For whom the HITECH Bill Tolls?

As part of a sweeping effort to address the woes of the current US economy, the government has placed $19 billion on the table for HIT, aimed at containing healthcare costs and creating new jobs. The ultimate instruments for implementing this HITECH bill are America’s physicians and there is much confusion and apprehension in the physician community regarding the net effects of this bill on doctors in particular and healthcare in general. The HIT stimulus effort will not reach its stated objectives without voluntary adoption by our doctors. The government and the HIT community must find a way to draw physicians all over this country into the process of defining and implementing the stimulus package.

In very broad terms, interoperability standards will be defined, Electronic Health Records (EHR) technologies will certify compliance with the standards and physicians will be provided financial incentives to acquire, and meaningfully use, those EHR technologies. The assumptions are that use of these standardized EHRs will reduce costs by reducing medical errors, reducing duplication of tests, improving quality of care and encouraging evidence based clinical decisions. Jobs will be created as the EHRs are deployed across the nation. Experts are already at work “on the Hill”, in the White House, in the boardrooms of HITSP, NIST, CCHIT and other acronym organizations. Technology vendors are feverishly doing their part, from creating websites devoted to the HITECH bill, to making products available at Wal-Mart, to sudden revelations that HIT is really their main business. Everybody is actively involved in making this bill a success.  Well, maybe not everybody.

There are tens of thousands of physicians out there, mostly practicing in 1-2 doctor clinics, from Wichita, Kansas to Troutville, Virginia, where waiting rooms are packed with seniors pushing aluminum walkers with yellow tennis balls on their bottoms, some holding Ziploc bags full of medication bottles for Diabetes, Hypertension, COPD, Hyperlipidemia and worse. Doctors  are seeing 30-40 patients every day in an insane hamster-wheel race that repeats itself day in and day out. That is where health care is being administered in America.  Most of these doctors cannot spell CCHIT, but thanks to the mainstream publicity of the HITECH bill, they are aware that the government will be giving them some money if they buy a certified EHR.

Will the acquisition of a certified EHR increase efficiency so more time can be spent with each patient without loss of revenue? Will it allow reimbursement for much needed coordination of care? Will it make preventive care easier to administer? Will it save time? It’s always about time…. Yes, “time is money”, but time is also quality of care for patients and quality of life for doctors.On the other hand, will this new certified EHR slow doctors down? Will the high learning curve result in significant  productivity loss? Will the computer devalue the personal relationship with the patient? Will the physician be required to collect data for unclear reasons and no reimbursement? Where is this liquid data going to end up? Who will be analyzing it? Will it be used to further cut reimbursements? Is it even worth the hassle? The incentive payment doesn’t even cover the outright price of a Wal-Mart EHR, not to mention all the hidden costs and disruptions to practice.

The question really is, will doctors buy into a process in which their voices are not being heard?

Interoperability is a worthy goal, and ability to measure outcomes is a must. Ability to move data across systems has benefits that physicians can and will embrace if placed in the proper context. Doctors transfer data every day using very basic and common tools: fax machines and telephones. Moving data across the internet should only make the process more efficient if the new technology does not impose an onerous burden on doctors. But if we are to improve healthcare, we must be able to measure its outcomes. One cannot improve that which cannot be measured. Doctors will see the benefits of creating a “clinical information highway” that allows for collection of evidence to be used at the point of care. However, physicians must be empowered to shape this information exchange channel and not just be asked to patiently bear the costs of building it.

At the risk of sounding childish and naïve, I am going to address someone that will never read this article: Mr. President, this administration was elected by the American people on the promise of Change and participatory government, by the people, for the people. Surely America’s physicians are people too. Why not take this decision process on the road? Town hall meetings could be an option. I’m sure the same people that ran the most sophisticated grassroots campaign in history can find a way to engage our doctors in this crucial decision making process.The real experts on healthcare delivery are not “on the Hill”, or in boardrooms of IT vendors and organizations. They are in Wichita, KS and Troutville, VA. They are busy seeing patients while  public policy pundits and IT experts are deciding what tools doctors should use to deliver healthcare to this nation. Moreover, physicians have ultimate spending authority over most of our exploding healthcare budget and physicians can make or break this initiative by choosing to adopt HIT or not. Costs will not be contained without physicians’ cooperation. Jobs will not be created if doctors refuse to purchase HIT tools. Their voice matters because they will be the ones paying the highest toll for this clinical information highway.

My sincere gratitude to David Kibbe, MD for much needed edits and suggestions.

Margalit Gur-Arie is COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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18 replies »

  1. Thanks for the review! Your post of your initial troubles and then solutions were really helpful and I think I may go out and purchase this grill/smoker! Thanks again!!!!

  2. Good Morning,
    To some degree I am in agreement with all of you, but I do not think we appreciate the fact that we finally have a President who is doing what he said he would do as far as health care reform. The primary reason for the nationwide implementation of Health Information Systems has to put an end to the 100,000 persons killed each year by doctors’ prescription scribble which that and along with the creation of extra jobs for the health industry(I believe along with infrastructure,manufacturing,/and new energies)were the basis of his campaign but his stimulus and budget.
    As far as 19 billion, I do not know about but understand that he will be not only able to finally implement health care reform but create several million jobs in health care. More importantly doctors not abiding by the new IT systems to save lives from their terrible hand writing will be fined and GOD forbid they choose to be hard headed and do things their way….if they sicken or kill a patient, I do not think any doctor will be giving any HIS to their kids.
    If we want to focus on things as patients lets go after Docs who not only accept medicare but also ,illegally, double -dip making money on patients for vitamin drips. I ask all of you this with all he has on his plate would you be able to do any better. We are in a hole that started about 25 years ago. I’d say the glass is half full. I would also have extreme respect for him, because he not only has walked into the biggest mess of any President,including the wonderful FDR, he has what I would qualify,as a level of fear that pathetic that he has received threats simply for following through on his campaign promises; I believe the first in my lifetime. As he said he needs our help,as nobody can do that job alone. So if anybody wants to try to implement some ideas that would require much leg work, that would be very uplifting. Please leave a post and lets work on something. I certainly would like to shove an extra piece of reform up the neos butts

  3. It is well known and acknowledged that our health care system is in disarray. This is not due to IT or lack thereof. To overlay our existing chaos with any IT model, no matter its promises, will not help. If we separate this enormous effort from the parallel effort of health care reform then we will, with certainty, lose ground, lose time, and lose billions.
    When any high cost initiative is put on the table, an important question to be asked is: who gains the most? This question needs review from the 100,000 foot level down to the provider’s office–with every level in between.
    When consumers/clients can no longer afford to cross the threshold into the healthcare world, what benefit will a multi-billion system provide?

  4. Ram, I don’t think there is consensus in the physician community and I don’t think there needs to be in order for physicians to get involved in this process. I can definitely see the wishes of specialists possibly conflicting with the Primary Care agenda, but that’s just fine. Nobody can object to the need to collect and analyze data (with full physician/patient privacy provisions). The debate will be over interpretation of such data and its a necessary debate. I would prefer a debate led by medical professionals instead of a debate led by insurers,IT vendors and all those HIT organizations.
    However, we are not there yet. We need to put technology in place first. If we fail to stimulate widespread adoption of technology in physician offices, there will be no data, no measurements, no analysis, no debates and no improvements.
    Yes, we could take the easy path of allowing the current certifying “authorities”, CCHIT, to continue to cerify a myriad of irrelevant minutia and a couple of interoperability standards that are already certified more efficiently by the market. How a physician conducts his/her office business is irrelevant to healthcare delivery cost-effectiveness assessment on a national scale.
    We need to get away from trying to standardize physician work flow and get around to standardizing clinical data flow.
    The former has failed to elicit any significant adoption and/or interoperability; the latter is yet to be defined and it needs an impartial experienced implementer such as NIST and physician input, ownership and full buy-in if it is to be successful.
    I second Dr. Levin in the call for physicians to contact AMA and demand to be heard.

  5. What if we start at the end? What if we define the holy grail of what HIT technologies are supposed to be? What if we identify the goals, agree that they are worthy, and only then build the IT tools to get us there.
    Posted by: Margalit Gur-Arie
    You hit the nail on the head.
    There is one problem: is there such a consensus in the physician community? You cite cost-effectiveness as one goal. I couldn’t agree more. However, are physicians, especially procedure oriented specialists, going to accept data-driven recommendations when they argue against major revenue generating procedures? My guess is that they will fight such restrictions tooth and nail while draping themselves in the “flag of patient care”. They will cite the “art of medicine” as their defense and maybe even assail the “socialization of medicine”.

  6. Your call for a dramatically different approach to healthcare IT couldn’t be more timely! If we’re not careful, we will waste the $19 billion designated for healthcare IT in the ARRA legislation just as we seem to be doing with payments to AIG and the banks.
    Like you, last October I offered my suggestions in the following letter to the Obama Transition Team but no one seems to be listening. I post it here in the hope that it enhances the dialog and perhaps even influences the legislation and programs being proposed. I apologize if it sounds like a commercial for the IT system we have developed but I describe our system to demonstrate that there really is a “better” way. I’m sure there are others.
    Posted to 1-4-09
    Dear President-elect Obama, Congressional Leaders, and Healthcare Transition Team,
    With all due respect to the advocates of healthcare IT, today’s healthcare IT debate is seriously misdirected. Instead of focusing on the broad question of how to make a patient’s lifetime health record available to care providers when they treat a patient, it focuses on electronic medical record details, whether to force adoption of electronic medical records (EMRs), and whether to subsidize their adoption.
    The Issue is the System
    While record interoperability and standards are important, how patient records are created — handwritten, transcribed, electronic, images – is only one component of a system that must be addressed. The others are: how and where patient records are aggregated and stored; and the “delivery system” that enables care providers to access a patient’s aggregated records on demand.
    To select the optimal system, we believe the following three simple but critical tests should be applied:
    1 Does it meet the needs of physicians and consumers/patients? If it doesn’t, they won’t support or use it.
    2 Is it simple, cheap, and available sooner rather than later? If it isn’t, it may never get off the ground.
    3 Can we afford it and is it financially self-sustaining? If we can’t afford it, we’ll never build it. If it isn’t financially self-sustaining, it will either be a continual financial drain or it will collapse.
    The “Conventional Wisdom” System
    While today’s “conventional wisdom” focuses attention on the need to adopt electronic medical records, it in fact is a provider-oriented, Internet-based system. It requires that:
    1 all care providers adopt and maintain electronic records.
    2 all records be stored on Web servers.
    3 all records be accessible over the Internet.
    4 all records be accessible, with patient permission, to any care provider.
    5 all EMR system vendors standardize their systems.
    Despite widespread support by IT vendors, healthcare analysts and observers, and many elected officials, this system doesn’t satisfy our criteria.
    1 It doesn’t meet the disparate needs of most care providers and consumers. 85% of our physicians and 70% of our hospitals refuse to embrace it; consumers have no say in it whatsoever and their concern for security is all but ignored. And if care providers are forced to adopt EMRs against their will, government probably will have to subsidize them. Given care provider resistance, even with subsidies it will take far too long to implement and will cost billions – which we can ill afford given today’s economy.
    2 It requires significant technical breakthroughs and reprogramming of systems, which will take time and money to accomplish. While we dawdle, people will continue to die unnecessarily, many will be made sicker rather than cured, and billions of dollars will be wasted.
    3 It requires not only the adoption of costly EMR systems but also the construction of extensive, multi-billion dollar networks to make patient records accessible.
    4 Its business model isn’t self-sustaining. Most RHIOs, HIEs and many other local networks are failing for lack of funding.
    In short, this system does not meet the needs of care providers or consumers, will take years to implement, will cost — by some estimates — hundreds of billions of dollars to establish and maintain, and isn’t financially self sustaining.
    If this were the only system that could do the job, I guess we would have to embrace it. But that’s not the case. We have developed one that gets the job done simply, cheaply and quickly; I suspect there are others.
    The MedKaz™ System
    Our company, Health Record Corporation, has developed an alternative, consumer-focused system that does meet the criteria, It is called the MedKaz™. One leading authority describes it as “a consumer-driven medical record idea that makes sense.”
    1 It satisfies consumer security concerns by storing a patient’s records on a portable device the consumer owns, controls and carries or wears, not on Web servers.
    2 It can be implemented quickly – it employs established technology and transcends the technical issues troubling EMR vendors and users.
    3 It is its own repository; it doesn’t require costly networks to make the system work. (The patient fulfills the function of a network – moving information from where it resides to where it is needed – merely by giving his/her care provider their MedKaz™.)
    4 It allows physicians to maintain either paper charts or electronic records as they wish, and enhances their workflow.
    5 Physicians are paid to upload copies of a patient’s records to it; a typical PCP can increase his/her annual income by $25 thousand or more.
    6 Physicians can electronically sort and search its contents to quickly access the specific records they need.
    7 It helps physicians get comfortable using simplified electronic records, and reduces the cost of subsequently adopting a complete EMR system.
    8 It can be implemented in 12 months rather than years.
    9 It is financially self-sustaining and doesn’t require subsidies.
    10 It is simple, cheap, won’t cost hundreds of billions of dollars — but can save billions. (Eg, if every Medicare and Medicaid patient carried a MedKaz™, we conservatively estimate the Federal government and states annually would save more than $16 billion and $6 billion, respectively!)
    The beauty of this system is that it gets the job done without getting entangled in the debate over technical issues or subsidies. At last, we can stop squabbling and solve the problem.

  7. This has been a good summation of the task at hand. Surely physicians should not be asking to be invited to the table to discuss their serious concerns about the processes they use to deliver health care. I would suggest, perhaps even demand that every specialty society and the AMA be represented at these ‘quasi-governmental’ organizations’ (which have more eponyms than letters in the alphabet).The unfortunate thing is that our ‘government’ listens to these ‘voluntary organizations’ which are largely supported by the self interests of the information technology industry. With the recent ‘promises’ of federal largesse the feeding frenzy has begun
    I suggest all physicians contact the AMA and encourage their involvement.

  8. Carl Parisien Natick MA good article thanks for the post, I think physicians should make the call.

  9. Maybe, just maybe, we are thinking in the wrong terms. When EHR technology is mentioned, we all naturally think about existing products in use today. As Deron S writes, obviously what is out there today is not doing much for the physician. Today’s “EHR” at its best is a productivity tool, mostly for office staff and rarely does it add value for the physician.
    What if we start at the end? What if we define the holy grail of what HIT technologies are supposed to be? What if we identify the goals, agree that they are worthy, and only then build the IT tools to get us there.
    For example, let’s assume that we want better outcomes at lower costs. The first thing we need to do is measure the existing outcomes and document the means through which these outcomes are obtained. Then we calculate the costs. Next we do comparative studies to understand what means generate the best outcomes and evaluate the costs, and so forth. I’m sure everybody here is familiar with this sort of analysis and there are probably dozens of algorithms and methodologies. One thing they have in common is that they require intensive data collection. Data collection immediately elicits concerns about privacy. Not just patient privacy, but physician privacy and I agree with “MD as Hell” regarding physician’s intellectual property, but do we really need to identify physicians and share the decision making process? Not likely.
    Now we build the tools to allow us to collect, compile, analyze and disseminate the data. First we define data sets and standard terminology, then we standardize on transport mechanism and lastly we build technologies to collect and transmit data from disparate office systems to a hub for study and analysis. Everything should be transparent and completely de-identified. This sort of data collection need not be performed by the physician and should not interfere in any way with normal workflow in a practice.
    Next we define the first incremental step in this data sharing and implement it with the stimulus funds.
    What to measure, how to analyze and mainly how to draw conclusions is, in my opinion, something that should be left to experienced physicians. Like Dr. Oates says, if we want to be successful, doctors must get involved

  10. Medical records contain lots of errors. Thanks to the federal desire to slow the doctor down, todays EMR cannot legally store a master list of facts about each patient. Each patient’s history must be regathered and reconstruted by each new provider to justify a new patient level five E & M charge. In my own hospital’s records there are many patients whose records contain bad information. Hopefully the winning national platform will only store facts, rather than opinion in it’s database of each patient. Just because I think you are a narcotic addict fraudulently seeking pain medicine for your chronic pain or other purpose doesn’t mean the next doc will think that. I could be making a mistake. On the other hand, if you are a drug seeker, you would not want my opinion in your national database. It would certainly make your task more difficult. And what about the never-expressed argument that a doctor’s care of a patient really represents the doctor’s intellectual property, something valuable and not for free distribution to the masses. It is assumed that all doctors do the same thing the same way. That is not true. Practicing medicine is proprietary. That is exactly why a caveman can’t do it, even with a computer and protocols and algorithms. The more a doctor has to massage a computer or a dictaphone or telephone, the less productive he becomes. If you must have your EHR, does it have to be in real time? I think not. Clerical people can enter data into the box, while the doctor is seeing more patients. And if the box does not improve the financial profitability of the practice, then it will not be used. The latest attempt at e-prescribe is a failure because it took too much doctor time. Also any drug on a controlled substance schedule required a live signature anyway. So what is the point of half e-prescribing and half writing? If you waste the doctor’s time you are wasting the most expensive resource in the equation.

  11. Assuring patients of the privacy and security of their medical records will be difficult to accomplish. Although there are many hurdles to overcome, by reducing medical errors and improving quality of care in the long term we will enjoy a much better healthcare system.

  12. “Will the acquisition of a certified EHR increase efficiency so more time can be spent with each patient without loss of revenue?”
    Margalit – The answer to that question is no. EHR makes a practice more efficient (i.e. staff not running around looking for paper charts) but it does not free up much provider time to see more patients. From a healthcare system stanndpoint, EHR is a good thing. At the physician level, the benefits are minimal.

  13. I’ll repeat a previous sentiment expressed by me on other THCB posts on HIT
    Of course users must be consulted/surveyed before a top-down system is “shoved” into their practice setting.
    Furthermore the culture of the practice settings must be studied by social scientists to permit succssfull embedding and implementation of any HIT system with some allowable modifications to match the practice setting and practitioners without losing the core interoperable data set.
    But I doubt if that will happen because we tend to still be stupid enough and immature enough as a nation and as a profession to deify technololgy with minimal regard for the social science input. In this regard we have a very long way to go.
    Dr. Rick Lippin

  14. It is necessary for doctors to buy in (i.e. endorse) the plan ONLY if the desire is for the plan to meet with success. Otherwise, we can follow the U.K path to a failed NHIN.

  15. I think Ms Gur-Arie has missed the unstated objective of the $19 billion for HIT. A significant share of this bailout will subsidize doctors to acquire the appropriate technology, as determined by the lobbyists closest to President Obama. (Google looks like it’s at the head of the line.)
    Taxpayers will pay, e.g., $60,000 to each solo practice to acquire the technology. Dr. Doe will install the technology, and her first logging in will generate the an invoice to CMS for $60,000. President Obama will then host a press conference in a doctor’s office, where he will announce the initiative’s success.
    That is likely the last time Dr. Doe will use the technology. If it includes hardware, she will give it to her teenage daughter for playing videos or music.
    There will be no improvement in health care, but the government will have served the lobbyists’ purpose.

  16. It is not necessarily important for doctors to buy in the plan. However their inputs must be taken.
    THe problem with 19 billion dollar spending is this. It is too much money for IT where we do not need. IF IT needs so much money, then we have to question the usefulness of McKesson, Eclypsys, Cerner, etc. They have been in the business for this long, made so much money and they can not even come up with a robust system!!!!!!!!!
    In my view the IT spending should be limited to about 1 billion. By listening to all the voices, and proper strategy, one can deliver alot more robust solution which would be acceptable to most. With due modesty, I think I can do that.
    EHR/EMR are simple things…made complex by greed and incompetence and hope former is the reason.

  17. Bravo!
    The question really is, will doctors buy into a process in which their voices are not being heard? The answer is a very emphatic… No! All of this planning and spending, no matter how well intended (or not), is all for naught unless mechanisms are architected that include more grassroots input. I want to see the HIT efforts of the Stimulus Bill and other initiatives succeed in promoting better health care. With the current road maps, especially dealing with privacy and interoperability, there is high probability of more dysfunction and more gaming of the system. There is low probability of significant improvement in the short term.