particularly like your ending — I agree that we’ll have to see, over the course of time, whether our initial steps, and missteps, will ultimately take us to a better place. I tried my best to understand this remarkable moment, as healthcare rapidly, reluctantly goes from an analog business to a digital one. But even after a year of thinking about nothing but this question — and interviewing nearly 100 experts with a variety of points of view — I came to realize that one can paint a future that proves the skeptics right (including some of the commentators in this chain), and an equally plausible one that vindicates the optimists.

Guest
Curly Harrison, MD
May 3, 2015

@wachter “Wachter believes EHRs, though flawed, have improved healthcare delivery.”

When did he last click 8 times to order 1 baby aspirin 3 times per week, or click through the time wasting CPOE maze for ordering denovo Factor Xa Inhibitor?

The tongue is indeed forked.

Guest
Curly Harrison, MD
May 3, 2015

@wachter “Wachter believes EHRs, though flawed, have improved healthcare delivery.”

When did he last click 8 times to order 1 baby aspirin 3 times per week, or click through the time wasting CPOE maze for ordering denovo Factor Xa Inhibitor?

The tongue is indeed forked.

Guest
May 3, 2015

“The cost of digitization is high, yet all will, one day, benefit from the wiring, not just practices which choose to be wired.” and

“The precocious adoption of EHR may have stunted its growth.” and

“Imagine if the government had subsidized the purchase of cars in 1896. Perhaps all Americans would have owned cars before the twentieth century, and horse buggies would have disappeared sooner. But would Henry Ford have innovated beyond the Quadricycle?”

Exactly!….points I have been trying to make for some time. The coercive/mandated adoption has harmed the evolution of EHRs…the best thing to do now would be to remove the subsidies and mandates and let the technology vendors cater to doctors and patients instead of the regulators and hospital system administrators who are the current masters….to the detriment of doctors and patients.

Guest
May 3, 2015

“The cost of digitization is high, yet all will, one day, benefit from the wiring, not just practices which choose to be wired.” and

“The precocious adoption of EHR may have stunted its growth.” and

“Imagine if the government had subsidized the purchase of cars in 1896. Perhaps all Americans would have owned cars before the twentieth century, and horse buggies would have disappeared sooner. But would Henry Ford have innovated beyond the Quadricycle?”

Exactly!….points I have been trying to make for some time. The coercive/mandated adoption has harmed the evolution of EHRs…the best thing to do now would be to remove the subsidies and mandates and let the technology vendors cater to doctors and patients instead of the regulators and hospital system administrators who are the current masters….to the detriment of doctors and patients.

Guest
Whatsen Williams
May 3, 2015

Brailer was hardly a liberterian. His failure, and that of those who followed, is that they did not hold the vendors accountable such as what occurs with FDA oversight. And Wachter, who speaks with forked tongue, failed to heed warnings of just how wicked and risky these devices are.

I would go back to paper, partially. The doctors and nurses should not be data entry clerks, which is what HHS has proscribed. Thus, a give me the data work flow is needed.

Keep the digital library of results and images. Rid the workflow of CPOE, cut and paste, macros, and templates. Doctors think better when they write notes and orders. Paper MARs are so much more user friendly than the digital gibberish impeding accuracy.

Let’s also hear about the cradhes and deaths from the crashes.

Guest
Whatsen Williams
May 3, 2015

Brailer was hardly a liberterian. His failure, and that of those who followed, is that they did not hold the vendors accountable such as what occurs with FDA oversight. And Wachter, who speaks with forked tongue, failed to heed warnings of just how wicked and risky these devices are.

I would go back to paper, partially. The doctors and nurses should not be data entry clerks, which is what HHS has proscribed. Thus, a give me the data work flow is needed.

Keep the digital library of results and images. Rid the workflow of CPOE, cut and paste, macros, and templates. Doctors think better when they write notes and orders. Paper MARs are so much more user friendly than the digital gibberish impeding accuracy.

Let’s also hear about the cradhes and deaths from the crashes.

Guest
William Palmer MD
May 3, 2015

We already have interoperability. Just tell your patients that each is going to have a web site that is read by obtaining her password..,,and that any provider or payer or policy-maker or researcher can access her data by this password and by using any browser. AND getting her permission. Nothing new. It is just like your IRA account.

Teeny tiny small problem: These other stakeholders want to read your data WITHOUT your permission and they don’t like this cruel-to-others system.

Guest
William Palmer MD
May 3, 2015

We already have interoperability. Just tell your patients that each is going to have a web site that is read by obtaining her password..,,and that any provider or payer or policy-maker or researcher can access her data by this password and by using any browser. AND getting her permission. Nothing new. It is just like your IRA account.

Teeny tiny small problem: These other stakeholders want to read your data WITHOUT your permission and they don’t like this cruel-to-others system.

Guest
May 3, 2015
Guest
May 3, 2015
Guest
May 3, 2015

Nice post. Dr. Jha.

Bob’s book is indeed excellent. I’ve cited it on my blog.

“ONC is remonstrating with hospitals not to block information.”

If ONC vetted and approved electrical wall outlets, there would today be close to 2,000 “2011/2014 CHPL Certified” sizes and shapes of 120VAC 15 amp 3-prong units at Lowe’s and Home Depot.

Karen DeSalvo, opining from her Irony-Free Zone, recently said we must “standardize standards.”

The clueless confusion is just breathtaking. Who was it? Jacob Reider? Who said that “the wonderful thing about health IT standards is that we have so many of them.”

Defenders claim he was joking. The snark didn’t come through to me.