PHYSICIANS/TECH: The intransigence of the AMA knows no bounds

Here’s what I wrote for FierceHealthcare today.

Attendees at the 22nd annual TEPR meeting could be forgiven for being a little anxious about the future. Conference organizer and Medical Records Institute Peter Waegemann put out a call for action, noting that at the first conference some speakers thought electronic medical records would be here within three years, then ten, and now more than twenty years later we’re still arguing about different standards. The keynote from AMA secretary Joseph Heyman showed where the problems lie. Although Heyman is a solo practitioner who runs a paperless office and has been using EMRs since 2001, he trumpeted his organization’s party line—No cuts in Medicare, or risk that doctors will stop taking patients. Great suspicion of pay for performance. Opposition to mandates to use technology. Demands for straight payment to acquire and use technology. Apparently the medical world has gone to hell and it’s anyone but the AMA’s fault, so apparently we shouldn’t expect doctors to save the health care system by using IT, unless it comes at no cost and inconvenince to them.

I’ll be back with a little more, and some much harsher words later.

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11 replies »

  1. Quick reaction:

    We docs know how to use computers. Thanks for building them. I’m using computers, but you can’t expect anyone else to be the best, highest quality, most efficient doctor they can be unless you give them more money.
    The only thing non-docs should care about is the disgraceful way they don’t pay docs for taking care of the poor. So long as one person is not entitled to pay a doc, Health IT is worthless.
    There are no medical experts at insurance companies, but they are in the driver’s seat, abusing information technology, and changing the medical services industry. Docs must wrest control back from those incompetent interlopers.
    The Medical Experts of the AMA know how to measure physician performance better than insurance companies or anyone else, and we’ll help any system vendor do it our way; the RIGHT way.
    But that doesn’t matter—Devil with actual performance. It can’t be measured. Patients should pay for technology adoption only. Tell you what—just give us alerts & reminders, don’t bother trying to measure performance or cost. That’s all we really need anyway.
    We know we need to do it, but we don’t want to pay for it and and its hard to use and patients shouldn’t want us to because the privacy implications are way too scary.
    We won’t do anything unless you just shut up and pay the bill we hand you so we don’t have to make any truly fundamental changes in the way we do things.

    I guess this sounds a little stark and harsh, but this is what I get out of it. I am glad that clinicians will be pushing for interoperability in the useless systems, at least for the electronic face-sheets that can’t contribute to performance measurements. Its a start.

  2. Reaction to speech by Joe Heyman:
    While I thought the speech was very interesting, I got the impression that the AMA and doctors generally think the solo or small group practice is somehow sacrosanct, and trends like IT should be both tailored to that model and heavily subsidized. However, the economic world in general became considerably more capital intensive and, especially, IT intensive over the last 20 years or so with the trend continuing apace.
    The ability to afford these new tools, including everything from EMR systems to multi-million dollar MRI machines requires larger economic entities. Why aren’t doctors all moving toward groups of 10 or 20 or 30 physicians or more? If they did, the could offer patients a diversity of specialists under one roof and be better able to afford the new technology as well as quality technical support staff to operate it.
    In prescription drug retailing, for example, there are approximately 55,000 pharmacy counters in the U.S. of which more than 10,000 are owned by two companies — Walgreens and CVS while the number of independent pharmacies has been declining for years and is now well under 20,000. Do you have any idea how many tens of millions of dollars the two big drug chains have invested in information technology, including state of the art distribution centers, to support their business? The same is true of the PBM’s.
    We should be looking to spread best practices whereever we can. I would be interested in some data on how well the existing larger practices are incorporating new technology and what their experience is with respect to patient outcomes, practice consistency, mistakes, etc. If they are doing a better job overall than small group and solo practices, maybe the idea to be copied is to sell out to and join a medium size or large group practice.

  3. Ladies and Gentlemen:
    I am including my complete speech below so that you can decide for yourself if my speech was so terrible, or if the mood of your lead blogger might have been the problem. He was clearly on the attack and quite unpleasant. He was more interested in making a point than exchanging ideas.
    My entire speech is below, and I hope it all gets placed on this blog:
    Thanks so much for having me here today.
    It is a privilege to represent the 900 thousand physicians and surgeons of America.
    And to discuss the physician perspective as seen from my point of view as a solo practioner in a small town — and as Secretary of the American Medical Association.
    And, by the way, a lot of you think we old dog physicians can’t learn any new tricks. But I’m here to tell you, I am the old dog. And I’ve had an EMR, an interactive website with a PHR and encrypted email, and e-prescribing since 2001 in a paperless office. And I know what many of my colleagues understand as well: this industry is making it possible for me to be the best, highest quality, most efficient doctor I can be, and I’m grateful to you.
    Your program is very innovative, exciting and inspiring as always. The vision of the medical profession entirely engaged in the use of this exciting technology is a goal we all share. This is all about improving quality and safety for patients.
    But what’s the point of all this, if patients cannot access that care at all?
    Ladies and Gentlemen, it is a national disgrace for the richest country on earth to have 46 million people without health coverage.
    Everyone pays. In 2004, taxpayers shelled out $35 billion in uncompensated, publicly funded care for the uninsured [Hadley and Holahan, May 2004, Kaiser]. That’s 4 million dollars per hour – each and every day. And this number fails to account for additional billions of dollars spent on privately-funded care, including charity care by physicians.
    Insurance premiums are directly affected by this burden. In fact, U.S. families will pay more than 900 dollars extra for health insurance this year – because of the cost of treating uninsured patients. One out of every twelve dollars spent on
    health-care-premiums goes to caring for the uninsured.
    What kind of health care results do these extra dollars bring? Uninsured people live sicker, and die younger. In fact, 18 thousand of them die every year from preventable diseases. That’s one person every half hour.
    I’m sure you know that in my state of Massachusetts, a bill was passed to face the uninsured problem head on. No more band-aid solutions. The Massachusetts plan is very similar to the strategy developed by the AMA. Over the last decade, we’ve been pushing a plan that could insure every person in this country for much less cost than an exclusively government provided system.
    The AMA plan involves, as its mainstay, a government subsidy based on annual income that would make insurance affordable and portable for every citizen. We are working with a large diverse group of organizations across the political spectrum to find Common Ground. If nothing else comes from my speech today, please remember that all of the incredible accomplishments with Health IT are worthless if patients cannot access care! This is one of our highest priorities at the AMA, and we want to see it on the front burner for every citizen before the next presidential election.
    I said before that improving quality and safety is more than just an idea. The hard work and unrelenting determination of each one of you in this room will change the future of health care. And many of us feel deep-down that if we do it right – we can leave a great legacy for the next generation of patients – and the next generation of health care professionals.
    I know Dr. David Brailer believes that. He spent the past two years working to make all of those potential benefits of Health IT a reality. We commend him for the work he did to build a strong program at the ONC, and wish him a wonderful future.
    But with all the changes in Washington, where do we go from here? First, we have to accept that the future is in our hands. With Congressional elections fast approaching and an Administration on it’s way out, we can’t sit back and wait for the government to do something.
    We must take back this movement and drive change. It is up to us – you and me, the physician in her office treating cancer patients, the home health nurse working with a diabetic. This is our cause. Let’s take charge — and make change happen.
    [Slide 10] There are three key pieces in this puzzle of change; the way we are approaching quality and safety in three specific areas.
    • Measuring safety and quality, and what some think is a good way to pay for that.
    • Removing barriers to the adoption of information technology,
    • And, efficiently and effectively sharing clinical information
    We know there’s always room for improvement – especially when it comes to making sure our patients get more than just basic care. We want them to have the highest level of safe, quality care imaginable.
    In this rapidly shifting medical environment, here’s another way that physicians are keeping up with change – and sharing in best practices.
    We are collecting and analyzing clinical performance information – enabling physicians to compare their choices of therapies to treatments established by some of the best academic researchers and clinicians – bringing research studies to patients.
    And since 1996, we have committed ourselves to describing measures for best performance. Our efforts have resulted in the Physician Consortium for Performance Improvement. Experts from more than 70 national medical specialty and state societies, specialty boards, accrediting agencies and government—convened by the AMA—have developed more than 100 individual performance measures.
    These in the areas of
    • asthma,
    • chronic stable coronary artery disease,
    • adult diabetes,
    • heart failure,
    • hypertension,
    • major depressive disorder,
    • arthritis of the knee,
    • prenatal testing, and
    • preventive care and screening.
    And this is just the beginning! We are approaching vendors to incorporate these and future evolving measures into electronic patient records. Performance reminders will be business as usual, protecting against negative human factors and exploiting positive ones. And if it is true that payment systems of the future are going to be based on quality, then these records will make reporting performance much less burdensome for our member physicians.
    If you are a vendor and want to license this material at no charge, just contact Thomas Murray at the AMA. He is here at this meeting. You can also go to the Consortium Website by searching: Physician Consortium for Performance Improvement.
    Medical experts – not insurance companies – should determine what good medicine is.
    With Health IT, information can be transferred faster and more efficiently than ever. And the value for transforming the way we care for patients is tremendous. But we can’t allow this technology to be misused by some to take the clinical decision-making out of the hands of doctors and nurses providing care.
    And speaking of quality measurement, we have great concerns about “Pay for Performance Programs” . . . especially after seeing some of the pilots. Some seem to be more interested in rewarding cost savings than quality. So we have set up some simple guidelines to protect our patients. We don’t want to see this become a rehashing of what we view as managed care abuses of the late 80s and 90s.
    First, do the programs ensure quality patient care and safety?
    Second, do they actually expand and enhance the patient-physician relationship? Do they allow physicians to use the best options and provide for patient preferences?
    Third, do the plans involve a broad base of physicians willing to participate? Is participation voluntary or mandatory? Are there technological and administrative requirements that might prove costly?
    Fourth, are the measurements being proposed measuring the right things? Are the data to be gathered in a fair and equitable manner?
    And fifth, are the incentives themselves fair and equitable to all concerned?
    And with any performance measurement, we have to ask how valid those measures are. The truth is we don’t know enough yet to measure outcomes. And we don’t really know much about how Health IT will allow us to improve health outcomes. There are several reports that make us very optimistic about the potential for quality improvement.
    So maybe, while we do that research, and instead of “Pay for Performance”, maybe we should encourage adoption through genuine
    pay-for-technology and adoption
    and use of valid performance measures, —
    instead of discouraging it by punishing the early adopters with unfair payment and measurement schemes.
    Medicine has always been an evidence-based science. And that is the most productive path to improving patient care – and patient safety. But as every scientist knows, you need accurate supporting information to reach the correct conclusion. And that is another piece of our puzzle – reducing the barriers to effective, efficient information sharing.
    We’re not talking about just transmitting data. We’re talking about the ability to turn many pieces of fragmented data into useful information . . . to see patterns clearly — as never before possible.
    But in order to do that, we have to ensure that all physicians have the help they need to transform their practice with clinical information technology. We clinicians need to learn about these new technologies. We need to dedicate our time to them. We need to invest in the future.
    That’s why we are supporting the Centers for Medicare and Medicaid Services in promoting and developing the Doctor’s Office Quality Information Technology initiative using our “consortium” measures.
    DOQ-IT should help physicians more comfortably migrate to electronic health systems. Since there isn’t going to be a silver bullet, one solution that suits all situations, DOQ-IT is an attempt to help physicians make practical choices and ease them into this new environment.
    It’s an opportunity to bring some of our rural and small offices into the 21st Century – and save more lives than ever.
    In promoting decision support functions, alerting us to spot adverse drug interactions, and inserting automated reminders, this program offers the kind of ground-up approach we need –
    And good doctors will sign on for IT improvements when they’re convinced they are helpful to their patients, they are affordable, they are intuitive and most importantly – they are secure; the patient-physician relationship in digital form is no less sacred than in human form.
    How are we going to facilitate adoption of this technology when there are several barriers. Most of the major experts in this area are affiliated with large health care organizations taking care of only about 20% of the population.
    Most folks are taken care of in small practices and small community hospitals. Policy guidelines need to address those smaller entities.
    The gap between the IT capabilities of large health systems versus small practices is growing wider. We have to level the playing field. Uneven access to Heath IT cannot prevent physicians in small practices from treating their patients with the best tools possible.
    We are very concerned about what will happen to small, independent practitioners in the wake of this technology movement. Electronic records must be designed specifically for small practices and we must find a way for the other 80% of physicians who have not yet adopted this technology to purchase, effectively use, and efficiently maintain their own office systems.
    Interoperability has actually been hindered to some extent by the larger organizations and their proprietary legacy systems. There has been a reluctance to change to more modern standards.
    Smaller practices need capital to finance systems. The cost must come down, and those who benefit from these changes must share the cost.
    The current issue of Health Affairs has an article pointing out that in Health-IT, we are about 12 years behind other industrialized countries where government and payers have borne the cost of adopting this technology.
    Our government says it wants payers to make a contribution. And some insurers have stepped up to the plate, but I don’t see lines of payers clamoring to pay for this technology in a significant way. And the government is the largest payer. Where is its share? It continues to send mixed messages.
    For those who can’t see it, the name of the patient on the right is “Medicare”.
    Reimbursement continues to be cut, physicians are closing their doors to Medicare patients, we’re paid less for doing more – something’s got to give. We can’t be asked to make significant investments in health information technology when payments are not keeping up with the increased cost it takes to treat patients.
    Put simply – the problem is this. After adjusting for inflation, Medicare payment rates to physicians in 2014 – will be a little more than half of what they were in 1991. For many physicians, these drastic cuts represent a challenge which their practices simply can’t meet. They’re forced to choose between staying in business and caring for Medicare patients. We have fought Medicare payment cuts every year now for three years. We keep getting temporary fixes that don’t equal the cost of inflation.
    Physicians cannot — and likely will not — make the sorts of investments needed to bring this technology to their practices until something is done about the payment formula, the Sustainable Growth Rate. It’s NOT sustainable, and it’s NOT growing.
    Because of these risks to patient access – and to quality and innovation – the AMA has been campaigning to replace the current payment formula.
    We want to put health care for seniors and the disabled on a firm foundation. No physician wants to choose between the welfare of her practice and the welfare of her patients!
    We’re not asking for handouts. We’re asking for a fair shot to get this in our offices and see the possibilities it holds.
    One of the barriers to acceptance is workflow interruption. I am confident that the software developers in the audience will make great strides to fix this. Many physicians are still less productive, especially in the first six months of EMR implementation than they were with a paper-based system. That has to change. Physicians need an efficient, intuitive product that enhances their workflow.
    And the providers of care – physicians, nurses, clinical staff – must be the strongest advocates for exchange of health information that is enabled by interoperability.
    Groups of physicians have coalesced around some of these issues. The AMA has participated in several national groups trying to move this agenda forward. Connecting for Health and the eHealth Initiative are two groups making a conscious effort to involve stakeholders from all aspects of Health-IT. We’ve raised their consciousness about practicing physician involvement and the needs of small practices and small community hospitals.
    We are thrilled to join with these organizations, and so many others, in building a framework to enable health information exchange in this country. Without interoperability, we will continue to have disparate information systems that do not meet the needs of modern medicine. And work is being done as we speak to develop standards for interoperability.
    The AMA has provided direction on content standards for EHRs and is one of eleven sponsors of the Continuity of Care Record, or CCR. This week at this meeting, we are hearing about the CCR versus CDA debate, but physicians want a finite amount of information exchanged in a simple, readable way.
    We don’t care about the religious wars that currently exist. We as an industry are better and smarter than that. We can collectively come to a solution – a solution that provides physicians with the core set of information needed to help a patient. As we all know, technology is not powerful enough to stop our ideas. But we all know the risks. As we build an interoperable information network, the privacy of our patients must be at the forefront of our minds.
    The risk of privacy breaches is not just conceptual. They really happen. For example, last year a database of medical records of more than 5,000 neurological patients of a hospital in Pennsylvania were accessible on the internet. In Texas a computer that contained the records of nearly 16,000 patients was stolen. (Source:http://www.healthprivacy.org/usr_doc/Testimony_on_HIT.pdf)
    These stories are not just scary headlines.
    We have to understand those incidents in order to develop strategies that minimize those risks. With thoughtful design and diligent monitoring, we can build systems that are secure. But physician and patient fears about this very real threat are another barrier to overcome.
    Now, I just want to quickly touch on some future possibilities. Presently, electronic medical records are based on a variation of paper records. We are moving to a situation where data and patterns are more important than format. I can’t help wondering what the more distant future might hold. Will it include some direct patient monitoring, with alerts when those monitoring systems find a problem? Will it be a direct connection between one patient and one health care worker, or will some vast system of care be doing the monitoring?
    Will we be monitoring with implanted chips that measure changes in blood constituents, and bodily functions? Will there even be a patient record as we envision it today? Perhaps it will be a constantly changing CCR with all kinds of pattern recognition technology. Perhaps it will eventually be providing some of the care itself, instantaneously without human intervention. And perhaps all of this will be consumer directed.
    I don’t know, but the possiblities are truly amazing!
    • So, in parting, I’d ask that you consider these ideas as you go about your business at this conference:
    • First, remember there’s no point in doing anything if patients cannot get health care.
    • The uninsured, the under-insured, those blocked by disparities in the system – all deserve special treatment in the future.
    • Second, we need to end the bickering over standards. History shows de-facto standards naturally arise as the Big Stakeholders debate subtle nuances.
    • Third – Let us never overlook small physician practices and small hospitals as we produce macro- and mega-solutions.
    • Fourth – the most fruitful areas for development are in monitoring and prevention – not in cost accounting and statistical niceties.
    • Fifth – the Consortium efforts I mentioned are a fact of life – a growing force and an ally for all our efforts.
    Sixth – and finally – remember that price controls – either in the form of mis-directed Pay for Performance schemes or short-sighted Government limits on physician payments – [Slide 24]
    • are the 800 pound gorilla in the living room we all share.
    I know I may have done a little complaining, but in spite of those problems, we physicians love what we do, and most of us would do it all over again, if we had the opportunity. There is nothing more rewarding than taking care of folks who need our skills. We think our profession is the best! And your industry has the unique ability to improve our lives, and those of our patients.
    Together we are stronger – and together, we can pass on a healthier America to the next generation of patients . . . and the next generation of health care professionals.
    Thanks so much for your hospitality today.
    Joe Heyman

  4. Tom- I have to respectfully disagree with your statement
    “docs and hospital departments and hospitals don’t care about interoperability because they don’t really want to interoperate”
    Doctors would love to have interoperability as it would make choices for IT easier. It would make it much less likely that they will end of with the “sony betamax” of EMR and practice management software.

  5. Jack Daniels asks:
    > isnt IT supposed to make things EASIER for docs?
    > Why would they protest against it?
    This depends on whom you ask. There are all sorts of claims from vendors about benefits to clinicians, and most of them are true. But there are costs (besides time and money) as well.
    IT is certainly supposed to make things better for patients. Its side-effects are a mixed bag for clinicians of all kinds. However, to carry a physician-centric view of the world forward into the Promised Land of Information at Your Fingertips&reg would be what’s called a Local Optimization. You make things better for one part of the team, or even two parts, but the total headache increases. IT is really about Global Optimization but that might make some people worse off compared to the current state — you are asking them to “take one for the team”.
    Even if IT were truly easy to use in the context of clinical care (and it isn’t) doctors and nurses and even managers would still protest because:
    1) You are asking them to change, and
    2) 85% of the benefits flow to patients and insurers,
    but docs and hospitals bear 100% of the costs. And
    there will be no incremental revenue.
    There is a huge misalignment of incentives.
    > We have 1000 different vendors competing, wtih no
    > standardization framework in place.
    There is a standardization framework in place. Trouble is docs and hospital departments and hospitals don’t care about interoperability because they don’t really want to interoperate. Vendors are resisting standardization because it will reduce their power in the market, and their customers won’t pay extra for it because they don’t really want it. The main excuse is that the framework is not perfect. They are right — it isn’t perfect. Nothing is. Nothing will be.
    Healthcare is stuck at the stage other industries were stuck at in the 1980’s — they think they are ‘unique’ and face ‘unique’ problems. WalMart and globalization created a crisis. SAP and PeopleSoft demonstrated that companies and even industries are more alike than different, and so you had the big ERP implementations in the 1990s (sometimes as a poorly planned crash project to beat Y2K, but often not).
    There is nothing to prevent healthcare systems being designed around standard frameworks ground-up as soon as someone creates a crisis to motivate it. This is not a technical problem. Most IT problems aren’t.

  6. I’m not sure if Matt placed this discussion and the previous one so close on purpose; “TEPR Conference, Phil Sissions, who recently left working for the UK’s NHS’ National Program for Information Technology – GPs have revolted when being told that they had to change out their practice management systems”
    Introduction of IT on both sides of the pond has the same problems. Docs have to put up with what the rest of us have to do all the time – throw out that old technology for some newer faster, better system. I’m certainly suspect about going out too fast to “upgrade”. A medical business is a harder switch due to the size of the record system. I do understand that when docs are private business people and they are pressured to make the “system” better when they can’t see the what’s in it for them $$$, not much is going to be done. IT is not the solution for the U.S. health system, double digit compounded price increases, as far as the patient/employer payer is concerned.

  7. JD- ‘VISTA’ is the VA system. Approx 1 year ago the plan was to make it available free, the next day it was changed to a small fee (but of course that does not account for the IT support costs…), and by the next week, the idea was shelved…
    VISTA has ‘down’ scalable issues that, to my knowledge have not yet been worked out. Also, it was not designed with a ‘back end’ in mind for scheduling and billing integration. Also, it is not really designed for the outpatient setting. And it is not optimized for specialty practices.
    I do not mean to be a downer, but interoperability is actually not an MD job when it comes to EMR. Many a medical practice has been burned over the past 15-20 years by investing in technology that quickly became orphaned or obsolete.

  8. BTW, this is not my doman so forgive my ignorance…
    but isnt IT supposed to make things EASIER for docs? Why would they protest against it?
    You give them a standardized electronic system that works in all hospitals, all clinics, and serves as a central repository for all prescriptions, lab tests, patient charts and I think the vast majority of docs would be happy with that.
    but my current impression that that there is no consensus. We have 1000 different vendors competing, wtih no standardization framework in place. Until that gets sorted out, its premature to blame doctors for failing to use IT. Why should they pay hundreds of thousands of dollars out of their own pocket when they dont know if thats actually going to be the industry standard? What guarantees do they have that they wont have to buy another 200k system 5 years from now?
    Give them a national standardized infrastructure that works EVERYWHERE, and I think docs will embrace it with open arms.
    I think the VA system is the closest. Just expand that to a national level.

  9. Good grief guys please get a clue as to what the AMA really is.
    They are a TRADE ORGANIZATION, NOTHING MORE. They dont dictate health policy. The AMA is not nearly as powerful as the NEA in the teaching profession, with its organization of massive unions.
    Less than 40% of all doctors are members of the AMA. They do NOT speak for all doctors.
    Lets quit putting the AMA up as some kind of monolithic doctors union. Thats simply pure fantasy.

  10. When you expand… please tell us all how doctors in general and the AMA in particular is responsible for the lack of interoperability and lack of standards for electronic medical records for the last 20 years…
    It is honest to question the impact of the planned 30% (not incuding inflation, in which case it is closer to 50%) cuts in physician reimbursement over the next 6 years. (Remember that the hospitals get planned increases of likely about 3% since the funding scheme is different.)
    It is honest to question P4P as planned… Will they use the model of, for example, United Healthcare where doctors are rated on cheapness? or will they choose a much better model like “bridges to excellence”, where carrots and sticks can be potentially applied to both patients and doctors?
    Is it reasonable to question about federal mandates (like HIPPA) that incur large costs without the ability to pass them on (you may have heard of the unfunded mandate) and recoup them?
    The AMA has much to answer for over the years. But remember that everyone ‘won’ when Medicare was passed in 1965. The Congress has reaped what it sowed when it pleased everyone.
    Matt S.– correction- the AMA is not a ‘labor union’; doctors cannot collectively bargain, it is explicitly forbidden by law. The AMA is no different than any trade group that has a lobbying wing.

  11. Put simply, I think the AMA is essentially one of the most self-entitled and backwards labor unions in this country, if not the world.