The HIT Job

I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).

Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”

Moreover, in the last few years we’ve gained a deeper understanding of the hazards of HIT, including new kinds of errors created by the stormy marriage of imperfect computer systems and fallible humans. We’re also becoming familiar with subtler problems, such as the copy and paste phenomenon now plaguing progress notes and the degree to which computers can distance us from our patients (Abraham Verghese’s “iPatient”). These problems are all-the-more irritating since IT was hyped – overhyped – as the solution to so many of healthcare’s woes.

So it’s natural to be disappointed in the present state of HIT, and even to wonder whether HITECH is on target. But overall, I believe that we are on the right track, that there is no better way to get to an HIT Promised Land than the path we are taking, and that the Federal government should be commended for getting involved in a reasonable way.

In the February 19th issue of The New York Times, one of the most off-base, unbalanced articles in my recent memory paints a very different picture.The paper’s lead article – yes, Page 1, Column 1, above the fold, called, “A Digital Shift on Health Data Swells Profits in an Industry,” focuses particularly on the consequences of HITECH. The reporter, Julie Creswell, does raise some new and legitimate concerns, such as the degree to which HIT vendors have jumped into Washington’s toxic swamp of money and politics.

Yet the tone of the article is inordinately conspiratorial about HITECH, and downright dismissive regarding the overall value of HIT. Creswell’s sources are disproportionally slanted to HIT skeptics, including her choice to quote my UCSF colleague Mike Callaham, who pronounced our Epic system “lousy.” (I’d venture to say that most people at UCSF – including me – find the system imperfect but pretty good. Moreover, we switched to Epic, a company that Creswell paints as a Goliath, only after a dismal experience with a different system built by GE, a $240 billion behemoth of a company whose electronic health record product is foundering in the HITECH world.) After reading the Times piece, I found myself in full agreement with Mark Hagland, editor of Healthcare Informatics magazine, who wrote,

The opening one-sentence paragraph says it all. Creswell writes, of a presentation by the Chicago-based Allscripts to physicians in 2009, “It was a tantalizing pitch: come get a piece of a $19 billion government ‘giveaway.’” First of all, characterizing HITECH as a “giveaway,” without in any way mentioning the penalties embedded in the law for providers who haven’t implemented electronic records (EHRs) by the end of 2015, is simply irresponsible journalism….

Ms. Creswell could easily have noted that no other large industry in the United States remains even remotely as paper-based as healthcare… or that study after study has confirmed the benefits to patient safety, care coordination, and cost-effectiveness of the automation of patient records. [The story] will undoubtedly be read by many thousands of laypeople who may or may not have any sense of how misguided and distorted its core thesis is.

The Times article ends as skewed as it begins: with a backhanded reference to the “gold-rush mentality” of today’s HIT players.

Let’s pause to ask a few questions: Does anyone honestly believe that computerizing American healthcare is wrongheaded? Or that the correct strategy was to continue toe-tapping, waiting for “the market” to promote IT adoption when, in 2009, only 16 percent of both US hospitals and doctors’ offices had functioning clinical IT systems? Or that they would like to be a patient, or a clinician, in a paper-and-pencil hospital?

I didn’t think so.

In 2004, then-president George W. Bush asked David Brailer – a brilliant MD and PhD in economics – to direct a new federal office of healthcare information technology, whose primary goal was to promote IT adoption. Brailer and his staff realized that a top-down program that had Washington forcing computer purchases on doctors and hospitals would be a disaster. (In fact, such a strategy was adopted by the UK’s National Health Service – a centralized, command-and-control initiative that, in 2011, was deemed a fiasco and junked, at a cost to British taxpayers of $19 billion.)

Instead, Brailer began planning a program consistent with American values, one that would allow physicians and hospital leaders to choose their own vendors, and encourage market competition. The plan that he and subsequent heads of the Office of the National Coordinator for Health Information Technology (ONCHIT) developed was to fashion a set of standards – relatively easy to reach at first and progressively more ambitious over time – and then to find the cash to fuel a national incentive program. They found the booty (about $20 billion worth) in 2009 when Congress and the president were seeking “shovel-ready” projects to include in the $700 billion federal stimulus package.

That, my friends, is the crux of the story. The meaningful use standards were developed and disseminated after extensive public comment. The IT vendors, a sleepy industry of true survivors (many of them barely maintained their pulses for over a decade, just hoping that the day would come when HIT adoption finally tipped to their side), did what all U.S. businesses would do when the feds were considering tossing money in their direction: they hired lobbyists and made campaign contributions. I don’t love this (and there is a risk that the Epics of the world will succeed in thwarting competition by scrappy upstarts), but that is our system, and any responsible business would have done the same thing – in fact, they’d be stupid not to.

It’s not a conspiracy. It’s America.

And trumping everything, the program has worked. The HIT adoption curve, previously stuck on flat, is now extraordinarily brisk: by 2011, 35 percent of US hospitals had functioning electronic health records, more than double the percentage of 2009; a similar surge has been seen in outpatient practices. The literature continues to demonstrate that, overall, these systems do reduce medical errors and harm. The promise of easier data collection to fuel transparency, pay for performance, and quality improvement activities will soon be realized, and we will ultimately enter the long-awaited world of “Big Data” in healthcare – one in which we can aggregate patient-level data on millions of patients, paving the way for more efficient methods of determining best practices and risk factors.

There have been problems. The systems are not great, and the vendors – including Epic – are putting most of their energy into keeping up with the insatiable demand for installations, and relatively little into improvements. Studies have demonstrated that the promised productivity gains have been weak to nonexistent. We have the aforementioned problems with IT-based errors and new challenges to clinician-patient communication. But the history of IT innovation is one in which systems become optimized only after many cycles of user feedback and vendor improvements. That cycle is beginning to play out, and the result is sure to be better, more mature HIT over time. There is no shortcut.

The Times (full disclosure, my wife Katie Hafner, writes about healthcare and technology for the newspaper) has covered HIT, including its glacial pace of adoption, responsibly, up to now. The Creswell piece, by failing to acknowledge the value of healthcare IT, the absolute necessity of wiring our healthcare system, and the fact that a federal program to kick start this process was a perfectly reasonable policy approach, was unbalanced and unfair. While a cautionary note is welcome, one could come out of reading this article clamoring for a Congressional investigation of the HITECH program and of the activities of Epic, Cerner, and Allscripts. If our goal is to find ways to create an improved, and ultimately less expensive, healthcare system, such a response would be unwise, even counterproductive.

The HIT industry, and those who regulate it, don’t need any special favors, and the Fourth Estate should keep a close eye on things, particularly now that there is gold in them thar hills. But as journalists are drawn to the increasingly vibrant world of healthcare information technology, it will be important that they do their homework and strike a balanced tone. The Times piece, I’m afraid, was a HIT job.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

44 replies »

  1. How, may I ask, that you people have been so duped by the HIT industry, its trade group HIMSS, and its offspring, such as CCHIT? There has got to be big bucks flowing into grants, consultancies, “safety” programs, faculty plans, CIO pockets, etc. Dr. Wachter has lost his objectivity. Why?

  2. Seechit is an interesting organization, spawned by HIM$$ and EHRVA, to legitamize the CPOE devices and provide the illusion that they were safe, effective, and usable, in their lobbying efforts with Congress.

    CPOE systems meet the definition of a medical device in the FD and C Act. The FDA leadership has said that. Hence, they are CPOE devices.

    Kreinky is comparing CPOE devices to drugs. Not exactly a good comparison, sir!

  3. Certification of an EMR is required, or the federal government will not make the incentive payment to a physician for installing and using it. That might have been a nice thing for the NYT reporter to have pointed out, but space in the paper is limited and it’s hard to fit in a discussion of the broader context for those payments when you have an ax to grind about the industry lobbying.

  4. Well i suppose I don’t quite understand what the point is in establishing “minimum standards” if there is no requirement to meet them …

    In any case – my comment was primarily meant as “snark” re the FDA …

  5. EMRs are not approved by an agency – you can’t do that for software anyway, as it has no actual direct therapeutic effect (nor does it directly harm) a patient the way an agent introduced into the body can. Doctors, nurses and other providers still stand between computers and people, and that should never change. The only gray-area is dosing and automatic medication dispensing via software, and regulating them as devices is something HHS and the FDA is working on now.

    EMRs are certified by an independent non-profit http://www.cchit.org/ that works with HHS to establish minimum standards for EMRs that will

  6. Well i have to admit, i hope that if we set up an approval agency for this stuff, it will operate to higher standards than the FDA …

  7. I cannot speak from experience – but i have heard, here and there, that the VA system is pretty good – does anyone have an opinion on whether that might serve as a template for a standard?

  8. In order for a drug to be sold, it must be approved by the FDA. In order for a prosthetic knee to be sold, it must be approved by the FDA. In order for an EHR and CPOE machine to be sold, it must be approved by no one. Go figure.

    What I would like to know is who is getting favors and greenbacks in this scandal?

  9. The HIT industry is a bunch of vampires, sucking the healthy blood from the medical care system. The New Tork Times opened the door to moor investigation of the flow of money in and out of the organizaions such as HIMSS, AMIA, CCHIT, AHIMA, and hospitals invested in their vendor.

  10. As in the UK, the costly HIT experiment in the US is failing, with little to show for it. The NY Times report was an excellent description of the slick conduct of the principals of the industry.

  11. The current state of HIT is indefensible. Until the devices being used to run the care of the patients are assessed for safety, efficacy, and usability, the entire programme is nothing but an unregulated experiment using the patients, doctors, and nurses as unconsented guinea pigs to enrich the HIT manufacturers.

  12. Fantastic return to reality, Bob, though I’m a little surprised and disappointed that your excellent summary didn’t inspire the usual nihilistic tirades against everything wrong with health care, medicine, capitalism, democracy, and the human condition, with EMRs being only a proxy for them. (Though there were a few stabs at it from the usual suspects.)

    I will admit that the NYT article wrecked my day, as I personally know all the people involved, and like to see them brought down a notch or two – but I also know the article was slanted, devoid of context, and bordered on muckracking.

    As for the predictable parts of the response on here – and at the risk of sounding like an HIT champ’s version of the NRA – I’ll say only that it’s best not to blame a technology for its failures (in this case, little or no working interoperability) when you should be blaming the owners/operators of that technology, i.e., the executives who install it and set priorities about its implementation and use.

    Brailer’s ONC knew on day one to create methods, standards and processes for data interchange, based on prior generations of work during the pre-industrial phase of EMR adoption. HL7, CCD, CCR, LOINC, DICOM – the whole alphabet soup, which tastes great intramurally – has been boiled, cooled, strained and thrown all over the walls of this blog since its own day one. And we all know (or should know) that entire careers have been made creating that soup, and twice as many fouling it. None of these standards are perfect but their greatest failures have been inter-murally, as none have been used toward even 5% of the task of moving now-computerized records out of one system and into the system of a competing provider’s system.

    Oops – spilled the alphabet soup beans: note the word “competing.”

    Blame it on RHIO? Not by the hair on my rinny-CHIN-CHIN. (For the millenials: what we now call HIEs were called CHINs, before they were called RHIOs.) The acronym thus perfected, the HIEs were finally funded, kinda, by HITECH, but then the money ran out before the lights went on, and now there’s almost nobody home.

    Who REC’ked the HIE ball? Adam Smith did, with his invisible hand. Seems like everybody is now off working on the HIXs, now that they’re done not finishing the HIEs. This is not an accident, lobbying dollars driving the process or not. The failure to reach any kind of critical mass, so far, on true interoperability is an act of willful self-interest.

    To wit…hospital CEO and CFO, thinking out loud, in meeting with CTO and CIO: Our patients’ data is our customers’ information, so explain why we should invest our limited time and money – diverting fixed resources from your aptly named Epic install – to make it easy for that information to cross the street to our competitor?

    We do not have a lack of EMR interoperability because we cannot figure out how. Where there is an economic will, there is a technical and operational way. The real reason: hospitals and modern group practices are individual rational economic agents with limited resources, and they know (if only intuitively) that there is not only no good reason to cooperate and interoperate, but a countervailing reason NOT to. Sure, they have HL7 in there, so they can check off the interoperability box on the meaningful use form. But you don’t think any of them are actually going to help those CHIN / RHIO / HIE people, do you? They’re stuck in ENOUGH meetings with the Epic install!

    It really is that simple. If you don’t believe me, see how easy it is to move your account history data from Comcast to TimeWarner, Hertz to Avis, Amazon to Barnesandnoble.com.

  13. Very apt analogy. We need this single standard; ideally, from a convening of appropriate bodies of both HIT and the various specialty groups in the U.S. Why this has not yet occurred is a mystery to me.

  14. “interoperable” is a misnomer that has become a cliche. Don’t expect to “operate” an Amazing Charts install from an e-ClinicalWorks client, etc. What would then be the point of different EHR “products”?

    What we need is a master data dictionary standard. ONE standard. You “certify” to that comprehensive data transparency standard and then innovate away (or not) around it; features, functionality, efficiency, usability– which become your value/price differentiators.

    The way we’re going now is to “promulgate a breadth of competing standards” so that, in effect, we really have none. Lotta busywork going on. The is ONE standard in the U.S. for 120AC there-prong grounded interfaces. You don’t have 4,000 ONC-CHPL “certified” sizes and shapes of those interfaces (the male & female plugs and receptacles themselves, excluding the differentiating cosmetics surrounding them on the racks and in the bins at Lowe’s).

  15. ” I, for one, am ready to try something new.” says Dr. Wachter

    I doubt it

    Dr. Rick Lippin

  16. Ron: Well said. I don’t have the technical background to know the next steps to bring us to “future state” but I agree that what we are doing now is not it. I’m all for disruptive innovation but it has to be innovative. Various versions of non-interoperable ehr’s have been around for at least 10 years. Implementation has accelerated over the last 3-5 years yet the systems are propitiatory, have poor user interfaces, hamstring the physicians, are massively expensive and drive up the cost of healthcare, do not support team care, adversely impact primary care (already in peril) and are unsafe for patient care. Please tell me what is good about this?

    Dr. George Margelis says we are 1/2 way through and disillusioned. Any technology should have early wins as it is being developed. Where are the early wins? Where is the improvement with each new upgrade or version? The basic flaws keep getting perpetuated as more and more money is shoveled into the developers.

    It’s time to take a breath and start aligning incentives that leverage technology that is out there but just not yet incorporated into ehr. I’m glad we are trying something new and I believe most clinicians are READY. But don’t push crap on us and expect us to say “Thank you master, may I have more gruel”.

  17. “I believe that we need a strategy that will get us to a new place in our healthcare system in the next 5-7 years: interoperable electronic health records, accessible to both clinicians and patients, that can serve as a scaffolding for levels of decision support, advanced analytics, patient engagement, trainee education, and quality improvement that we can only dream about today.”

    But that’s exactly what’s NOT being implemented today as a result of HITECH.

    Systems that weren’t designed to be interoperable, to be usable, to support the kinds of complex analytics for useful CDS, to use common metadata, to support flexible workflow, to support team based care, etc., etc. can’t magically or incrementally morph into systems that can.

    And that’s the problem. Much of the expense, time, effort and political capital spent on HITECH’s promised ROI, promoting, buying and implementing yesterday’s systems (and their closed architectures) is not well aligned with the goals.

    You just can’t get there from here without MORE massive expenditure to rip and replace stovepipe systems, buy and implement new ones.

    It’s as if the government provided incentives to purchase Dynamos (http://en.wikipedia.org/wiki/Dynamo) to provide electricity for each and every hospital in America…and then wondered why there isn’t an electrical grid.

  18. It is natural for a degree of disillusion to foster half way through a major project, and I suspect that is what we are seeing here. At the outset everyone is excited. Half way through we get frustrated by the challenges, and see some people profiting up front whilst those doing the hard work are not seeing any significant rewards. However it is important to stay the course and focus on the end goal. This requires clinician collaboration and strong leadership. You seem to have that in the USA, Keep in mind the rest of the world is watching you, and look forward to leveraging off your success.

  19. Bob & Bev, forgive my metaphor, but assuming that the government had to launch this entire HIT thing because it was not going anywhere on its own, and assuming that in the long run it doesn’t really matter if the launching mechanism was perfect or not quite so, the HIT craft is now soaring.
    It is a disastrous mistake to keep the rocket boosters and the clumsy fuel tank attached to the craft, just so its trajectory can be better controlled from Washington. These things (i.e. meaningful use and such) are slowing natural progress now, serve no further purpose, and need to be discarded before they cause the entire contraption to crash into the ground.

  20. Rob,
    Good points from the real world, and good posts; however on this, I have a different conclusion: the need for accountability (MU, Hedis, PQRS, better coding systems) and more granular data are absolute necessities in any attempt at a new healthcare model that unleashes the powers of automation and maximizes technology for optimal patient care. Yet there is just no way to help patients without the fiduciary, trust-based dyad of doctor and patient. Our path forward is both-and, not either-or. When the two methods conflict, we must choose the latter, but I think the next step lies in standardization of the data elements and even in the how-to of incorporating the EMR into the actual patient interview. We need to create the standardized passenger jet and its cockpit so we can retrain us biplane pilots to fly such jets, and teach the new docs how and when to use autopilot and other assisted in flight controls…and when not to. To the point of this article here, I agree with the author that HITECH and the current incentives did better than expected, and are cause to celebrate – as well as continue moving this forward. For all the imperfections (no interoperability yet?!?; lack of safety and usability testing; etc), there are for many, still ways to make the new systems work; although at a considerable toll on many (financial; stress). However, I really believe there is room in the emerging system for alternative models such as your own; indeed, for all my support of a new system, I remain fairly dogmatic about the doctor autonomy thing and keeping care fairly legacy-like in my biplane practice…until it is clear patients will be served better by the new jets we will someday fly.

  21. Bob, I definitely agree with your comment about insanity, and that also applies to the health care law. In both case the status quo just had to be disturbed, even if the disturbance was painful and not quite on target, it got the ball rolling.
    I am not sanguine, however, that policies alone can get us where we need to go. Good old customer pressure for a better product is the only thing that will get us what we and patients need, and that’s hard to bring to bear when you can’t boycott the available product because the government says you can’t. Someone desperately needs to come up with a product that works, so everyone will flock to it, and the companies that lose out will quickly follow suit. How do we make that happen?

  22. Thanks for all the thoughtful comments on my post – this is understandably an issue that people are passionate about. While I appreciate the concerns about the existing HIT systems and federal policies, I believe that we need a strategy that will get us to a new place in our healthcare system in the next 5-7 years: interoperable electronic health records, accessible to both clinicians and patients, that can serve as a scaffolding for levels of decision support, advanced analytics, patient engagement, trainee education, and quality improvement that we can only dream about today.

    If you accept that as a goal, then the question is not whether Epic is perfect (it’s not) or HITECH is flawless (it’s not), but rather: What is the set of policies that are most likely to get us to that place, with the least pain and cost? I believe that the present strategy is about right. (Of course, like any policy, it’ll have to be tweaked over time as we get smarter, as will the HIT systems themselves, but that would be true of any path that we might choose).

    For those who disagree, I’m looking forward to hearing alternatives that aren’t a blend of status quo and wishful thinking. Remember what they say about insanity and doing the same thing… We’ve tried the same thing in healthcare for 20 years – while every other industry computerized, to great effect – and we see where it has gotten us: low quality, insufficient safety, poor reliability, confused patients, massive waste, and backbreaking cost. I, for one, am ready to try something new.

    Thanks again.

  23. “the needs of both clinicians and patients”

    Completely irrelevant to those calling the shots these days.

  24. Margalit, good to talk with you; it’s been awhile. The only reason I mention Epic is because others have cited them as a threat to innovation – and innovation is the only thing that will help us out of these clunky products. I don’t see any of the existing companies ever able to change their mindset enough to produce something that meets the needs of both clinicians and patients.
    I think we all agree this is not the optimal road, but we are too far down it to turn back now.

  25. You got it all wrong, Rob. The system is supposed to be about consumers, providers, margins, expenditures, capital investments, risk and speculation, market-share, campaign financing, dividends, etc. Those two entities you mention are incidental to the above.

  26. Howdy Bev, sometimes when you walk in circles, it seems like you are moving ahead, and even ahead still has 180 degrees of choices…. We will get there sooner or later, but this is not the optimal road for patients, doctors and taxpayers in general. And, this is not Epic’s fault either…..

  27. If Epic is the best there is, we are in big trouble. I think it is a bit of “the emperor has no clothes”. Large systems spend $millions (billions!) on the system and cannot go back. It is the end users that suffer because the user interfaces are not build for clinicians and the system is clunky and cumbersome. Is this the best we can do? I agree with Bev that we must go forward but if we can’t be honest about the mess HIT is in, we can’t crawl out.

    So far I do not see “better,safer care” with Epic ehr. It impacts productivity, safety and patient satisfaction. When the experts tell us “you will never get back to 100% productivity with ehr” one has to wonder who it is really serving.

    Epic is neither innovative nor intuitive and was not developed for good clinical care. Period!

  28. I think your right on the money, Bob. You can’t stop progress, but rational and thinking people can shape it. You seem to be a little of both.

    I think that the medical industry crying foul that EMR vendors went to washington is hypocracy at its finest, but thats a topic for another discussion.

  29. Not that Congress will give ONC another however-many-billion dollars to do HITECH II (Electric Boogaloo) but forward shouldn’t mean more of the same.

    ONC is vigorously executing a flawed plan.

  30. Criticism of HITECH has been unrelenting, some of it accurate. However, let’s not forget there is only one way out of this mess – forward. We cannot go backward. Therefore, the only solution is to incentivize better EHR systems by exerting all the pressure we can bring to bear on both the government and the industry to provide a better product. If that means anti-trust action against EPIC or others, so be it. But users, never forget – you can criticize and Monday morning QB all you want, but the only way out is ahead, not back.

  31. I always take your admonitions seriously, giving that you are actually walking the talk.

    I hear such vastly varied pro- and con opinions about Epic, I can’t tell if it’s “The Cream of the Crap” or “The Turd That Just Won’t Flush.”

    Be interesting to see what throwing ICD-10 into this sHITstorm will end up doing.

  32. My 2 cents:
    HIT is designed to make the health care system work better. This sounds like an innocent statement of fact that could not possibly be a bad thing, except when you consider what the “health care system” is: the payment system. HIT has been shaped by the payment system and is an enabling tool to allow increased complexity (i.e. more data faster). This is, again, possibly not a bad thing, except when you consider what gets left out: patient care.

    As a doctor who used to be in the forefront of HIT, even talking at NIH alongside the national coordinator of HIT, I used to agree with the “good direction” theory. Then I left our health care system to practice care that was centered on the patient, not documentation or payment and discovered something: peel away the HITECH, E/M, and other “Health Care System” parts of an EMR and you don’t have much. Patient care is buried in the detritus of the payment system. I didn’t see this as a doctor in the system because my main task was to deal with the system; now my main task is to give care and communicate with patients and the IT is woefully deficient in this.

    I challenge the defenders of HIT and the use of programs like ACO’s, PCMH and others to see if the emperor is really wearing clothes. What of the physician-patient encounter? Lost in all of this are the two entities who the whole system is supposed to be about: the one providing the care and the one getting care. Neither seems to gain much by any of these initiatives.

  33. Reading through this discussion, I’m reminded of the early days of electronic billing. At least with the electronic bill there was an agreed format and a single purpose to collect data to get reimbursed. It wasn’t pretty and many physicians spent thousands and thousands of dollars on hardware and software not to mention coding clerks and other administrative staffs.
    These memories were so painful that when faced with EHR and meaningful use, many physicians ran to their hospitals and said, “please employ me. I promise I’ll be good. ”
    HIT is the right direction but I see a journey undertaken with only a compass…no map…no GPS but the persistence that we need to do this. But like everything in health care today….someone’s cost is another person’s profits.
    As long as the health care remains mired in an information imbalanced between providers, insurance, and patients, it will behave as an unregulated monopoly or oligopoly.

  34. I don’t believe that anyone doubts that information technology can and will have profoundly positive impacts on healthcare quality, safety and efficiency.

    Reasonable people can question whether the HITECH program’s structure and execution have been successful: The real question is: Have HITECH and its execution by ONC been successful or failed policy?

    The role of ONC, as Dr. Wachter correctly notes, is to “promote IT adoption.” That means that the Office of the National Coordinator’s role is to cheerlead and promote adoption of certified EHR systems and its performance is measured by the number of eligible providers that adopt and “meaningfully use” certified EHR systems. Part and parcel in ONC achieving “success” in this role is to remove any barriers to adoption and to discredit and discount concerns or issues, legitimate or otherwise, that could slow adoption (of commercial systems).

    HITECH injected a massive amount of money into an industry with products that its customers largely hadn’t wanted to buy or go through the trouble of implementing. The timeline and structure of HITECH necessitate that healthcare organizations buy and implement what is/was on the market and not what is/will be needed to support the models of care envisioned in health reform and to move us away from the FFS hamster wheel. To really get to the triple aim…to coordinate care…to unlock the value of big data, will health systems have to rip and replace the systems that HITECH funded?

    HITECH failed to spur real innovation in health IT. Meaningful Use, as it has been structured, has driven some incremental improvements and evolution in systems but the systems of today are largely the systems of yesterday. Same heterogeneous data models that ensure that quality reporting is cumbersome and problematic. Same problems with usability. Same problems with interoperability. Same bugs, legacy platforms and shoddy development that reflect the EHR industry’s heritage as a cottage industry of piece-part acquisitions and insular cults of personalities.

    Because ONC views it as counter to its mission, it has largely ignored and overlooked establishment of an oversight framework to learn from HITECH and has failed to drive the EHR industry to collaborate on foundational issues and to police itself. There is currently vague talk of an industry code of conduct…but will it materialize and amount to anything in a way that ensures that there is transparency in the EHR marketplace, that health IT-contributed errors are known and acted upon?

    This has also been a failure of healthcare organizations to demand more of the EHR industry and to demonstrate how they’re going to turn the taxpayers’ investment in HITECH into better care.

    And a failure of Congress to ask hard questions.

  35. RE “In 2004, then-president George W. Bush asked David Brailer – a brilliant MD and PhD in economics – to direct a new federal office of healthcare information technology…”

    What does Brailer think of the result? A “colossal strategic error.”

    What do I think?

    “By the way, to just to be clear, I am much in favor of digitizing health data. The problem is that we digitized the “Data-at-Rest” but not “Data-in-Motion” or “Data-in-Use.” Between an unequal playing field created by Meaningful Use and inadequate technology (see My Fixing Our Health IT Mess), we precipitated a “colossal strategic error” (in the words of the our first health information czar).”


    Wordle Based on 40,000 Words in 500 Comments to NYT’s “Digital Shift on Health Data Swells Profits”



    Fixing Our Health IT Mess: Are Business Models or Technology Models to Blame?


  36. If Creswell’s article is irresponsible journalism for showing how government spending can be bad for health care, is it irresponsible doctoring for telling a patient that smoking may lead to lung cancer? Allocation of federal funds have the power to transform the ecosystem of medicine from the inside out. Although Creswell’s article may have had a toe outside the line, we’re better off knowing the failures of EMR policy, lest we have to eternally settle for “cream of the crap.”

  37. Whatever the intent, and I believe it was mostly good, I’m not sure that the “American way” has always been to hand out cash for doing the right thing. Traditionally, we handed out tax deductions to encourage spending on goods and services, thought to be beneficial (e.g. energy efficient appliances, education, charity, etc.).

    I don’t see why we had to hand out cash here, most of it to large corporations that don’t really need it. Of course, if this was a tax based incentive, all those “charitable” non-profits that are now raking in most of the HITECH money (for something that they were doing anyway), wouldn’t have gotten as much taxpayer support in a recession….

  38. I don’t agree that the NYT piece was that far off the mark. However, I do agree that wiring healthcare is deeply necessary, and the current path is the best one we’ve got to achieve that … until a better approach comes along.

    The part in the Times piece that I thought hit the nail squarely on the head, and that Doc Wachter doesn’t give enough shrift to, is the risk that big players like Epic will literally squash open-source development in HIT like a bug. (Note: the NYT and Wachter did not use those words. They’re all mine.)

    ’70s “vendor lock-in” IT thinking is what’s driving a lot of EHR technology development, and sales. That’s the infection that’s gotta be cured. Until that happens – and with the big players throwing money at regulators via K Street, the infection remains untreated – the frustration with what’s implemented will remain, and accelerated development won’t be as possible.

    HIT’s goal is purportedly to break data silos, and enable better care across the system. Unfortunately, right now we have 700+ new, smaller silos, with little to no wiring created to share the data effectively outside the EHR bubbles. When that starts to happen – really, not just in someone’s project outline – then I’ll start cheering.

  39. Dr. Lippin, you are correct, I know several physicians in the Chicago area that use an EMR system that one of their techie buddies made as a hobby. They’ve been using the system for a few years now and for the most part they’re happy about it.

    However, I agree with Dr. Wachter that giant EMR companies can easily thwart competition. Going head to head with Epic, a company with their long contractual buying cycles, aggressive marketing team, and product that many docs say is “pretty good,” would be hell on earth.

    Maybe the next big thing in EMR won’t come from these industry monstrosities, but rather from a handful of people who know how to do it right. Perhaps that’s what the free market is about in the first place.

  40. Terrible, terrible post.

    The NYT article was about the financial wheeling and dealing that were necessary to get doctors to buy a product that wasn’t selling on the open market. The author states briefly and correctly that some like EMRs, some don’t. She does not address the clinical benefits of HIT.

    But Dr. Wachter, posting from inside the bubble, finds any article that is less than 100% positive regarding EMRs to be “off-based and unbalanced.”


  41. ” I don’t love this (and there is a risk that the Epics of the world will succeed in thwarting competition by scrappy upstarts), but that is our system, and any responsible business would have done the same thing – in fact, they’d be stupid not to”

    No Dr. Wachter- America is NOT only about the free market and paid lobbyists

    Dr. Rick Lippin
    Southampton, Pa

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