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TECH: Can doctors ever learn to love the EMR?

This was my editorial at FierceHealthcare on Friday

This week I heard a very bitter physician complaining that using an electronic
medical record got between him and caring for his patients, and imposed
secretarial tasks on him. Then on Tuesday we got perhaps the most negative news
yet about a problematic CPOE installation at Childrens’ Hospital in Pittsburgh,
where after its introduction patient mortality increased. There was also news
about an emergency department in Arizona pulling the plug on its EMR.

Whatever the real reasons behind the data, it’s clear that simply installing
an EMR or CPOE system did not have the desired impact on patient safety. My
cursory assessment is that electronic records are vital in improving the
healthcare delivered to patients, particularly those with chronic illnesses,
over the continuum of care. But it’s clear that when they’re introduced to ICUs
or ED, where speed is the key and care processes are not well defined, things
may not be so successful. A real examination of the process absent the
technology, and a massive commitment from vendors to improve the human-computer
interface, is quickly needed before the movement toward CPOE and EMR is stopped
by these kinds of stories. After all, it’s easy for a hospitals or physician
groups to decide instead to do nothing.

Well, some people were reading. Kelly Clark a physician from Boston, recently relocated to
Louisville, wasn’t too impressed. She wrote to me:

Any time you want to hear a physician complain about using
CPOE/EMR, simply ask any clinician who makes their living actually treating
patients and billing insurance for their services. “Speed is key
and care processes are not well defined” as the default condition for the
current practice of medicine – it is in no way limited to the ICUs and ERs. 
A large amount of information on digital access is useful to care
coordinators who are salaried to manage a fairly small caseload of patients with
chronic conditions. The time constraints placed by the market on
the physician-patient encounter do not allow for the thoughtful assessment of
large quantities of historical data by a practicing physician. Physicians are happy with their CPOE/EMR system in the salaried and
subsidized world of the VA. Outside of that arena, the
administration and the 1-3 physician champions of EMR in each health care system
will be the primary sources of effusive positive regard for EMRs, but those of
us in the trenches are typically not quoted and not happy. Having
been forced to use these CPOE/EMR systems and seeing them severely limit the
efficiency and safety of medical care, as well as increasing error rates, I am
among the practicing physicians who can wax eloquent about their problems.

You are correct in the need for aggressive assessment of
the way medicine is practiced and huge investment in improving human-computer
interface systems in order for the EMRs to work well and realize any savings of
dollars or lives. However, I believe you are incorrect in
predicting that the stories you quote may result in stopping the movement toward
EMRs because it is “easier for hospitals and physician groups to do
nothing”. This is not true. The move toward EMRs is
not being led by physicians or hospitals, so our input is amazingly
irrelevant. The movement is largely based on a fallacy that
improved technology will lead to decreased cost, with a side bar of improved
quality of health care. It is led by business interests and
followed by the government – ie, the payors. Improved technology will be a huge
boon for consulting firms, administrators, and other types of technician and
advisors. It will absolutely not decrease costs. Only improved rationing of health care resources will do that. However, since no one wants to deal with the true issue, our current
resources have been diverted to The Holy Grail of Techno-Salvation. The interests behind this are well-entrenched and will not be stopped by
a few facts that contradict their ideology. This is evident with
the push to P4P, when there are almost no “performance” scales that are relevant
to medical care for real patients with real co-morbid
medical/social/psychological issues that impact their health and health
care.
It is not easier for hospitals to do nothing, because
Medicare continues to be a main player on their field, and the push toward
electronics by Medicare cannot be ignored by hospitals. As
economies of scale push toward large Kaiser-like systems and physicians move to
stable jobs being employed by large entities, EMRs will make more sense. In the meantime, the move toward these large systems of care, including
the fits and starts of competing EMRs, will lead to more wasted health care
dollars and worse medical care, as well as complaints by bitter physicians who
are being devolved from being professionals toward being marginalized purveyors
of a technical commodity.

I actually agree with much of what Kelly says especially about the lack of conversation about rationaing, although I’m not so sure that payors are leading the way towards EMRs, or that anyone is. I suspect that underlying the lack of appreciation of the EMR is the realization that it in fact only really makes sense for bigger organizations. What Kelly may be underestimating is the ability of the AMA and others to delay the imposition of IT, such as the rejection of the mandating of electronic prescribing in the House-Senate conference of Medicare Part D. But this debate and this process is by no means settled.

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  1. Keeping mailing record is very useful thing for the cure of many diseases. specially the problems like the pigmentation problems of skin in which slow progress suggest the effectiveness of treatment and this this is necessary for any dermatologist to treat disease in better way.

  2. Really good article. I have been following your blog for several months. You have good knowledge on medical billing software. It was also helpful to me to update my site.Please continue the good work. Thank you.

  3. Hi.. It is been a very big discussion on EMR or CPOE system..Really they do provide the desired impact on patient safety.the move toward these large systems of care, including the fits and starts of competing EMRs..Its really very much helpful to physicians and professionals toward being marginalized purveyors of a technical commodity..I really enjoyed your valuable information on your blog..

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  6. I think that there are two views points to be considered when strongly advocating the use of EMR in practices. For a Doctor it needs to easy to use and save time so that more time can be spend on the patient. Currently we have many vendors with different types of EMR that are so hard to use that it simply puts them off. I think healthcare technology companies need to develop product after regular interaction with doctors to ensure that they provide just what is required. At binaryspectrum we have developed our healthcare solutions after spending countless number of hours with doctors to ensure that its work flow is kept simple and intuitive. This is then followed up with a period of Beta testing in real time environment before it is offered as a product in the market.

  7. Is it just me, or did anyone else notice the time and date stamps so close together on the July 20th postings. Hmmmm…

  8. Kelly Clark:
    You hit the nail on the head. I could not agree more about your comments about the EMR and who is likely behind the push. I’d been trying to figure it out myself this past year in our hospital.
    I see these companies pushing EMR’s no different than the pharmaceutical industry.
    Eric Harrington

  9. I have used Soapware for many years and as such have grown with it. I have found it a very cost effective and efficient way to streamline my office and facility operations. More importantly I have been a meical school faculty member for 22 years and a regional medical director for a major insurer for 7 years. I have found Soapware to be an excellent teaching-and compliance tool in our clinical teaching site. I am responsible for the development and implementation of evidence based guidelines. This is an invaluable tool in that sense. As such it is also a risk management tool that increases patient safety. I presently encourage all students to strongly consider the implementation of an EHR at the outset of clinical practice- and at that stage Soapware is without doubt the most affordable and flexible-allowing progressive growth and implementation

  10. mmd.net EHR is the best product as part of usability and legal compliance concerns.
    we would recomment all small and medium size healthcare providers to contact us for schedualng a Web Demo as to have better feel of versatility of the mmd.net EHR.

  11. I agree with the positive comments made above regarding the use of Soapware (DOCS, Inc). The program is simple, user friendly and is designed to be used by physicians, not by institutions. It is also designed to be affordable. Other systems are extremely expensive, require extensive training, and require costly annual fees. Within weeks of our purchase, my partners (neither of whom are very computer savvy) and I were all using the EMR system. We have had no issues with customer support. To the contrary, we have found the support to be excellent and the training opportunities perfect for our needs.

  12. Any criticism of SOAPware must be taken with a large dose of salt. (way more than a grain!) And if the detractor doesn’t have the heart to sign his/her name, that in itself eliminates any credibility as far as I am concened. My name is below. I will be more than happy to talk to anyone who wants to know about SOAPware.
    I have used SOAPware for 4 years and I have looked at numerous other EMR’s as well. I am owner/operator of a primary care clinic. Without SOAPware I would have a LOT more work managing my documentation. It is cost effective far beyond any other system I examined when starting my clinic in 2002. Support is top quality, far better than from any other software maker I have EVER dealt with. I cannot recommend SOAPware highly enough to my colleagues.
    Stephen Shortridge, PA-C
    Clinic Director
    Rainbow Medical Clinic
    Big Lake, AK

  13. Simply put, SOAPWARE by DOCS, Inc. is the most widely used EMR in the marketplace. And it’s that for a reason: it works !
    I researched countless EMR programs when our office moved to EMR.
    We chose SOAPWARE. That was many years ago and we haven’t had any cause to look back.
    Quite a few doctors have visited our office to observe SOAPWARE in action during their search for an EMR and have made the decision to choose SOAPWARE for their practice too.

  14. Disagree totally with SCREAMING MIKE:
    I have been using SoapWare for two years & love it more each day. Labs go directly into chart, can make your own templates the way you like them!!!
    Support is fantastic. Every call returned within an hour and the problem is alway fixed… cold. The tech takes control of the computer remotely. I go back to seeing patients.
    Using MS SQL database allows you to scan in everything, including all those bits of loose paper that fly around, without worry. SoapWare has never crashed in the 2 years. MS SQL automatically backs up the database and checks for internal consistancy.
    It takes a bit of time to get SoapWare to do what you want it to do, the way you want to do. However the concepts are easy to learn, very powerful and very, very flexible. You do not have to hire a group of programmers at $150/hr to make changes like some other EMRs.
    The GUI is a little dated but so what!! my dated GUI gets me into my new beemer and off to the links lickedy split.

  15. Soapware rocks!! During the 10 years that I have used SW, a number of surgery residents who rotate through the office have seen and appreciated its functionality and easy adaptability and have later started using it in their own practices. The developers are easily accessible and incorporate suggestions for improvements. I have seen it grow since Version 2, which was good. It just continues to get better.

  16. I have used SOAPware since 2004. The tech support is excellent. And it only costs $300 a year!! I am looking forward to the new version. My staff loves it, it really has saved us a lot of time and effort in our office (I am sure any EMR can do this, but at a much higher cost!)

  17. A brief comment regarding the earlier post on SOAPware by a gentleman by the name of “mike”.
    I have been using SOAPware (by DOC’s, Inc.) since 1998 and I have no idea where “mike” is coming from. The program works well, the notes generated hold up in court as well as with the various insurance and managed care companies, and the support has always been quick, helpful and thorough. SOAPware has been a sound and reliable EMR and is routinely being improved as the EMR world evolves. Again, the EMR world is evolving and none of us are quite sure where it is going. SOAPware is a great effort by the people at DOC’s, Inc., it is, and has been all these years, an indispensable part of my practice. Oh, by the way mike, I started practice in the 1970’s and there was nothing like this. If “mike” was unhappy why not simply ask DOC’s, Inc. for his investment back (DOC’s has a guarantee). I have simply not seen a more reliable and consistent EMR program for the money. I’ll stay with SOAPware.
    Dr. Holland

  18. I have used SOAPWare for 3 years and totally disagree. I found it to be fully customizable giving me the means to mold it to my style of practice. I also like the expandable codes which allows protocols to be developed and a few letters and a space bar spits out a comprehensive treatment. You then just check off what you did and clear everything else. I have never had any problems with support and have never had any real problems with any of the program.

  19. I am also a happy Soapware user. I have been using it in a paperless outpatient environment for 3 years. It is relatively easy to use and I have had excellent support on the few times that I have had issues. I think that it is an excellent value. The basic module costs $300. You can add additional modules as needed. Soapware does what I need at a price that I can afford.

  20. I started out in solo practice about 2 years ago. I got estimates from several vendors, including GE, EMDs, eClinical Works, PMSI, etc. They were well over 15,000! Then I found SOAPware; it was written by a family doctor, and served my purposes just fine; I installed on my laptop, didn’t have to buy a server, and added modules gradually as my practice expanded. I agree it’s not the most high-tech product like some of the others, but it’s very economical. The company is coming up with a killer product – Soapware Liger, and if you look at the functionality it is a big improvement over even the more expensive products. Also, I am able to do e-prescribing, and export charts, and Soapware has dedicated themselves to being a truly “open” record. I use Soapware in conjunction with Medisoft for billing. As for the documentation, the macros actually save time and create a nice note that doesn’t look like it was generated by a computer. If you want, you can buy dragon dictate and dictate your note directly in the computer if you don’t type fast.
    I think even $4000 for a complete package is very reasonable compared to $15,000+ for the other guys – and I know Soapware will be around, they have excellent customer service, and the ongoing annual fees are minimal for what you get. Any problems I have had have been resolved by customer service.
    Please feel free to contact me for any specifics on Soapware, and I am happy with it overall and pleased with the new version that is going to be coming out.

  21. I have used Soapware for over 2 years – my experience has been the opposite of Mike’s. It is a very stable system – one of the cheapest that you can buy and my experience with their tech support has been excellent. Compared to other emr’s that I have tried data entry and functionality has been if anything better

  22. we JUST BOUGHT AND INSTALED A PROGRAM CALLED soapware – WHAT A JOKE – STAY AWAY – HORRENDOUS SUPPORT – ARCHAIC PROGRAMMING – SAVE YOUR MONEY – LOOKS LIKE IT WAS WRTTTEN IN THE 1970’S

  23. Why can a little $295 and a $1,000 EMR vendor produce a demo link of their EMR in action when the expensive ones are not?
    Customers want:
    Give us dynamic demo’s of the EMR in action of the common office functions.
    How to book a patient.
    How to create a note for new patient (and old patient).
    How to write a Rx.
    How to functionality of document managment.
    etc, etc…….
    Customers SAY: Inspire us with your goods ! Fill in the gap between screen shots and the tailored “demo sessions” that one signs up with the sales dept.
    Regards,
    EMRWorld.NET

  24. It is amazing to see the divergent thought processes of practicing doctors, the programmers, health care administrators . It is easy to talk about quality but hard to define it objectively. Perhaps the only measure of efficacy of what we do is “how well is the patient feeling, in spite of our treatment!”. This is an area that has been well leveragerd by people who administer “miracle Cures” or practice the “Feel-good medicine” and make a lot of money by writing books and being on national TV ( Example: among the super Quacks Kevin Trudeau, and among the formally qualified Dr Deepak Chopra).
    Talk about CPOE/ EMR to a neurosurgeon operating on the base of the brain or a pediatric heart surgeon fixing multiple congenital anaomalies in a newborn heart, you will hear a different tirade. Medicine should never cease to be an art. Practice of good Medicine is borne out of years of really hard work, tuning the mind, body and heart to the care of sick people, learning by mistakes. Computers are just an adjunct to make our work processes easier. EMR’s as they are being currently touted do NOT meet the needs of practicing physicians and should be soundly rejected, subjected to rigourous testing and usability analysis before forcing it on doctors.
    Allan, why do you consider it “EVIL” to include keywords somewhere in a billing software? It just helps me to retreive my patient lists for clinical studies much more easily than the billing codes would. The ICD-9Cm and the CPT codes are not yet detailed enough to describe the nuances of all diseases we see, particularly emerging diseases.

  25. This blog has the flavor of the old “nature/nurue” question, or the “cure for cancer” quest of the 1970’s and 1980s. Now we accept that all cancers are not the same and there isn’t a universally applicable “cure,” and we all accept that most diseases require a genetic predisposition and certain environmental influences to become pathologic. Yet we argue about which group is primarily responsible to push IT/EMR forward. Of course, all groups are responsible.
    The use of technology to improve that very human and non technical interaction between the physician and patient will require the utmost effort from all parties; physicians, payors, govt, patients, IT vendors, etc.
    To David:
    ‘As noted above, successful computerization of any process depends heavily on self-knowledge. If you can’t or don’t want to analyze your procedures, to a level well beyond normal human awareness, then your project is doomed to be Broken As Designed’
    The “techies” have their own cultural resistance to improvement of EMRs in a primary care setting that I find most amazing. I’ve been part of two EMR implementations, one at my own (considerable) financial cost. I have analyzed my own mental and physical processes for the tasks invlolved in providing care. I’ve tried unsuccesfully to communicate the nuances of these tasks to the development staff and they simply can’t seem to hear me saying “it’s too many clicks/ it takes too long/ it’s oversimplified and doesn’t work.” When I ask an EMR vendor salesperson how many click/minutes it takes to update a medication using their product they NEVER know the answer. If I ask if there are any industry standards for a basic set of functions and the industry target in time/clicks for each of the those functions I get a blank stare. I really don’t think the IT development folks have enough self knowledge; does your process development include a primary focus on speed and efficiency for the user? Do you have an industry standard for measuring the efficiency of use of your product?
    There simply isn’t a vernacular for EMR efficiency. We don’t speak in those terms, there aren’t any standards for evaluating the efficiency of a EMR based on “number of clicks” or “average total hours of physician training required to meet an established basic proficiency standard.” I can’t imagine how we can develop technology solutions for implementation into a complex decision making envirionment like the delivery of primary care medicine without some standards in terms of what the basic tasks are and setting standards for time for performance of those tasks and the training time required to master those tasks.
    I do agree that the efforts of the acadamies have been abysmal. The AAFP has an ambitious project, and yet they haven’t proposed any basic standards or models to measure the efficiency of use or efficiency of implementation of the the 400+ EMR’s available in the market.
    For now I’ll remain a physician on the sideline waiting to see meaningful head to head comparisons of EMRs. Never again will I squander what could be part of my children’s college education on a poorly conceived, poorly “field tested” product.

  26. I think we need to take care that such claims as “increased quality” of healthcare provision are based on reality. Often, the evidence that is spoken of in “evidence-based” development of “best practice” type approaches is only short-term. For example, published evidence on the value of benzodiazepines in anxiety disorders is 1) only a few months in duration, and 2) based upon exclusion of patients with substance use disorders. Since at least 1/4 of patients with anxiety disorders also have substance use disorders, a recommendation for use of benzos as first-line treatment for anxiety disorders is foolish as we know most docs don’t spot substance use disorders, and many patients are prone to hiding their symptoms quite well. Such a recommendation, though often made, leads to long term problems for a significant percentage. Those of us in the field recognize that even those without substance use difficulties, if left on benzos for an extended period of time, often have significant side effects that are worse than the original disease. This is only anecdotal, however. Until state-of-the-art research is conducted over several years (better yet, a decade), using drugs that may be off patent, and requiring a non-exclusionary process of admission to the study, development of best practice guidelines is without significant merit in this and many similar situations. MDs recognize this, which is why we often look at “best practices” with disdain. But it is difficult if not impossible to convince the public of these issues, let alone the academics who so often are simply producing the research that they can get funded (e.g. pharmco-funded and hence biased studies). Tom Leith has a good point in that data generated by EMRs will be of potential value to academics looking to develop best practice guidelines. As an academic myself, I have a soft spot there as well. But GIGO applies – what may well be a best practice for Doctor #1 might not be for Doctor #2, who has a different patient population, a different level of rapport, and different personal strengths and skills. Since the practice of medicine always comes down to the 1:1 relationship between patient and physician, I suspect it would be unlikely and indeed inappropriate that any group of best practices beyond the obvious would be applicable to all physicians. If I’m paying for healthcare from the best doctor available, I want that doctor to be able to do whatever he thinks of as best. I don’t want to be forced into accepting mediocrity just because it’s the best practice as judged by a review of data coming from, by definition, the average doctor. Some patients may, of course, choose to see the average doctor, or may not have much of a choice, just as some may choose to eat chicken with skin fried in oil instead of steamed fish. But that’s another issue entirely.

  27. I’m not a medical type at all — I’m a techie, in fact a computer programmer, and I can *completely* understand why doctors don’t like EMR systems as they exist now. The First Rule of Computer Science is (still) GIGO: Garbage In, Garbage Out. The important point here is, that’s not just about data and results! It applies equally well to system design, which is where Dijkstra’s comment comes in.
    As noted above, successful computerization of any process depends heavily on self-knowledge. If you can’t or don’t want to analyze your procedures, to a level well beyond normal human awareness, then your project is doomed to be Broken As Designed. Medical practice in general has rarely been analyzed to the “operational” level needed for system design, and the natural variations in practice are poisonous to (usually premature) attempts to generalize such a design. (And don’t get me started on user-interface issues!) It doesn’t help that the “computer knowledge” and the “medical knowledge” are usually provided by different groups of people, or that both groups are vulnerable to “political” interference by other stakeholders, especially the folks paying for system development….
    It’s an unfortunate fact of life that the costs of a major software development are unpredictable, and prone to overrunning the initial budget. Admittedly, some of the overruns come from political failures, such as failing to get the users on-board beforehand, or trying to treat a bespoke design project like an off-the-shelf product spec. (“Here’s what we want, don’t bother us until you’ve got it done.”) Regardless, if you try to limit the budget by fiat, you get “Space Shuttle syndrome”, where every “cost-cutting” measure adds another liability or risk to the product.
    And then of course, you’ve got “dusty deck” issues (i.e., the existing paper records, and/or existing computer systems), hardware spec and procurement issues, infrastructure issues (Exactly where are you putting all the new machinery? How will you get the network cables installed in ‘clean rooms” such as the ICU?), support issues, authority issues (“the computer says you can’t do that”), et many al.

  28. The biggest complaint I have about the EMR system is the wait time for new meds to be put into the system. It makes the patient’s wait longer to receive medications, especially pain meds. It does prevent medical errors when passing meds if used correctly. (ie: not accidently giving someone in A bed B bed’s meds, or allergy alerts)
    The doctors I work with don’t want to have to type in their own orders and they continue to ask the nursing staff to act as secretaries even though they have access to the computers themselves. With the handwriting being so bad, it’s a wonder more patients aren’t hurt or killed. Computer order entry will also cut down on the amount of calls to offices in order to clarify orders as well as cutting down redundant orders..

  29. “any QI process that relies only upon patients as its key actors powering the engine of change is, I’m sorry, not a very serious reform attempt. ”
    First- I never said ‘only’, I said “best, first step”.
    Second- if patients refuse to take the minimum of responsibility for their own healthcare, you or I or anyone else can dream and plan and even try to implement change– it will not work.

  30. Allan–your point was (and is) rock solid, and I couldn’t agree more with the “who pushes who” chain you outline in terms of quality and cost containment.
    And you were completely right to leave out the human cost to the consumer, because it’s really not a part of the causality chain at this point. It’s that fact, and not your analysis that I was railing against and I apologize for my poor writing suggesting that you were not aware or were indifferent to this human cost. Quite obviously, you are not.
    John C, I would like to share your optimism but I do not feel that employers will maintain this commitment for a long time. They’ve bought the “improve quality and costs will be contained” argument on faith, but they want to see an ROI, and they won’t have much patience for it. This is reasonable–again, they didn’t go into the car business to reform the health care system, they went into it to sell cars. If this approach doesn’t control the cost of building cars, they have a responsibility to their shareholders to find a solution that does. And find it quickly.
    Eric, the problem with expecting that people will have this record is that, well, they’re supposed to have it now and bring it to every appointment and they by and large don’t. http://www.ahrq.gov/consumer/quicktips/doctalk.htm.
    I think it would be great if people did this! But sick people tend to be really irresponsible and confused. Should we try to engage them and improve their behavior as part of a QI process? Sure. But any QI process that relies only upon patients as its key actors powering the engine of change is, I’m sorry, not a very serious reform attempt.

  31. The topic of EMR/CPOE has generated some fine discussion about quality and cost. I have come across many examples of implementation of quality programs at local hospitals that have had positive impacts on the bottom line and patient health. One thing I’ve notice about them all is that it takes a lot of work and effort to implement new ideas and processes correctly. Dr. Benjamin Brewer’s discussion of his improvements in his solo practice in Illinois in the Wall Street Journal are one good example where he has increased patient health while increasing income by approximately 35%. The website IHI.org has many other positive examples. One common tool to all of these seems to be local implementation of quality tools that fit the local situation with local champions of the change.

  32. Theora- using profanity demeans your argument and is not nearly as interesting as ‘conflating’!
    Kelly- thanks for the kudos: ‘brilliant insight’
    Theora- what is the problem with expecting that when you or I or anyone else comes into a doctor’s office, urgent care, emergency department, that he or she has a simple record of current medications and dosages and significant medical conditions? I cannot understand your resistance to this idea. It is simple, cheap, and would be very effective- and it does not require legislation, regulation, or interoperability.
    That is the best, first step.

  33. I agree with Allan point that payers and purchasers incentives are often not aligned. Payers are essentially contract administrators. As with any private market, payers are responsive to customer demands. The problem lies in the ability for customers to demonstrably measure results (what will this do for me).
    How long has HEDIS been around? The push for payers to have quality certification (NCQA) has produced what tangible benefit for consumers (employERs and employEEs)? I believe the Leapfrog Group goals will result in the same outcome, a lot academic hype but not much in the way of tangible results.
    Remember most large employERs self-insure the majority of the employee’s benefits (nearly 80% for firms with more than 1k ee’s). Therefore, in many instances the payer and purchaser are one in the same (GM, Ford, etc). It is these purchasers that are primarily pushing for efficiencies. They have good reason to believe efficiencies will produce tangible results (we’re talking $$$) because of their own experience. Most other industries have made great strides in efficiency and increased production capacity through the implementation of technology. So they figure (and I believe they’re right) that the efficient use of technology should produce the same results in the health care system. I sat in on national conference call a few years ago were GM was beginning to take this approach with its health care vendors. As they saw, we were part of their supply chain. And in their manufacturing thinking, they wanted to apply lessons learned from improving the mfg supply chain to the health care supply chain. Pitney Bowes started to do the same thing.
    What happened? As Pitney Bowes’ CMO found, the health care system is not as unified as the manufacturing sector. The various stakeholders (hospitals, physicians, specialty physicians, outpatient centers, etc) all have very strong self-interests. Plus, they don’t need to hitch their future to a handful of purchasers like the mfg sector.
    Because the health care delivery system, despite consolidation and vertical integration, is still highly fractured. Most physicians are essentially mom-and-pop-type operations with very little interest or capital to invest in major IT improvements. Event though they will benefit in the long run. That is why I believe the only party who can truly push technology is govt, but they must also provide the incentives (or subsidy) for the transition (and I’m a conservative).

  34. Allan writes:
    > purchaser and payer incentives are fundamentally _not_
    > aligned, unless the purchaser takes a very, very
    > active role in telling the payer exactly how they
    > must structure the health plan
    Well, I think this is exactly what is happening: puchasers are getting very involved — look at the Leapfrog group. The member companies are the purchasers, and they’re telling the ASO contractors what to pay for, what to demand from providers, and what quality data to collect. This is far from universal right now, but it is happening. And what is “shift[ing of] more health care costs to employees” BUT a restructuring of how the health plan works? Medicare/Medicaid absolutely will get into the act, as Theora reminds us. In fact, they already are. When insurers take risk, they’re both the purchaser and the payer (within limits).
    I think purchaser and payer interests are converging, and they will force change, including the technology adoption to make the reporting work. The government will be important (and has been already on the financing side with the mandatory transaction sets that came with HIPAA) but I bet the private sector moves faster. Oh, and don’t forget the Mother of All Data Warehouses being built by the Iowa Foundation for its QIO contract for Illinois and Iowa with CMS: OK it uses billing data as a proxy for clinical data, but it is a huge (government) move.
    So, I think purchasers & payers will be driving the adoption of EHR and quality initiatives.
    Dr. Murali has a great approach: start with electronic document management and transcription. This will help him understand what he needs from an EMR, and get him and his staff in the habit of integrating IT into his practice. After using this for awhile, he will be in a great position to either build on what he has, or he’ll have a great “requirements document” for a replacement system. But he should never include keywords in his billing software’s miscallaneous column. This is evil. The billing software should not have a miscallaneous column in the first place. When he has a need for some clinical vocabulary, he should specify his needs to his software vendor so the syntax and semantics of the data will be understood. I encourage him to consider a truly robust backup process, with offsite storage.
    Finally, it is not magic we rely on to sling these messages around the net, but causality, whose existence can’t be proved empirically. Causality is the first of the metaphysical truths.
    t

  35. The currently availabe EMRs are terrible. Absolute waste of time. Each practice needs to know its work flow and design the IT it needs. There is no one size fits all when it comes to EMR. Look at it this way. If you want quick, secure, rapid, reliable access to your records in the wayyour paper records look and feel, buy a good quality high speed scanner and start scanning your records using Adobe PDF. Use intelligent managable databases to track meds/allergies and write prescriptions or to create disease management modules. If you wan to collect data for clinical studies include key-words in your billing software’s miscallaneous column so that you can get the charts to be reviewed any time. I have bought, tried and discarded multiple EMRs. EMRs using pull-down menus are ill-suited for medical care. they are OK for structured data entry for procedures with repetitive data. Consider incorporating voice dictation technology into your practice. Have access to your records either with a secure VPN or carry it on a small notebook PC with password protection. You will be in business. I see 2000 new patients per year, do as many procedures and have a PA assisting me. I do manage to get out of my office by 3:30 PM everyday and NEVER leave my office with any pending work! By the way, we do not outsource transcription to India. We do it using voice transcription in the office!

  36. Tom,
    I’m going to have to disagree on the source of change– I strongly believe that, absent a significant restructuring of the current healthcare delivery system, the purchaser and payer incentives are fundamentally _not_ aligned, unless the purchaser takes a very, very active role in telling the payer exactly how they must structure the health plan (the contract administered by the payer on behalf of both the purchaser and the provider). In fact, this disconnect has led to the large corporations with significant numbers of covered lives (and therefore very significant exposure to rising health costs) taking a very active role in forcing the payers to push change onto the providers. Now, I’m not saying that the payer doesn’t have a big stick (the reimbursement that you so aptly point out), I’m just saying that, absent purchaser pressure, there is no strong economic/profit incentive for the payer to do so. (That is, unless one believes in some altruistic corporate mission on the part of the payers to make America a better place– a mission that I personally am unlikely to be persuaded to believe exists)
    Interestingly, medium-to-small companies are not as terribly bothered by healthcare costs as large companies. Perhaps this is because they tend to receive some “insurance benefit” from the purchase of health insurance from a payer because they do not have such a large population to cover (I have NO IDEA where the breakpoint for this might be, so don’t take me to task on this). It could also be because smaller companies tend not to have the legacy costs (through pensions and the like). Overall, though, this means that the net effect of large purchasers focus on healthcare quality is diluted because the vast number of American businesses don’t see healthcare with the same urgency as (for instance) a General Motors. So in their yearly negotiations, driving quality measures into the delivery system is not as big an issue (actually, it is unlikely to exist).
    Theora,
    Thank you for taking me to task on saying, forthrightly, that the impact of poor delivery is higher on large corporations than on individual patients. At the time I actually thought about inserting a caveat that my point that in ranking those affected by poor care I was mapping them on an “aggregate economic loss + ability to motivate change” basis. Obviously, as is pointed out above, all of these costs do trickle down to the individual consumer, many times in heartrending ways. But while the cost to a family of losing a family member (or simply that capacity to work) due to poor delivery is a tragedy and enormous cost for that family, it cannot be recognized in a terribly effective way to create change in the system (at least today). But you’re right– on a proportional basis the cost is highest on a family unit– it can be destroying. But it might destroy GM too.
    Finally, Tom, even though I am far removed from the electrical engineering magic that got your thoughts to me rather than a bucket of water, I am afraid that metaphysics were not involved. Nicely put, though.
    Allan

  37. Matt writes:
    > payers seem, from a provider’s standpoint, to be
    > pushing the systems, when for many of them the
    > push comes from the purchasers
    I tend to lump purchaser and payer into the same heap when I think their interests are pretty well aligned. I don’t think you (or I) have caused any confusion with this, but it is a good distinction all the same. Thanks.
    > The biggest [surprise]is that many seem to
    > think that the payer is in the best position
    > to effect change in the system.
    I don’t say he’ll effect the change, but he WILL force it with a very, very blunt object: reimbursement. At first he will demand transparency in pricing, and some data to back-up claims of quality. I think the Guild in dialog with the payer/purchaser will sort it out from there. They’ll have to. And it won’t be pretty.
    > But why stop at claims data?
    We should not stop at claims data: we should start with it because it is what we have. We should improve it. And we should add to it. All at the same time. But first we need to convince people they should provide it and find a way to prevent its misuse. The plaintiff’s bar LOVES this stuff, and we should find a way to make sure they love it less.
    Oh, and metaphysics is provable: we rely on metaphysical truths every day. For example, I trust right now that the little electrical impulses I am manipulating will not produce a gush of water when their effects finally reach your computer screen so as to soak you, but will rather cause it to light up so you can read what I’m writing. I think it is the under-reliance on metaphysical insights and truths that have led some to emphasize the Double-Blind Placebo-Controlled study at the expense of retrospective studies that might not prove causality (a metaphysical concept) but can still point the way. Or at least a way. But this is a little beside the point. Or maybe not. Hmmmmmmm.
    t

  38. The analysis of more – and more accurate – data will allow researchers and – hopefully someday – physicians to gain the benefits of our collective medical wisdom, in a useful “package” at the point of care.
    I agree wholeheartedly with Tom that even claims data – used appropriately (i.e. severity adjusted, etc.) – can provide a great window into clinician performance and quality.
    But why stop at claims data? Or assert that databases no matter how big or deep will ever provide insight that could be helpful in assisting clinicians practice “better” medicine.
    Clinicians for years (including the AMA) have questioned quality improvement initiatives because of the quality of data (primarily claims) fueling them.
    EMRs can be the source for much better quality data. So shouldn’t this remove a great hurdle? Isn’t SOME performance measurement / feedback better than NONE?

  39. Allan’s point is a really good one–he’s right that the pressure on payors is a secondary one, driven by employers’ complaints and employers’ desire to control costs without ticking off their employees by restricting access (and for the more enlightened, a desire to invest intelligently in their employees’ health). And it’s a key insight that while payors have massive leverage because they control the dollars, they really lack the expertise and infrastructure to effectively use this leverage to improve the quality and efficiency of the care delivery system.
    This is why I don’t think private payors will be the innovators. Practice reform through IT isn’t an easy thing to do, they lack the skills to do it, and their motivation to do it will last only as long as employers keep wanting them to do it. And frankly, employers are in business to sell widgets, not to reform the healthcare system, so I sense their commitment to the cause will wane fairly quickly once they can find a way to stop paying for care without taking the flack from their employees.
    Which is why it’s all the more appalling that improving the practice of medicine is something that physicians not only see as “not their job,” but that posters on this board actually think that patients are hurt less by the poor quality and inefficiency in this system than employers are. While their direct financial exposure is unquestionably less, they pay the price perhaps more than anyone else.
    46 million Americans who can’t afford healthcare, whose teeth are rotting out of their heads and whose children are up all night crying because they aren’t getting their ear infections treated are paying the price of our system’s inefficiencies. The thousands of Americans who literally die from medical errors are paying the price. The thousands of uncounted Americans who routinely receive sub-par care that we don’t count as an error (like the famous MI patients who don’t get aspirin) are paying the price.
    Daily, I have less and less patience for physicians who argue that business-as-usual must be tolerated because medicine is an art. The much vaunted “local knowledge” above is simply blown away by the 30+ years’ research that’s been done at Dartmouth on the clinical impact of practice variations.
    And I’m terribly sorry physicians are suspicious of efficiency, but I personally think it’s ludicrous that 70 year-old cancer patients are expected to bring every pill bottle prescribed by every specialist to every doctors’ visit; that their test results are unavailable unless they have sought out, maintained, and brought their entire medical record themselves to every single visit; that one can walk into a hospital to visit a sick relative and no one has a goddam CLUE where they are or how long they’ve been waiting in the hall for an MRI (and how many of their scheduled medications they’ve missed as a result); that I’ve got to wait 25 extra minutes at the drug store because the pharmacist can’t read my doc’s handwriting and has to call the office, which has to pull my chart, which has to confirm with the doctor…etc.
    All those problems have a technology fix today. Could it be a better fix? Absolutely. Should physicians be financially rewarded (or at least not penalized) for implementing these fixes? Without question.
    But none of these things will happen until physicians stop pretending that they’re practicing in the 1930’s, where handholding was all they had to offer. If as a physician you really feel your job is pastoral care, then do us all a favor and ditch all the expensive tests and specialized training, and take the pay cut to join the ministry. I didn’t think I needed to state the obvious, that physicians should be agitating to make their professional practice more effective through better application of scientific knowledge and technology, but apparently this is not something all physicians believe.
    The bottom line is that we need to contain healthcare costs in this counry. Physicians would do wonders for their own credibility and would help the rest of us go after more promising cost containment targets if they would stop defending the indefensible and instead engage in a proactive effort to contain costs through practice efficiencies and improved quality.

  40. Quick clarification–
    In my initial comment, I stated (somewhat inaccurately) that payers are pushing EMR/CPOE systems when in my comment above I state that the heathcare purchasers are doing it. I fell into that inaccuracy because I was thinking of the situation from Kelly’s perspective (payers seem, from a provider’s standpoint, to be pushing the systems, when for many of them the push comes from the purchasers). I apologize for the inconsistency and any confusion I may have caused.

  41. Jumping back in here–
    Several things that surprise me from the comments above.
    The biggest one is that many seem to think that the payer is in the best position to effect change in the system. In fact, I think the following incomplete list shows who is hurt (in aggregate) by the poor delivery and quality (from most to least [vastly simplified]):
    Companies (especially large companies [GM, UAL] with large pensioner populations)
    Government and government-sponsored entities with pension plans
    Large companies and government entities without pension plans
    Small to medium companies
    Large hospital / care groups
    Individual patients
    individual physicians
    Payers
    The important thing to note is that rising costs / poor quality / poor delivery has the least impact on payers. The payer organization is primarily a contract manager, and the incentives for them are to not pay for items not covered in the contract and to be as efficient as possible in processing these payments. Even in a high-inflation environment, their contracts with employers are basically short-term (usually reopened / renegotiated every year). The payers basically act as aggregators of activity (claims processing) and to blind the specific health care costs of individual employees from the employer (so as to keep health-cost discrimination by employers to a minimum). There is minimal incentive to reduce costs through improved quality, especially if fees are indexed on a percentage basis of the dollar amount of claims processed. While payers appear to be in a very powerful position by dint of having contact with both the source of funds and the use of funds, they have minimal incentives to push quality.
    (Note that this is not necessarily true in the case in which there is a strong organizational tie between the payer side and the delivery side, as in the Kaiser Permanente organization.)
    Large employers who pay medical care costs for their employees and, in some cases, retirees, have the most to lose if poor quality is leading to increased health care costs. That is why they are pushing for payers to require providers to adopt quality measure requirements for the delivery organizations. The overall dearth of data means that they can only call for a few measures that have proven, or appear to have proven, that they increase the likelihood of positive outcomes and lower costs– presence of computerized order entry systems and pushing procedures to the venue that performs the most of that type of procedure in a service area.
    Kelly Clark throws in a couple of red herrings above– the concept that efficient delivery of care is anathema to the practice of medicine and the idea that “pointy headed academics” worship only at the altar of the double-blind placebo-controlled study. The human body certainly comes equipped with more than the minimum requirement in several areas, the presence of two kidneys and lungs aptly noted above. However, in the delivery of health care services to patients, we are dealing with a vastly less complex system than an individual human body, one that we can decompose into individual actors and processes and understand. This understanding allows us to make adjustments to the system and improve it and, yes, increase the efficiency at which health care is delivered to the ultimate consumers, the patients. This increase in efficiency is to be welcomed, as an increase in efficiency will allow for the same (supposedly agreeable) level of spend to buy more services and thus result in less rationing of healthcare. Increased efficiency is better for patients and for the overall economy. The databases of information to be produced and ultimately analyzed by “pointy-headed academics” will not produce results that prove hypothesis (which is the purpose of the double-blind placebo-controlled study), but will be invaluable at identifying what appear to be best practices that can be tested and, if proven, can become part of the standard practice of medicine.
    Finally, I certainly hope that physicians do not expect us to see them as analogous to clerics, whose focus is on metaphysics– the unprovable– versus the scientifically provable practice of medicine. I, for one hold my doctor to a far different and more tangible standard than my priest, and expect that he or she will use judgement based on sound scientific principles. After all, how many clerics are sued for malpractice?

  42. Dr. Clark writes:
    > Eric Novack has succinctly summarized our
    > current level of solid quality of care knowledge
    > – we know what should absolutely not be done.
    > This is a brilliant insight, and should turn on
    > its head our rush to evaluate performance.
    So maybe we should call them “Not Bad” practices rather than “Best Practices”. It wouldn’t inspire much confidence, but maybe we overmarket our skills and care anyway. This only leads to high expectations and lawsuits.
    Seriously now. Leaving aside the obvious that there are infinitely many things that absolutely should not be done (We should absolutely not shoot our patients, for example) I think this is pretty much where we are. For example “We should absolutely not fail to deliver an aspirin to AMI patients without contraindications.” Despite the fact that there is no disagreement that we ought not, we do fail about half the time to do so.
    It is too bad that this kind of rule in the very simplest cases represents our best knowledge of measurable quality intervention. It is exactly this kind of thing, however, that can be effectively monitored by information systems using information we collect today. There is nothing subtle here.
    > I don’t hear physicians say “we don’t want any
    > more data”. I hear “we don’t have enough data
    > to let algorithms practice medicine, and we never
    > will”.
    I think this is polemical. Science Fiction writers dream of it (Witness the Emergency Doctor on StarTrek Voyager) but I don’t hear anyone else calling for it. What I hear is something like “There are things we know; let us make sure that they are done every time they are appropriate, and hold accountable those who regularly fail to do them.” I should think the Guild Members would want to do take care of this themselves, and I think anyone who can’t get on board with such a modest goal as this deserves to be called “obstructionist”.
    t

  43. Thank you all for such stimulating comments. A few disagreements, a few clarifications, and a huge agreement:
    Several people have stated “You can’t improve what you can’t measure”. This is not true. You can’t measure the improvement of what you can’t measure. As an example- one part of our health care system involves doctoring. Doctoring is at core the fostering of a relationship that drives patient’s understanding, behavior, the alleviation of suffering if not of disease. Called “bedside manner” in medical school or “soft skills” in business school, these skills represent improvements that can be made in the delivery of health care that cannot be appropriately measured. The attempt to quantitate what is essentially a qualitative exchange has led to the derision the natural sciences have long held for the social sciences.
    I was surprised to see so people complain that physicians aren’t “formulating clear guidelines as to what constitutes quality care”. We do have guidelines – they consist in large part, in the language of Evidence Based Medicine, of “local knowledge”. This is not measured, manageable information that can be used by anyone outside of the guild system. It is why medicine is an art and not a science. It is also why those outside the guild system mistrust physicians and our motives – we cannot easily explain our actions. It is temptingly easy but inappropriate to be wholly cynical of this system, because despite many flaws there is still much merit in it.
    The appropriate and highest quality care of a person with heart disease may be contraindicated for a person with both heart disease and lung disease. The appropriate care and highest quality care of a patient with a severe brain disorder may be contraindicated by the presence of diabetes as well. The more illnesses present, the more professional training, “local knowledge”, and weighing risk/benefit issues based on experience are needed. “Measurable, evidence-based best practices” are beyond the ability of even the largest databases to parse any statistical significance in these real-world situations that could be applicable to a single patient’s care. Practice guidelines are tools to think about treating patients who have diseases. We have many, many guidelines. They are not appropriate fodder for processes of Total Quality Management, Six Sigma, or the Next Big Thing in process or outcomes management.
    Yes, better information will help improve care. Large databases will lead to improved practices in some areas with large enough sample sizes – such as the dropping of the aspirin-a-day-for-women recommendation. I don’t hear physicians say “we don’t want any more data”. I hear “we don’t have enough data to let algorithms practice medicine, and we never will”. Best practices evolve, and are considerations for treating groups of people. The physician treats an individual, a highly variable entity within the group, and this essentially is and can only ever be an experiment with n=1. Letting algorithms practice medicine does not gall physicians because it represents a loss of our autonomy, but because it is horrifically bad medicine.
    Regarding who benefits from EBM, having done thousands of utilization reviews, the major beneficiary of EMB to date seems to be the payers. They can deny payment of treatments and tests because not enough studies have been published to qualify for evidence-based payments. Does anyone really want medical care to be allowed only if strongly supported by Cochrane reviews?
    Regarding “pointy-headed academics who will want to use the data generated for a number of purposes, discovery of best practices included among them” from the large databases to be collected, I have been many meetings of medical academics who discount all real-world research (not much money in it, anyway), and are interested in examining only the ”gold standard” of placebo controlled, double blind studies that exclude any real-type patients from the study group (but generate good drug company research revenue).
    As a physician, I am suspicious of efficiency. Redundancy is good. It is highly useful to have multiple kidneys, lungs, cerebral cortexes, arms, legs, collateral enervation and vasculature. If we ran our bodies with just-in-time Dell “efficiency”, we would have very short lives indeed. “The one best way” is an anathema for a physician, because we take a multitude of variables into account, and have to alter our plans rapidly as other issues develop. And, by the way, these mental calculations are too rapid and nuanced to be realistically documented in any EMR for the crunching pleasure of others. But as Marx was to Hegel, measuring the worst rather than the best may be our best way to move the dialectic.
    Eric Novack has succinctly summarized our current level of solid quality of care knowledge – we know what should absolutely not be done. This is a brilliant insight, and should turn on its head our rush to evaluate performance.
    Physicians have done a poor job of articulating what our jobs actually entail. When we try, we are easily labeled as obstructionists, unwilling to change. We do change, and practice evolves. But our job is much more complex than is often considered, and our effort to elaborate is necessary for many reasons. While surgeons may be more like engineers, physicians are more like clerics than may be suspected. How do you measure the quality of pastoral care in the affirmative? Could this only be done, as Eric Novack suggests, by measuring the absence of the negative?

  44. theora- my kudos to you for the use of ‘conflating’– first time I have seen its use on the blog.
    You are right— the issues are different, but, like the rest of healthcare, very interrelated.
    When I teach and speak to others, I try to explain a couple of quality related concepts: first, while there is generally more than one right way to handle a problem (for example, treatment of a given fracture), there are definitely wrong answers. We- physicians, researchers, health policy experts- ought to be determining the ‘wrong answers’ first. This sets the bar at the low end for care. So called evidence based medicine as we use the term today tries to set the bar at the upper limit- an impossible task.
    Health care delivery and assessments are not one-dimensional– that is to say, multiple approaches can have the same outcome (remember 2D and 3D vectors in geometry).
    Must go now- but I appreciate your point.

  45. I hope Dr. Gitlow doesn’t draw his conclusions about what might be expected from EMR systems on the basis of a HyperCard stack he wrote 20 years ago.
    As for the claims he makes, in a small practice, he’s probably right: the current crop of EMR offerings won’t improve very much efficiency or treatment, or reduce error rates in that setting. I fear that he focuses too much on local optimizations, however: the one small practice isn’t the only place the patient is seen. And I think he discounts the well-known shortcomings of the PMR (Paper Medical Record), chiefly its notorious unavailability, illegibility, and incompleteness.
    He leaves at least one constituency out of his list of EMR proponents: pointy-headed academics who will want to use the data generated for a number of purposes, discovery of best practices included among them. I have a very soft spot in my heart for this last group.
    To characterize an EMR as a point-of-sale system I think misses the point. I think we can all agree with Matt that they’re nowhere near as sophisticated as the pointy-headed academics envision them, but they are more than charge-capture devices even today.
    All this said, I do not blame primary care docs (especially) for their reticence to adopt EMR. The economics are all wrong, regardless of the capability. This is what must be overcome somehow.
    t

  46. Eric–It’s quite obvious to everyone that better public health would improve health outcomes and lower costs–as a group, healthy people who eat their vegetables, exercise and don’t smoke really don’t run up much in the way of medical bills.
    But eventually most of us get old and sick, and you’re conflating the issue of poor health choices by individuals with the miserable failures of our current healthcare system to treat disease once it develops. The fact that our public health system needs improvement doesn’t let our healthcare delivery system off the hook. Given the amount of money we spend on our healthcare system, we should have one that’s able to get an aspirin to a guy who’s having a heart attack–regardless of whether the heart attack was caused by a lifetime of inactivity or was just a freak thing.
    I’m glad to spend more money on public health. And I think you’re right that it’ll have a bigger impact on health (which sort of leads one to wonder why we’re paying physicians so well and public health workers so poorly, but that’s quite another rant).
    But suggesting that because there’s a need to improve public health that one should simply continue to pour money into the endless suck of the healthcare delivery system? No.

  47. Matt- in spite of the fact that Matthew, our host, blasts the WSJ today (and I admit it is not the greatest exchange), the point is made that the cost of healthcare is already borne by employees in the form of lower wages. As I remark regularly on this blog, it is a vagary of the IRS that the workers of this country do not see their compensation in terms of wages and benefits at the end of the year.
    To add some modicum of frankness to the conversation, you should look at total compensation, not just wages. The money comes from, and goes to, somewhere.
    With regards to your first point, you need to look past the headlines, and understand the costs associated with compliance. Some estimates are that the reporting requirements will cost physicians more than the 4.4% cut.
    One question- how would you induce the public to behave in a more healthful way? This is the only real way to substantially reduce healthcare costs and improve outcomes.

  48. Here’s the proposed Medicare payment “cut”:
    “The Senate bill would replace the scheduled 4.4 percent decrease in Medicare payments effective January 1 with a one percent increase. The Senate budget bill also contains pay-for-reporting provisions starting in 2007…” http://www.acponline.org/college/misc/latest_medicare.htm?hp
    Juxtapose that with:
    “General Motors and United Auto Workers on Monday announced that they have reached a tentative agreement on changes to health benefits for union employees to reduce company health care costs, a deal that likely will prompt other automakers to shift more health care costs to employees, the Wall Street Journal reports…The agreement will reduce GM retiree health care liability by about 25%”

  49. My most humble apologies to our esteemed web-host!
    And back to Matt– the proposed cuts, BTW, are 26% over the next 7 years (not accounting for inflation), which means a real cut of about 50%.
    And, I agree with Abby, a long thread without discussing CDHP is impressive.

  50. You might be interested to know that Texas is preparing to procure an administrator of some sort (probably an HMO model) to cover all foster care kids in this state. One of the requirements will be use of a ‘health passport’ which appears to be a watered-down version of an EMR.

  51. Kelly Clark has hit the nail on the head with her comments. I’m a longtime early adopter of technology; I used to work for Apple Computer and wrote my first EMR program in 1987 with Apple’s HyperCard. But do I use an EMR in the office these days when I’m seeing patients? Absolutely not, and for all the reasons Dr. Clark mentioned. It doesn’t improve efficiency; it doesn’t improve treatment; and it doesn’t reduce errors. The only ones making the arguments for moving toward EMRs are politicians who are grabbing onto them as a potential and unproven method for reducing an already-low medical error rate by an additional fractional amount, and the third party payors, who are attracted to the fact that EMR data, when collected in one large pool, will provide them with an incredible amount of market research. For the small and medium sized physician offices, there’s no question that even the advanced and very expensive packages simply slow things down. Because when you come down to it, this is a point-of-sale package in search of a “point,” and the point is made up of rapport between two individuals, not the sale of a box of Jell-O. You can’t make rapport more efficient!
    One final point: the AMA isn’t some high up group of good ol’ boys. Its organizational structure is made up of input from grassroots physicians like myself. I was vice-chair of their emedicine advisory committee for many years and continue to participate actively within that group. If any of your readers are physicians who would like to become more active, all they have to do is drop an email to the AMA or to me and I’ll be happy to make an introduction.

  52. Great comments all, although like Abby I am upset that the HSA won’t solve this problem by itself, and amazed that we haven’t heard it will (although now we’re just trash-talking). Just a quick note to readers, Matt is not Matthew (i.e. me your host here at THCB), and I have amended Eric’s comment to reflect that, and so that I’m not the one assassinated when the AMA decides that it’s time to take action!

  53. Whether healthcare kills 49,000 or 98,000 people per year in the US, it’s still a big problem. You can argue with the IOM about the statistics. Or with Modern Healthcare about physician compensation statistics.
    And I – personally – would prioritize the safety/quality problem… and the problem of the uninsured and under-insured… well above so-called “malpractice reform.”
    Unfortunately, safety/quality, cost, uninsurance aren’t incrementally solved issues (even with lots and lots of IT), they’re inherent to our current healthcare system. My bet is that if you polled specialty physicians and asked them: would you rather take: a) a 3% reduction in Medicare Reimbursement once per decade or b) radical redesign of the healthcare system such that it addresses the core problems of cost, coverage, and quality/safety, that most would choose the former vs. the latter…. even if the AMA were given a prime seat at the table in building such a system.

  54. Great, quality comments! There’s not a word about the miracle of the HSA. (Oops, I just put one in.)
    I heard the CEO of Partners Healthcare say that there was no incentive for small/ solo practice physicians to put in EMRs, because (1) it wasn’t as efficient for them (you need to get tech support and maintenance–a lot easier to pull a file off of a shelf) and (2) the doctors were being asked to put all of the money into developing a system which would probably cut their payments in favor of the insurance companies.

  55. Tom’s point about physicians’ sleeping in the bed they’ve made is a powerful one, and he’s right. If physicians don’t change the way they practice medicine, someone else will make them change. Or, perhaps push through other things like cuts to reimbursement. While most people like their doctors, they really hate rationing more. Given a choice between their mother getting cancer treatment and their physician being able to afford his country house…they’re not going to lose a lot of sleep.
    That said, while I think payors will lead the way for IT development and implementation, I don’t think it’ll be private payors–it’s just far easier to make money in the private market by avoiding sick people than it is to make money by providing better care.
    The innovation will be led by the people who can’t avoid sick folks–government, and maybe Kaiser-type systems. Once they’ve figured out the trick to generating an ROI, the private payors will copy their success.
    What’s most tragic here is that physicians could really do this well, and they should want to. The AMA should be leading the way on this, making it a policy priority, partnering with software developers, etc. Physicians should be leaders here, showing everyone a new way to practice medicine more cheaply and effectively. I mean, as a group, doctors are incredibly bright and they’re incredibly experienced in this field.
    However, by and large they are choosing not to, and are instead being largely reactive and obstructionist. That’s a tragedy, really–they’d do a better job of designing and implementing these systems than any other group would. Unfortunately, their self-concept of professionalism doesn’t extend this far. It’s a real pity.

  56. Physicians political clout is very overstated as Tom implies. Medical liability reform cannot get even a hearing in the Senate and was recently defeated in Washington state.
    And Tom (and I) continue to mention the impending cuts in Medicare payments.
    Matt, in just a couple of paragraphs, manages to employ class warfare-“the nation’s highest-paid profession”,
    the absolute inappropriate use of statistics- “healthcare kills 100,000 people a year”- data that is questionable and neglects the millions of people whose lives are saved and improved and prolonged by US healthcare, and an “ad hominem” attack (more or less)-“45 million uninsured”.
    The moving target of government regulations are the greatest impediment to quality improvement in healthcare. Implementation of technology alone will not improve anything, except the bank accounts of those who make the programs and those whose careers are based upon analyzing and recommending them.

  57. I agree that physicians aren’t the only parties behind “malpractice reform”, but they certainly are the “trusted” face of it.
    Physician political influence is less about incremental losses like Medicare cuts but preserving an autonomous yet highly-paid profession from systematic overhaul that is well overdue. Of course, physicians aren’t the only ones stemming the tide of reform and accountability in healthcare, but they’re key.
    In the payer vs. physicians battle, the losers are employers and consumers. Managed care and capitation (i.e. provider risk) are largely dead… replaced by premium increases and the “empowerment” (i.e. risk shifting to consumers) of CDHP… and all dysfunctions of the “healthcare system” are still in place.

  58. Matt writes:
    > Physicians have the infrastructure to affect change.
    If they have the political clout you attribute to them, how come they can’t stave-off declining Medicare reimbursements? I am not so sure it was primarily physicians who pushed through the malpractice limits.
    The involvement of physicians will be crucial, but it remains to be seen who will be in the driver’s seat. I’m betting on payers.
    t

  59. Tom-
    I do agree with you to a degree: I have little patience for the “I just want to practice medicine” statements.
    However, unless the discussion moves to joint responsibility for outcomes, doctors and patients, no actual improvements in quality of life, functioning, cost reduction, etc., will occur.

  60. > But what irks me is that physicians as a group,
    > do have the infrastructure to enact changes.
    The political influence of the nation’s highest-paid profession is very high. Political pressure from physicians has pushed limiting malpractice awards to the top of the legislative agenda when healthcare kills 100,000 people a year and 45 million have no insurance. Physicians have the infrastructure to affect change.

  61. Rick says:
    > But what irks me is that physicians as a group,
    > do have the infrastructure to enact changes.
    Maybe, Rick, but they don’t have the (direct) incentives. About 90% of the benefits of evidence based medicine and EMR flow to patients, but under your scheme 100% of the costs would be borne by physicians or hospitals. And they ain’t gonna.
    It seems to me the incentives are best aligned at the payer level, and that’s where I expect to see the changes come from. I know this directly contradicts you.
    Insurance companies want to make a profit. But to do this they must have lives to cover. So the insurance companies that do the best job of simultaneously lowering premiums and reducing claims will do the best. So far, claims reduction has come mostly from risk avoidance on the enrollment side. But there’s only so far they can go with that, and not least because of the political pressure being brought to bear on them for being so successful at it.
    This leaves risk reduction on the provider side, and it will look a whole lot like managed care, at least to the physicians. The insurance companies will need information technology to keep tabs on the physicians, so they will provide it, and mandate its proper use.
    As you say, the failure of physicians to behave professionally, as a Guild, has been stunning. What I tell my clinical buddies is “If you don’t take care of this yourselves, it is going to be done for you by people who don’t care a whit for your perrogatives or incomes, and you will collectively deserve every bit of what you get.”
    t

  62. As Matthew previously mentioned, EMR/CPOE without systemic change in the way overall care is given can actually make things worse. Just look at Matthew’s previous post about the increase in mortality from the institution of CPOE.
    Doctors certainly are not deviod of responsibility for developing best practice guidelines. However, outcomes are, in most cases, only partly due to the care delivered.
    Best practice guidelines (somewhat different than evidence based medicine)– must be accompanied by best patient practices to maximize patient outcomes.
    If this is proposed, I suspect that doctors will be much more amenable.

  63. Matt says “You can’t improve what you can’t measure”. He’s right.
    Allan says two things in his second paragraph:
    1) some healthcare organizations had their act together better than others before EMR implementation [and maybe this explains their relative satisfaction with them]
    2) There is good evidence that implementation of EMR leads to improvements.
    Since some organizations were able to improve without an EMR, this says there is a great deal we can measure even if we use the billing abstraction as a proxy for a clinical abstraction we only dream of.
    I do not think it is existence of the EMR that brings about the improvements — I think it is that the act of implementing an EMR causes people to think about what they’re doing. And then it helps make sure they actually do it. Everything else the EMR brings is a bonus.
    Some organizations really were better at getting people to think about what they were doing than others: this I think comes from leadership. If an EMR has value for the leadership, it comes from having a way to focus everyone’s attention, and for having something to blame for whatever pain comes up along the way (i.e. “its the system’s fault”)
    I think the example of spending on new drugs versus improving delivery of the old ones is the right approach for the EMR. The Holy Grail is the fully integrated system, but there is no sense building one until you understand what you want to do with it. The famous computer scientist Edgar Dijkstra recognized this more than 30 years ago with his famous bon mot “If you don’t know what your program is supposed to do, you’d better not start writing it.” So we should focus on getting the best out of systems we have today with some clever extensions keeping the Pareto rule in mind. When we figure out what we want and how we’re going to get there, then look at Big Technical Solutions.
    Kaplan and Cooper in their book “Cost and Effect” say pretty much the same thing. Companies should not try to jump from traditional cost accounting systems oriented towards manufacturing and financial reporting all the way to the Holy Grail of their Stage IV integrated-with-everything Activity Based Cost systems that reflect their actual organizational structures. They won’t be able to do it because they don’t have enough self-knowledge.
    t

  64. I’m about tired of hearing defeatism and the can’t-do mentality out of physicians, hospitals and health plans. Someone needs to take the lead, take a can-do approach and move the ball down the field on improving care, reducing errors, and increasing efficiency.
    The problem, as I see it, is that the players with the most wherewithal to advance CPOE/EMRs, the health plans with their enormous profits and cash reserves, have the least incentive to take the lead since they have the least to gain. Hospitals, the least capitalized of any stakeholder, have the most to gain, but can’t afford to do it on their own. And the hospitals, with their sub-1-percent margins can’t afford to try something that doesn’t work, which would likely explain why their frequent response is to do little or nothing.
    Physicians, however, would seem to have a moral imperative to, at the very least, formulate clear guidelines as to what constitutes quality care. Several specialties have already created lists of evidence-based guidelines, and congratulations to them. But I am shocked at the list of specialties that have NO evidence-based guidelines. They are: dermatology, gastroenterology, infectious disease, neonatology, nuclear medicine, ophthalmology, otolaryngology, pediatrics (PEDIATRICS!?!?), plastic surgery, rehab medicine, therapeutic radiology, urology and vascular surgery. This would be the logical first step in creating a good CPOE/EMR, since as another commenter succinctly observed, you can’t improve what you can’t measure.
    And please don’t misunderstand. As the son of a physician, I’m well aware of the pressures being placed on the doctors, and I am nowhere near advocating that any individual could or should be the catalyst for change. They’ve got enough to do.
    But what irks me is that physicians as a group, do have the infrastructure to enact changes.
    Speaking as an outsider looking in, I have to say to the doctors that it looks like you accept from your specialty societies and the AMA the status of old-boy, country-club network and/or lobbyist-protecting-turf. Docs need to put pressure on their societies and the AMA to take the lead, not only by completing and continually updating evidence-based practice guidelines, but to also quit crying about how poor the interfaces and processes of CPOE/EMRs are. Get some of your leaders to take sebaticals and go consult with the leading developers of CPOE/EMRs and get it done.

  65. Theora-
    “There is absolutely no question that when healthcare IT is properly implemented, care is improved.”
    The devil is in the details– “properly implemented”– is often in the eye of the beholder.
    Healthcare rationing is about to take a big step forward when January rolls around and the 4.4% Medicare pay cut for providers (4.8% increase for hospitals, by the way) results in diminshed access to care.

  66. Exactly. Of course CPOEs and EMRs aren’t a panacea. And anyone who says differently is selling something.
    However, the fact of the matter is that the current practice of medicine is abysmal. Our healthcare systems routinely fail to perform the most basic and effective health interventions (aspirin for heart attacks, anyone?). It’s long-standing and it’s inexcusable, but correcting it will not be easy–there are too many people, from set-in-their-ways physicians to the billing department to the legal department who have an investment in business as usual, and who are threatened by change.
    EMRs and CPOEs are good not only because they allow us to measure, as described above. They are good precisely because of their destabilizing impact on practice patterns. They force us to actually look at our ad-hoc and chaotic care delivery systems. One actually has an opportunity to ask the question, “um, why do we do things this way? It seems really stupid.”
    Now, one may not actually ask this question. One may ask this question and come up with the wrong answer. One may not have the institutional strength to actually implement the right answer.
    But I’m sorry, it’s rather pathetic to argue that our policy priorities shouldn’t be on how we can most effectively leverage IT to get the right answers to these questions implemented, but instead that our focus should be on how best to ration care. There is absolutely no question that when healthcare IT is properly implemented, care is improved. I think it’s a rather spoiled “professional” who thinks it’s more important to preserve his self-image as a cowboy and not a functionary, and who would prefer to see care rationed than be forced to do his job better.

  67. For years, physicians – including the AMA – have railed against the accuracy of claims-based performance measurement. EMRs support measurement of what is actually occurring in a clinical encounter… and not an abstraction of it created for billing.
    I couldn’t agree more that technology alone isn’t the answer. Process redesign as an outgrowth of data-driven performance improvement is.
    I also agree EMR systems are nowhere near as sophisticated as they should be. Gartner has a 5-stage model that describs EMRs (Stage 1= Data Collector and Stage 5 = Mentor, if I recall). No EMR on the market meets all of the requirements for even Stage 3 (Helper).
    What’s missing is urgency to change: we have a system that spends exorbinantly and kills nearly 100,000 people per year. To say nothing of the uninsured. The status quo does harm.
    You can’t improve what you can’t measure. EMRs provide that critical element in the performance improvement process. Organzational leadership, physicians, and those dedicated to supporting the transaformation will need to do the rest.

  68. A quick rejoinder: The conversation about rationing is a difficult one to have in current care environment, in which data on treatment is not captured in a systematic and analyzable manner. Everyone would like the aggregate costs of US healthcare to decrease and the aggregate quality of that care to increase (which is what “rationing” is actually about– spending money in the right places to improve outcomes), however, there is not a large enough body of data to do the kinds of analysis required to support “rationing”.
    EMR and CPOE systems are, as Kelly points out, being pushed by the payors, but this is precisely because to date the evidence is strong that implementation of these systems actually improves quality and outcomes (and therefore reduces cost), especially for the most expensive chronic-care patients. One hypothesis that needs to be considered is that the first “wave” of EMR/CPOE implementations were led by medical organizations that already had their “act together” and that the addition of a tool (the EMR) designed to enhance the specific operating environment in which those organizations provide care. The desire to replicate those results has likely led to the proposed or actual adoption of generic EMR/CPOE systems that would likely not be effective without a rethinking of the delivery processes in conjunction with the implementation.
    There’s a lot of work to be done here.

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