By HAYWARD ZWERLING, MD

As a result of the determined efforts by Massachusett’s politicians, businesses, health insurance companies, hospitals, individual physicians and the Massachusetts Medical Society, nearly 100% of patients in Massachusetts now have health insurance. This is something all the healthcare players in Massachusetts can be proud of, and “universal insurance” enjoys broad public support here in Massachusetts

In an attempt to improve healthcare quality and reduce cost, Massachusetts is moving away from the “fee-for-service” system and replacing it with “physician groups” which contract with insurance companies. Most of these contracts include financial incentive/disincentive clauses about “quality” and “cost.” As a result, in Massachusetts, it is now almost impossible for a solo practitioner to obtain a contract directly with one of the state’s largest insurance companies. Almost all contracts are mediated through a local physician organization, such as an IPA, PHO or ACO.

As a result, health insurance companies now have much greater influence over the Massachusetts healthcare industry. These large insurance companies define the terms of the contract and can tell the small or medium-sized hospitals/physician contracting group their contract is a “take it or leave it” proposition. Needless to say, it is impossible for any small or medium-sized hospital/physician contracting group to refuse to accept the insurance contract when their financial viability is predicated on having access to the insurance company’s patient panel.

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value.

Recently, The Office of the National Coordinator for Health Information Technology (HHS)  asked the RAND corporation to review all EMR data. RAND created the “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities”

Unfortunately, the RAND authors appeared to have accepted the author’s conclusion at fax value. In addition, there appears to have been little or no attempt to evaluate the quality of the study and look for evidence of bias in either the design, funding or analysis of the trial. Further, the authors made the decision to collectively lump “positive” and “mixed-positive” results together in their conclusion. Clearly, this decision can only be expected to put a more positive “spin” on the overall effects which EMRs have on the quality/cost issue. As a result, I think if is likely that none of the editors of the major medical journals would reject the RAND study for publication.

In the end, the RAND report concluded that …

…that health IT, particularly those functionalities included in the Meaningful Use regulation, can improve healthcare quality and safety. The relationship between health IT and efficiency is complex and remains poorly documented or understood, particularly in terms of healthcare costs…

…much of the health IT literature still suffers from methodological and reporting problems that limit our ability to draw firm conclusions about why the intervention and/or its implementation succeeded or failed to meet expectations, and their generalizability to other contexts…

At this time, I believe it is reasonable to conclude that:

1. Clinical decision support systems probably has a salutary effect on quality of healthcare.
2. We do not know if “meaningful use” has a significant impact on the  quality/cost issue.
3. EMRs may have a slightly positive effect on the quality of care but we do not know which EMR features improve the quality of healthcare. EMRs have not been shown to reduce the cost of healthcare.
4. A large percentage of physicians are not happy with their electronic medical record program.
5. It remains to be determined whether an ideally designed electronic medical record programs (or assemblage of HIT components) has the ability to improve the quality of healthcare delivered or reduce the total societal cost of all healthcare expenses.
6. Physicians tend to believe that if their EMR enables them to run a more efficient practice, it will result in a salutary effect on the quality/cost issue. In fact, these two goals are not causally related. For example, I use Quicken in my office which allows me to run the financial side of my office more efficiently, but this has no effect on the cost of running the US banking industry.

In recognition of the federal government’s desire to promote electronic medical record programs, and despite the lack of “proof of efficacy,” the Massachusetts insurance industry appears to feel that they too should promote the use of EMRs/ and Meaningful Use. As a result, some of the large Massachusetts insurers are including clauses in their contract which mandate that physicians use certified EMRs according to Meaningful Use standards, and they are applying these mandates both to primary care physicians and specialists.

Given the lack of objective data about the effectiveness of EMRs, this is an outlandish overreach by the Massachusetts insurance companies which will interfere with the patient-physician interaction. As a practicing physician I am appalled to learn that the Massachusetts insurance companies seriously believe that they know how I should structure the use of my time in the exam room.

I believe that electronic medical records need to be looked at as a tool, which a physician may choose to use or not use in their practice, depending on the clinical situation.  Sometime the tool will be useful, other times it might interfere with the practice of medicine – but the only person who can make that decision is the person providing the care – the physician.

I am deeply concerned that the “EMR/MU insurance mandate” clause strike at the heart of the uniqueness of every physician-patient encounter. Essentially, the “EMR/MU insurance mandate” clause treats all physicians like vendors and tells them that they must click “this button” and “that button” every time they see a patient, even if the button click has no relevance to the clinical situation.

Massachusetts contracting entities, who are supposedly working on behalf of physicians must tell the insurance companies that the “EMR/MU insurance mandate” clause is a non-starter and “not open” for negotiations. If all the IPAs, PHOs, ACOs make the same demand, the insurance companies will have to back down. If any of these contracting entities, who are suppose to represent their physician members, fails to draw a hardline on this issue, they should be forcibly removed from their position and replaced by a person who is actually representing the best interests of physicians, the patients and the healthcare system.

Hayward K. Zwerling, M.D., FACP, FACE is an a board-certified internal medicine physician who specializes in endocrinology. He practices at the Lowell Diabetes & Endocrine Center in North Chelmsford, MA. Zwerling is also the president of ComChart Medical Software, LLC.