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What Are They Thinking: ONCHIT and RTI – Brian Klepper

I’m sure I don’t really get the deeper issues involved here, but sometimes its hard to not have your breath taken away by some people’s notion of a good idea. Maybe its because I’m not a true geek, but what I’m about to describe strikes me about the same way I feel as when I see a young adult with multiple facial piercings and hear her/him say "Aren’t these great!?"

Modern Healthcare has an interesting piece on a report that was developed by RTI, a contractor to HHS’ Office of the National Coordinator for Health Information Technology (ONCHIT). The report urges revising Electronic Medical Records (EMR) standards to make it easier for payers and the feds to access the records and spot  fraud.

Now I’m as big a transparency advocate as the next guy, and I routinely explain to doctors how claims or clinical encounter data can be used to accurately rate their pricing and performance relative to peers within specialty. I believe we should use performance ratings to reward the high performers and to incent the poor ones to do better.

But to really get to the system we need, doctors first have to implement and use EMRs. They’re key to making the health system as a whole work better. Fewer than a quarter of physicians currently use them at this point. While there are still some buggy whip advocates out there, a large and growing number of doctors get that. Young physicians take it for granted.

Still, there are a lot of hurdles to installing an EMR system. They’re expensive. They force you to change your practice’s work flows. Some of the designs aren’t all that friendly. They’re complicated. And who wants to learn a new system. Heck, I know I’d like what it can do for me, but I haven’t gotten up the nerve to tackle iMovie yet on my Mac, and that’s about a tenth as complicated as an EMR with embedded practice guidelines.

We KNOW EMRs are a good idea but there are lots of reasons for doctors to say NOT YET. This Administration, to its credit (he said, grudgingly) has gloried in their advocacy for these new
technologies, what they can do, and how they can help improve quality and cost. (Remember Newt’s
line, "Paper Kills?")

So WHY would the guys leading the charge on EMRs announce that one of the really great things to use EMRs for when doctors finally bring them online is to WATCH AND CONTROL THEM MORE EFFECTIVELY.

Dumb, dumb, dumb.

But I’m sure I don’t see the big picture here.

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16 replies »

  1. > Using fraud and abuse detection as a
    > carrot (!) to get providers to participate
    Nego majorem, Matt, and I guess this goes for Brian too. Fraud and abuse detection is a carrot to get payers to require adoption by providers as a condition of being paid, and the feds (who sponsored the study) are the single biggest payer. ONCHIT is in the business of making life better for purchasers (and by extension, patients) not providers. Nothing in the list of goals on their web page says anything remotely like “improve hospital operating margins” or “increase physician income”.
    Providers will in the end do what they must in order to be paid — it does not matter what they might prefer to do.
    t

  2. Using fraud and abuse detection as a carrot (!) to get providers to participate in a data exchange is about as enticing as telling them that if they participate in an exchange that they’re performance metrics will be publicized to consumers, purchasers, etc. (i.e. value based exchange).
    There aren’t many better ways to STOP clinicians from sharing data. Seriously stupid stuff…

  3. I’m a recovering IT guy. One bit of advice: Never underestimate the cost of free software.
    There is modestly decent interoperability among hospital-based systems now. It still requires more tweaking than it ought to, but in the main its possible to get your nursing systems to talk to your order entry systems, and so-forth.
    There is still a lot of work to do in order to have interoperability across organizational boundaries (i.e. hospital 1 doc hospital 2 hospital 1), but this is much more a managerial problem than a technical one. Even if everyone implemented VISTA, interoperability across organizations would not be there.
    t

  4. I don’t know if I’m one of the “IT pundits” joe blow had in mind, but for the record I also don’t make any money off of any EMR system and have nothing invested in any of them.
    That said, joe is wrong about the cost of implementing one of these systems. It has been coming down, and is no longer 50K and certainly nowhere near 200K. If you’re paying that much, you’ve either been suckered or someone screwed up the implementation. There is no reason why a physician should pay more than 30-40K to install an ambulatory EMR these days.
    That’s still a lot, and I completely agree that the biggest, inexcusable obstacle is lack of interoperability. And I agree that greed is fueling it. I even agree that government needs to lay down the law to stop this.
    But I don’t agree that CMS should mandate Vista. There is no reason to do this when CMS could instead mandate that (a) all physicians have a system by 2014 or they won’t be paid for Medicare (b) all vendors produce systems are fully out-of-the-box interoperable according to next-generation CCHIT standards (or some other organization), (c) Vista is made available as a free option if you don’t want to pay for a commercial system, (d) some modest subsidy if you do purchase a commercial system (say, for those earning less than $150K per year). It’s a little more complicated, but a lot more sensible.

  5. My office has been paperless since 2000 but I do not represent the average doctor in this regard. While I am techno-ancient at fifty years old I was an early adopter being involved in computer development and education in Orthopaedic Surgery since the late 1980’s and continue adopting new technologies in my office.
    To point on this topic- in my travels and lectures it appears that the low adoption rate of EMR is a combination of some of the following factors:
    1. Cost
    2. Quality of the actual software to deliver what is promises
    3. Cross-platform connectivity
    4. Fear of the financial stability of the company who sold you the software
    5. Difficulty in actual learning the complexities of any new program (vs. simple writing or digital tape recorder).
    6. The individuality of each patient encounter trying to be distilled into a “template” that actually reflects what was done in the office.
    The road to my leading a completely digital medical life was not having all the EMR answers on day one but rather understanding that the systems get phased in based on the behavior of the physicians and the nature of a particular practice’s patient-doctor relationships.
    I see a problem with government mandates in EMR in that technology needs to advance at such a greater rate than government moves. By the time most of these mandates are applied operating systems and other technological advances make these mandates obsolete. In my lectures to Orthopaedic Surgeons I have made the case, for many years, that adopting the many aspects of a paperless office (EMR, digital radiography, e-mail patient communication) makes good long-term business sense. The initial outlay is costly but a return on investment does eventual come in money, time, and quality.
    Ira H. Kirschenbaum, MD

  6. Joe Blow expresses himself a little meaner than me, but I agree with his basic point. And docs are easy picking for consultants, and the consultants know it.
    Lack of interoperability is another great point. Paul Levy’s blog recently had a post regarding large hospital systems like Partners (Mass General et al) “capturing” doctors’ offices on their exclusive EMR system that won’t work with competing hospitals…..

  7. Au contraire mon Frere, Mr Blow. I don’t sell any IT systems, I don’t own any stock in any IT company and I dont make any money advising about which ones to buy. And I think your idea is a very good one–and if I were King I would do something very similar.

  8. If I was a doctor, why in the world would I want to invest 50k or 100k on a system whcih does NOT interact with any other system? Why would I pick that system when there are 500 other competitors and each hospital system uses a different one and they dont communicate with each other? There is zero reward for making such a risky venture.
    Here’s what should happen to correct this scenario. Medicare implements new rule stating that you cant get Medicare fees until you implement VISTA. Next, Medicare makes VISTA available free to download everywhere and provides an extensive online support structure to speed implementation.
    Of course, Matt Holt and the ohter “IT pundits” who are on this forum dont like this idea because they want to sell their fancy 200k software packages and suck a shitload of money out of the healthcare system for their onw greedy reasons. They dont want a true solution to the IT problem, they want to sell a product that makes them rich but which makes very little sense for doctors to implement on a wide scale.
    BAltimore has 8 major hospitals, and each of them use a different EMR that has zero compatibility with the others. Now you tell me why the private doctors in BAltimore are at fault for failing to make a 50k commitment to one of those software “solutions” sold by greedy MBAs/CEOs looking to make a profit.

  9. This debate reminds me of the rabbit holes U.S. healthcare goes down on virtually every issue. Analogy: we assume a month’s worth of Mepron (a drug brought to market in the early 1980s for malaria) has to cost $1250 a bottle at the pharmacy to treat p. carinii for AIDS patients, and set our policy accordingly.
    We assume it has to cost at least $30,000 a doctor to set up an Electronic Medical Record system and set our policy accordingly. We use databases just as large, complex, and secure as EMR every day that cost a lot less.
    If we started from the position that we need to figure out how to get Mepron to patients and EMR to doctors effectively, both could be done. And at a reasonable cost.

  10. This debate reminds me of the rabbit holes U.S. healthcare goes down on virtually every issue. Analogy: we assume a month’s worth of Mepron (a drug brought to market in the early 1980s for malaria) has to cost $1250 a bottle at the pharmacy to treat p. carinii for AIDS patients, and set our policy accordingly.
    We assume it has to cost at least $30,000 a doctor to set up an Electronic Medical Record system and set our policy accordingly. We use databases just as large, complex, and secure as EMR every day that cost a lot less.
    If we started from the position that we need to figure out how to get Mepron to patients and EMR to doctors effectively, both could be done. And at a reasonable cost.

  11. If ever a case could be made for standardization in healthcare this seems to be one. Having confidence that the product will work and still be the standard a few years down the road are key to their acceptance. I agree that computer/systems implementation can have a huge downside (been through one) but other businesses also have these problems and they still implement them -so why is healthcare being so resistant? Could it be that the 1000’s of docs are just resistant by character, AND there is NO competitive incentive because there is no competition?

  12. The equation was finally starting to tip in favor of EMR adoption, and now this comes along. I agree with everyone else: this was just stupid.
    Now that this cat is out of the bag, there really isn’t an alternative to mandating EMRs to keep the momentum going. CMS will have to insist that it won’t pay claims to providers who aren’t using EMRs by some date, like, oh, 2014.
    By the way, ambulatory systems are getting better. It now costs an average of $30,000 per physician to implement one, with administrative savings of 1 clerical FTE per year (less for solo practitioners). Even with upkeep costs, that means the systems are paying for themselves in 2-3 years, and then providing a profit. There have been a number of surveys and studies done of this, all pointing in the same direction. So there is actually a financial reason for physician offices to get EMRs…or there was until this announcement.

  13. I think the 3 top reasons are cost, cost and cost. I was hospital-based, but the clinical docs I talked to said it was hugely expensive (you know what consultants charge) and they had no sophisticated staff person to guide the process to successful implementation like hospitals did. There are still numerous horror stories about hospital implementation failures, for Pete’s sake, (and I was involved in one of them); just read HIStalk. What doc wants to take the financial and legal risk for zero incentive? Get real!

  14. Unequivocally NO! At this point, the reasons for poor physician uptake of EMRs are resistance to new technology and cost. This report – and its brazen announcement that it will be used for control – are new.

  15. “The report urges revising Electronic Medical Records (EMR) standards to make it easier for payers and the feds to access the records and spot fraud.”
    “I believe we should use performance ratings to reward the high performers and to incent the poor ones to do better.”
    “Fewer than a quarter of physicians currently use them at this point.”
    As a cynic, don’t the first two statements explain the last statment?
    “(Remember Newt’s line, “Paper Kills?”)”
    I think he said or meant to say, “Paper trails kill.” At least that’s what this administration believes. Can you hear the shredders yet – 08 is coming.

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