NPfIT Blazing the Trail

The National Audit Office (NAO) in the UK has recently published a report evaluating the status of “The National Programme for IT in the NHS” (NPfIT). The program is a very ambitious top down initiative to deploy Health Information Technology across all NHS facilities in an attempt to provide an electronic care record for every patient in the UK. The blunt conclusion of the report states that “The original vision for the National Programme for IT in the NHS will not be realized” and “This is yet another example of a department fundamentally underestimating the scale and complexity of a major IT-enabled change programme”. Is this gloom ridden report in any way pertinent to our own quest for an EHR for every patient by 2014? Of course not. We don’t have a Socialist system where the government can decide on a particular EHR product, buy it, contract billions of dollars in services, and force all hospitals and doctors to install it and use it in their facilities on a government dictated schedule.

Instead, the United States Government is building a National EHR, and I find the business model fascinating. No, the Feds did not hire a team of software developers, did not set up a business entity and didn’t even hire a defense contractor to do all these things. Instead, they legislate and engage in a flurry of rule makings which are then applied in quick succession, like giant levers, to the delivery side of our health care system. This is nothing short of brilliant.While NPfIT engaged in the purchase of two EHR products, defined future releases and paid for implementing those in medical facilities, the US government is skipping the capital investment in EHR products, replacing it with a complex incentives and penalties scheme intended to ensure that all health care entities invest their own money in implementing technology which is designed to government specifications. The initial lever is commonly known as Meaningful Use (MU). There is a secondary and smaller lever embedded in the definition of Patient Centered Medical Homes (PCMH), and the final gigantic lever will be pulled along with the advent of Accountable Care Organizations (ACO). The holy grail of both NPfIT and the US government program is, of course, interoperability which will allow the creation of that elusive EHR for every patient and the global reporting of health care indicators to government agencies. At first glance, it seems that the uniformity and mandatory nature of NPfIT would better serve this goal. But NPfIT is failing miserably, so perhaps our way is the better way. If we can achieve universal health care by mandating that millions of people purchase government defined insurance policies from private corporations, subject to minor penalties, why can’t we achieve universal health records by mandating that a few thousand health care providers buy government designed EHRs from private vendors, subject to equally minor penalties?

We probably can, but only if government is thoughtful enough to allow meaningful customer choices and humble enough to admit that customers are not stupid (excuse the harshness). In the case of EHRs, the customer is the clinician. Yes, hospitals, integrated systems and probably even health plans, may be buying these products, but as many have discovered the hard way, if physicians don’t like the technology, nothing will be accomplished. Industry publications are overflowing with indictments against EHR products being designed for administrative purposes instead of patient care and designed by engineers with no regard to, and no input from, practicing clinicians. That’s the past. The present is witnessing the top down design of all EHRs by government committees of experts in health policy, academic research, business, insurance, technology, and a myriad other special interests, with the expressed goal of advancing current health reform policy.

The basic Meaningful Use lever is now in its second stage of design and according to the government, it is an “escalator to where the country needs to be from a health reform point of view”. As such, it is imposing an ever expanding list of items that physicians must record when seeing patients. You must record patient demographics, of course, but you must be sure to capture a refined definition of race and ethnicity. You already knew to ask each patient if he/she smokes, but now you must phrase the answer in one of several sanctioned formats, and you should also ask about second hand smoking, and even if you are an optometrist, you should ask about these things. There must be someone, somewhere, extremely interested in the type of contact lenses purchased by Native Hawaiian and Other Pacific Islander populations who were exposed to second-hand cigarette smoke (cigars don’t count). You are certainly recording vital signs now, and if you are a pediatrician, you probably have those lovely growth charts to go with it. If your young patient is hospitalized for, say, an appendectomy, you will be pleased to know that the hospital too must maintain growth charts, so we don’t miss even a few days of growth. You will also have to document your response to various drug interaction alerts in a soon to be defined standard format and record family history in another pending standard format. Following a national storm in a teacup, CMS elected not to reimburse physicians for the advance directives “discussion”. Too bad, because you will have to document that discussion now, along with the equally unpaid for, secure messaging with your patients. And the list goes on.

In 1995 and then again in 1997 CMS saw fit to define exactly what physicians must document during a visit in order to get paid. Those guidelines were the foundation for most EHR designs until very recently, and those guidelines are the reason for EHRs being perceived as billing oriented instead of patient care and clinician oriented. Compared to Meaningful Use, the CMS E&M guidelines are child play in their complexity and prescriptiveness. Since every EHR vendor today is busy implementing Meaningful Use designs with the same fervor that they implemented E&M guidelines in the past, it looks like we are going to end up with pretty much the same result – technology that will allow customers to collect money from CMS. One could argue that this is a very pessimistic view. After all, unlike the E&M guidelines, Meaningful Use is supposed to be about improving quality of care, patient centeredness, interoperability and better outcomes for patients. What’s wrong with supporting policy if the policy is good and sound?

Nothing really, except that policy-driven software design, enforced by certification, is minimizing the most important factor in widespread adoption of any product – the voice of the customer. What little influence customers were gaining on EHR software design is now drowned by the relentless grinding sound of vendors trying to keep up with Meaningful Use directives and certification criteria. Substituting committees of experts for actual live customers and their often unexpected wishes has never been proven a successful product strategy, and unlike the NPfIT in the UK, our government is not giving out these soon to become cookie cutter EHRs for free, and is not (yet) in a position to force physicians to use them. Increased market penetration and successful adoption of technology usually hinges on the product’s ability to solve a problem for which the customer is willing to pay. I may be wrong, but I doubt that the majority of physicians in this country are willing to pay for health reform.

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5 replies »

  1. ‘ some of the benefits (improved quality and cost-reduction)’

    There’s really no good evidence to show that “large-scale health care delivery” actually results in those benefits.

  2. Margalit: I agree; the confusion at the end of the article is probably due to the cloudiness of the crystal ball. As we enter uncharted areas, trying to predict the precise reactions of the many participants and how they will affect the end result may not be the most productive exercise. I am more interested that we set effective policy goals and find practical ways to steer toward them, making necessary corrections as we proceed. The article helped me gain some perspective on the rather large-scale health care delivery changes that have been occurring in the past decade, together with some of the benefits (improved quality and cost-reduction) and risks (market domination and price increases) posed by them. Thanks for your insights.

  3. Interesting that you mention this article, Gary. I was in a meeting today talking about ways to bring technology to physicians in small practices, mainly rural and underserved settings. Somebody brought up this article saying that the problem may not be critical anymore since they are all getting bought out anyway. Well, they are getting bought out, and it seems like a majority indeed were, but it also seems to me that a significant number of practices have no suitors. I don’t know what will happen to those, and more importantly, I have no idea what will happen to their patients.

    On a different note, I found the article a bit confusing, since its upbeat final conclusion is not supported by the preceding narrative. I guess we’ll have to wait and see….

  4. “I may be wrong, but I doubt that the majority of physicians in this country are willing to pay for health reform.”

    You may well be wrong. According to a recent NEJM article, “[m]ore than half of practicing U.S. physicians are now employed by hospitals or integrated delivery systems, a trend fueled by the intended creation of accountable care organizations (ACOs) and the prospect of more risk-based payment approaches. …A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals since 2000, and recent hospital announcements suggest this trend is accelerating.” (emphasis added) The authors state that “the young doctors being hired today tend to value better work-life balance and are more willing than preceding generations to trade higher incomes for the lifestyle flexibility and administrative simplicity provided by hospital employment.” The article points out that this hiring on the part of hospitals and integrated delivery systems is strategic. By employing physicians they are better able to control costs by standardizing practices and requiring use of health information technology, thereby positioning themselves to compete under various reimbursement scenarios. Whether cost-savings are passed on to consumers is another story, but reform it is. It appears a majority of U.S. physicians have already made a down payment on reform by trading their autonomy for employment.