KevinMD turns into raving socialist…

Well not quite, but in his op-ed at USA Today Kevin talks about why it’s a problem for the US not to have wide deployment of EMRs, and notes that it’s the wrong incentives that are to blame—docs have to pay but others reap the rewards. So in Kevin’s words:

One needs to look at the Department of Veterans Affairs for an optimal model. All of the VA’s primary care physicians, specialists and hospital-based doctors across the country use the same electronic record system. It has played a significant role in the reduction of medical errors, optimization of cost efficiency, and attainment of high scores in preventive care measures.

Kevin’s usually criticizing me for being the wooly lefty, but I could be pardoned for thinking that he’s suggesting that we junk the current US system in favor of rolling all docs and patients into the VA. I wouldn’t suggest that but far be it from me to tell Kev that he’s wrong!

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6 replies »

  1. I’m a technologist. I’ve been implementing information technology professionally for 25 years. I’ve been doing EMRs for the last 5. There are lots of ways this can go wrong, large or small?
    1) Resistance: People hate change. Sometimes they’re correct. Most often they’re a self-fulfilling prophesy as, without technologists having support from above, and engaged knowledge from below, we end up the scapegoat. You can’t computerize people. You can only make computers part of their job. Just as you can’t make people fit a paper form.
    2) Hyper-acceptance: Problem-solving people with good intent come up with brilliant ideas that ignore the basic nature of technology. Even if you include all stakeholders, unless they trust a professional technology staff, if they ignore good advice, if they simply order technologists to do as they say, it won’t work. Information Technology is really People Psychology, and the best of us know something about both.
    3) Technological Eeyores: A large percentage of technology professionals are about the machine. They’re about the what and the how. They’re not about the who. It’s easy to fall into the view that the system was working perfectly before people got to it. Technology is 90% people. What are they doing? What is the real need? Can we do this without adding a gadget? These are hard questions to ask, and the broken and cynical among us won’t ask them. Sometimes they’re right that no one will listen anyway.
    It is said that technology is an artifact of all the compromises the designers made to create it. I disagree. At its best, it is a living thing that’s part of what people do; it’s an aspect of its users. It can’t tell us what to do, though. Nor can it ask. This can all go right, though. It can be successful.
    That takes people. They’re expensive. That’s another thing. Can I, in all candor, ask that we, as a society, stop seeking cheapness and start seeking shared excellence? To me, that’s the real issue.

  2. While Kevin points to the VA, the more pertinent point is that large medical systems generally have implemented EMRs while small, independent practices have not. It’s not a government or socialism thing. That 13% EMR penetration statistic masks a huge disparity between the bulk of physicians in 1-3 person practices and the minority of physicians in large practices (or at hospitals).
    The EMR problem reflects on a larger problem of fragmentation in the US medical sector that serves no purpose for the larger public interest. The Mayo clinic manages to offer some of the highest quality care in the US, does cutting edge research, has some of the lowest rates of unnecessary resource utilization, and pays its doctors a salary. Those things are not accidentally connected (well, the cutting edge research part is).
    Given the huge lift necessary to move physicians into integrated delivery systems, I’m not holding my breath that it happens soon. There are things that can be done with private practices, but they present challenges of their own. One relatively unheralded effort I’ve been involved with is New York City’s Primary Care Information Project, which is providing a good, standardized EMR at highly subsidized rates (over 50%). These EMRs are equipped with public health-directed enhancements like connections to disease and immunization registries and reporting of HEDIS-like data. The plan is to link them in a health information exchange and allow for more sophisticated (and easy to administer) pay for performance or value-based payment. The physicians involved are in small private practices and public health clinics.
    But it is a huge slog to get these physicians signed up in the small private practices. For some physicians, the comprehensive EMRs are almost free and yet you have to talk to 20 doctors to get a single one to sign up. It’s not just resistance to change. There is also an attitude among some that they’re making enough money as is, and doesn’t need to make any change. There is a resource problem: these offices have just a couple staff people who aren’t very technically proficient. This is a big problem. Sometimes staff will undermine your effort to get in touch with the physician because they don’t want to be bothered, and also because they suspect (rightly) that their jobs may be in jeopardy. A large practice can reduce administrative FTEs by about 1 per physician. How this translates into a small private practice is a vexed issue. Do you fire one of the 3 staff people who have been working with you for years and feel like family? Or maybe your staff actually are family members. Sometimes the solution is to turn one staff member into a part time worker, though that can create its own dramas and problems for solo practices. But if you don’t let anyone go or reduce FTEs, you aren’t going to save money on your EMR.
    Problems like this obstruct progress in EMR implementation less in a large institutional context where letting people go or retraining is easier, where tech support is a whole department, where people can spend time thinking about the strategic direction the EMRs serve and can engage in a formal RFP process to at least have a better chance of not getting stuck with a loser EMR, and where large capital investments can be more easily managed as part of the corporate planning process.

  3. Absolutely. Unless EMRs can be implemented so that we can communicate between practices (and legal issues such as HIPAA can be resolved), there isn’t much upside to using them. There is a very significant cost, though.

  4. I’d like to take partial credit for helping to convert
    Kevin (who is a reader).
    Saving America, one American at a time.
    (Kevin is actually very smart, and fair-minded, so probably doesn’t need my help.)

  5. If we are going to coordinate care the way care needs to be coordinated, we either need to all use the same EMR system or we need to have standards that allow the disparate systems to talk. I’m concerned that there has already been a lot of investment before we’ve really had the chance to develop the right standards.
    Regarding the funding of EMR systems, there are a lot of insurance companies stepping up to the plate and sharing in the cost with providers. Medicare is also going to offer a bonus to providers that purchase an eRx system.