31 replies »

1. We should start with a national enrollment database that the insurance companies update and use to post emr .. Would help start towards fixing the inconsistent data we see.. Maybe navinet would build and operate

2. As one who was once an EHR enthusiast and proponent of the HITECH when it first came out, I see the greatest error in this was the obsession with “trees” while ignoring the “forest.” By that I mean that the thing that drove medical records away from utility and toward interfering with care was the fact that the data were more important than the records themselves. I understand that there was fear that a doc might call a word processing program their EMR and so get paid for minimal EHR effort. But this missed the fact that if the physician using a word processing program achieved high standards, this should be enough. As stated in other comments, the certification program (and requirement of certified EHR’s) was the death knell to usability. Quality of data trumped quality of care in the construction of EHR products and so they were built to the satisfaction of government regulation over that of the users. This is obvious when you see any “certified” EHR.

   So what about this proposal? I do think that it is a step in the right direction when the focus is given more to the usability of the records in real practice. Certainly cutting back on the inane requirements for documentation and the overly granular documentation of the data is a welcome change. The problem is that these changes feel to many physicians like the promises of an abusive partner who promises to change and start loving instead. Trust must be won back by backing away from data and truly focusing on operability in practice. If, as many believe, EHR’s can improve a physician’s ability to give quality care, then it should be an easy sell. There was never a “meaningful use” program proposed to get people to use ATM’s. They were simply easier than waiting in a bank. In that sense, arguing the merits of these new criteria is of very little value. Build a system in which truly good and usable record systems are encouraged, and much of the crying will quiet.

   I am no longer in Medicare, so MU is meaningless to me. In leaving this morass, I once again was able to consider how records would look like if their real objective was good patient care. I was constantly thinking about how to meaningfully use my records (that I built on a database) and judged any systems marketed to me in their utility in making my care better. I wish somehow we could use general guidelines that would allow for innovation and improvement. I sense some of that in this article, which speaks of allowing physicians choosing measures that would improve their care. This gives some hope.

   But there is an awful lot of mistrust that must be won back with more than just words.

3. Admin, if not okay please remove!

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4. I’m so grateful that I’m a poor doc and practice in the sticks so I had no money to get an EHR and I applied for exemptions–and got them. My charts are on paper, and a hacker will have to physically take a machete to my room with charts in order to hack them. I never have to wait for a system to boot up or the update. My patients know this, since they’ve never received a notice that my software was hacked, they know it’s confidential “like in the old days” of 2006 and so they’re truthful with their habits and illnesses. I’m ready with paper and pen, and when a colleague needs my notes, I fax them. More efficient and sane than the nonsense page breaks and unreadable-charting I see from other clinics with Epic, for example.

5. Advancing Care Information…engaging the patient with EHR…reporting measures…all in between the tearful depressed diabetic with leg ulcers and the rheumatoid arthritic patient with mycoplasma pneumonia…and gee hmm, really difficult to do when my patients can’t get their records to me from other offices “because HIPPA” and we’re all reduced to waiting around the fax. How much brain power and intelligence equity was wasted on Meaningful Use for it now to be flushed down the toilet?

   But I digress. The real issue is that they’re running out of other people’s money and the pie is getting smaller every year. Health care costs are astronomical, and has anyone bothered to ask why?? Well, my Biohazard pick up fees have risen 10% annually for the past 4 years, utilities only go up, my own health insurance premium is 4 figures, malpractice insurance going up…not DOWN as it it should be, if I’m economizing on the ordering of tests and procedures, then I better get tort immunity from following government mandates on cost reduction and utilization management. “Mrs. Smith, Medicare won’t pay for your mammogram this year, if you want it done today you’ll have to pay.” SO Mrs. Smith WILL NOT pay for the mammogram because hey, she paid into Medicare and she’s OWED it. Then next year when breast cancer is found on the “covered” mammogram, I get sued.

   Non seigneur, I have her sign a document that she chooses to go without. In the end, the patients are suffering and they’re pissed as hell after being lied to and manipulated for a bunch of nonsense statutes that get thrown into the recycle bin of history.

   We are doctors in the trenches. We aren’t population experts nor statisticians nor epidemiologists. If you need these sorts of personnel, hire them. If you don’t have the money, earn it or go without. And you better not tax me for the info-fest.

   Federal bureaucrats and politicians will have to summon the courage to tell the public that they’re going broke and they’re going to be bearing greater costs for their health care. The eligible age for Medicare hasn’t been meaningfully touched in decades. I see 94 year olds getting stents, defibrillators, artificial hips, etc on the Medicare credit card. Start means-testing the supreme 1%. They can afford it. The Part B Annual Outpatient Deductible of $166 is absurdly low–non Medicare plans under age 65 with $2500 deductibles are allover the place. Doctors cannot be held accountable for every outcome and result; patient non-compliance is at an all time high from my experience because they won’t pay for their prescriptions and they won’t come in to have their health problem assessed because they can’t afford the copay (if they don’t have a supplemental insurance plan). They want to sit at home and eat the hot dog, drink beer. Not all patients are bicycling to Erewhon for the wheatgrass latte while checking their TSH on the health App we’re supposed to miraculously develop. Most of America is Archie Bunkerville. Wake up bureaucrats, this mess isn’t pretty and the backlash will be severe (as it is already playing out).

6. Very good dialogue. I certainly hear the frustration and blow back and see that Anish has a new THCB post, The Angry Physician. And I share some of his observations below. I’ve also started reading Dr. Abraham Nussbaum’s book, “The Finest Traditions of My Calling,” which purportedly presents a robust and somewhat unique view from the trenches of medicine.
   Again, I understand the angst and spoke to it in my recent Health Affairs post.
   As with so many issues, I think the truth lies in the middle here. Doctors have legitimate gripes about measurement, meaningful use, government missteps, insurance company intrusion, etc. Medicine is a noble profession and docs take on a lot to pursue it. Primary care docs especially deserve a break since they don’t make the big bucks.
   At the same time, there’s just too much evidence that the structure and practice of medicine is NOT producing the desired outcome, at so many levels (treatment results, adherence to evidence, the high incidence of error, poor coordination of care, value for money, etc). There’s just no arguing with that; it’s been recognized for over a decade, with much research support.
   My overall point is that physicians are the primary responsible actors in the system and must be held to a higher level of accountability for the system’s failings than they have been. But I want to make clear that the entire mess cannot be pinned on them, nor can they alone make things better. Care systems must be improved. Patients/consumers need to be held accountable, too. That’s why I support such steps as lower premiums for people who quit smoking. Hell, I’d support tax breaks for people who quit smoking and/or can document to the IRS that they exercise 3 times a week for an hour each time!
   I’ve been called out to supply evidence on certain assertions. I’ll try to find time to follow up on that.

7. Agree with Margalit. My behavior has been changed though:
   I am consumed, on a daily basis, with mitigating the distraction of poorly functioning technology.
   I now spend and least twice the amount of time reviewing data, and twice the amount of time entering data. This defeats actual patient care.
   Other than that, physician behavior has not changed much. Mostly you are seeing work arounds. The fundamentals of how our screwed up health system works have not changed.
   I would like to move forward, but in order to do that, real change has to happen.
   The EHR is actually reinforcing many of the bad habits our health system has.

8. MU. We hardly knew you. Especially the ‘meaningful’ and the ‘use’ parts

   via TweetBot

9. Margalit is dead-on. The failure of federal “Certification” of health information technology as a strategy was called out by me the day it was announced as the path to HITECH. To any entrepreneur and anyone who understands open source software communities, it was obvious that open source health IT and innovators would be shut out of a process that is fundamentally incompatible with community-led software development.

   Six years later, we’re still fighting the same battle and it has a name: Data Blocking. Although the API Task Force is clearly saying that patient-directed access should not disadvantage open source apps, neither ONC nor the Federal Health Architecture have committed to implementing FHIR in a way that makes patient-directed exchange a first-class citizen. See PPR’s testimony https://www.healthit.gov/FACAS/sites/faca/files/APITF_Testimony_AdrianGropper_2016-01-28.pdf and https://thehealthcareblog.com/blog/2016/03/17/precision-medicines-first-test-is-blue-button-on-fhir/

   I can understand why EHR vendors and private-sector health systems prefer certification of EHRs and apps but why aren’t VA, DoD, and CMS setting a better example?

10. MU was not “partially bungled”. It achieved precisely the goals it set out to accomplish: dismantling the “cottage industry” and enriching the sponsors of said legislation.

    As to the explanations for why it was “harder than envisioned”, and I agree that it was, a) there was nothing new about the technology, b) why on earth would a dozen people in a little room by the Potomac, many representing special interests, be remotely empowered to engage in “compelling doc en mass to change their behavior”???, c) one can rarely fix a “screwed up system” by adding heaps of complexity to what’s already there.

    And the sad part is that we are expected to obliviously continue marching in this visibly disastrous direction…and refer to it as “forward”. Change is not hard when it’s beneficial to all. Government had to act, but chose to act for the benefit of the few instead of the many. In the end, I can only hope that we can muster the will, the strength and the treasure to do it over.

11. Steven Findlay or Hayward Zwerling….please post the citations here too.
    I wish Steven Findlay would back up his assertions about research with citations. He has posted re MACRA “The overall intent of the law is sound and its thrust is consistent with an overwhelming body of research and experience”. I just would like to see some of the “overwhelming body”. I think it would contribute to the debate rather than just to make broad statements.

12. Steve,
    The angst is driven by something real. I sense you would like to dismiss this is grumbling a of doctors who don’t want to change. The reality is that there is tremendous anger and frustration among any physicians that actually had to implement meaningful use. I was a devotee as well until I realized two years in how ridiculous this was. I always new it as a first draft, and was Willing to go along with the hopes that the leaders I elected were in this to help us to this better. Whether this was the intent or not, what happened was that nice sounding terms like value based care are essentially going to drive out the independent practitioner by creating a regulatory bar that can’t be met. I assume the powers that be would shrug their shoulders at this – and I would understand – if this was actually good for the system or patients. I have a very good view of hospital based practice and the idea that cost savings will come there is malarkey. No hospitals are planning for reductions in revenue.. They are looking to work whatever new system comes to make more money. It has taken me a while to come to this – but the current trajectory is is just not going to get us to the promised land. The comments below are the medical practitioners effort to sound an alarm. I wouldn’t dismiss it.

13. Steven
    I would be interested to see the publications you mentioned which support the proposition that “patient engagement” results in an improvement in the quality of healthcare. Please email me directly.
    Thank you
    Hayward Zwerling
    HZMD@me.com

14. I’m with Steven Findlay below. Andy has a rather tough job, and his willingness to blog here is appreciated. I hope he reads these comments. As with anything disruptive and technology based, initial attempts are pretty Gawd awful. But there is NO question that we must improve our patient-centered technology. Medicine has technology where it assists the care givers in performing care functions but not for communicating, coordinating, or saving waste/error. This is non-negotiable. We just have to do better. I agree with someone below who said offer $1B to whoever can come up with a universally adoptable app that patients demand, or some such words. Maybe not $1B, but some real money. Let our capitalistic system work for us in positive ways.

15. A lot of angst, frustration, and cynicism in the comments below. As one of the consumer/patient reps on the original HIT Standards Committee, and a close follower of HIT developments for years, I share the frustration. MU was partially bungled, but it’s not communism! Did we waste $30B? Maybe some of it. Was it all “MEANINGFUL?” In the end, I think, yes.
    It was all just harder than envisioned because it was (a) a new technology, (b) compelling doc en mass to change their behavior, and (c) being integrated into the developed world’s most screwed up health system.
    I think we need to leave the cynicism behind. And move forward.
    Re: Dr. Zwerling’s comments that there’s no evidence patient engagement and consumer/patient access to e-records improve care. Not true. There’s quite a bit of evidence on that, though as yet no evidence it saves money.
    I’m not yet sure “Advancing Care Information” is the answer to all EHR woes. I’m not even sure I like the new name. But it’s good we are moving on. I choose to keep the big picture in mind: there was no alternative; we had to make EHRs happen, and the faster the better. Change is hard. Government had to act. In the end, it’ll be worth it.

16. Advancing Care Information is another vague term as much as the “pledge” to not block data is un-enforceable. As long as HIPAA and the regulations prevent the patient from exercising:
    – an absolute right to transparency of how data is shared (no more HIPAA TPO exclusions), and
    – a right to direct our own data to any third party without delay under a digitally signed release of information,
    data blocking will continue because it provides significant benefits to the incumbent institutions and EHR vendors that HITECH created. The main vehicle for this benefit is the ability of these institutions and EHR vendors to control decision support as a means of manipulating the physician-patient relationship.

    The problem of lack of transparency and data blocking has not been solved and Congressional action remains the only obvious path to a patient-centered health information system.

17. Blah Blah Blah. BMI-check. Smoker-check. Recent fall?-check. Afraid in home?-check.
    Yeah this will fix it.

18. Oh, just forget all the pesky details guys. Here is what “you need to know” about MACRA: https://www.youtube.com/watch?v=7df7cHghaS4&feature=youtu.be
    (rainbows and unicorns available separately)

19. Oh my God, Dr. Borges….. how are you? Almost fell off my chair seeing your name here. Sounds like all is well at your end, and I hope that you will reengage in this public debate (like the good old days at emrupdate :-)).

20. I’d say yes:
    http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-physician-payment-reform.page

    They will probably make money on literature and seminars on how to “transform” your practice to conform to these changes.
    Thanks very much AMA and AAFP for your support.

21. Did the AMA endorse this?

    via TweetBot

22. Let me be a bit more precise. There is little/no data to support the conclusion that allowing patients access to their healthcare data, promoting patient engagement or facilitating the development of health information exchanges will definitively reduce the cost of healthcare or improve the quality of healthcare. While these are all admirable goals, achieving them will not guarantee better/less expensive health care. And it is not inconceivable that these processes may ultimately turn out to be a distraction from achieving the desired goal. Only time will tell.

    We all want the same thing, better quality and less expensive healthcare. Until there is definitive objective data to tell us how to achieve these ends, it is clearly more prudent to minimize the constraints placed upon the healthcare system (especially those which stifle innovation), have the Federal Government create interoperability “standards” while providing incentives to those who achieve the desired end.

    While I could elaborate further, I have to go see my patients.

23. I believe the decision to continue the mandate that physicians must use Certfied EHR is unfortunate as this will hinder innovative HIT solution by guaranteeing the longevity and power of the large Certified EHR vendors.

    Every rational person believes we need to reduce the cost of healthcare and improve the quality of healthcare. I think a more enlightened solution would have been for CMS to focus its rule-making authority precisely on that target rather then prescribing what solutions CMS believes should be implemented to achieve that target.

24. Annals of Praise and Accountability, Vol 2:

    Yes, and people who pushed this should be tracked down and have their pensions reduced to the FPL upon retiring.

25. You understand, that thanks to CMS, communication amongst providers is at the lowest point I have seen in a 23 year span of history. Notes, discharge summaries, home health communication, care plans: all about 99% useless garbage thanks to central planning. Carrier pigeon is more functional than the EMR in sending and receiving meaningful information amongst providers. The medical record is practically an unusable wasteland. Much of this is caused by deep dedication to our broken billing and coding system that MACRA was supposed to address. Turns out “value” simply gets overlaid on volume, which will produce the worst of both possible worlds. I’m not sure who your focus groups are, but I hope you get to see what it’s like to have to try to take care of people in this environment. You will quickly see where all medical errors originate and you will wonder why more people are not dying more rapidly. The EMR is NOT a communication tool for providers or patients. it is only serving the special interests who designed it. Enjoy the lovely view of the mountains of data…but don’t get out of the vehicle, it is far too dangerous. Physicians and the public have got to stop being lied to, and stop being punished for daring to show up and try to help the sick during this colossal mess.

26. Hmm, the AAFP seems encouraged by these developments, their constituency however, does not.

    By the way, this is what practitioners are saying about these new programs:
    http://www.medscape.com/viewarticle/862566

27. I see an opportunity for a politician and perhaps a party to run (with a populist tone) on repealing the mandates, penalties, subsidies for EHR…..highlighting the wasted sunk cost in clunky systems that expose patient data to disclosure/hacking….and interfere with physician’s interaction with patients and reduce productivity.

    Then let hospital systems decide what to do with their EHR systems based on whether they really add value….and IT companies would focus on getting them to really work…..then someday a company might come up with the iphone of EHR’s….ie an EHR that is so wonderful that patients demand them and hospital systems need to buy them.

28. I think we are going to end up with some written records within safe places. Analog returns a little, just like 33 rpm’s! People are not going to give truthful histories, e.g., if they are discussing old STDs, abortions, job-killing diseases, super high cholesterols, ad infinitim. It doesn’t take much imagination here to think of many dozens of examples where folks would do anything to prevent documentation of certain data. In our hospital lab, we found that about 11% of husband ABO and Rh types were incompatible with the newborn’s. How much litigation by embarrassed married women can a hospital sustain?

    Just a few more years and a few more hacking events, headlines and expose’s and we shall return to partial handwriting. “Meaningful return” will be the name for this phenomenon.;=).

29. My goodness, Andy and Karen just don’t get it. This looks even more complex than the prior versions. For the love of God, Stop all this madness. Oh, 11 objectives with multiple measures in each is better. What? And the calculus to determine some score and this makes a better physician? Really? How about you prove that first then we do it. Looks like more penalties coming for our group until we go nonpar. Please someone get to Andy and Karen that is actually on the front lines. As I predicted their solution is just as big a nightmare as the current system.

30. I read with much interest your article- “Replacing Meaningful Use, Advancing Care Information” and wanted to leave a comment but your system has lost my email & password. You still have my email, since I receive your

    Who are the 2 physicians that wrote this article? It seems that they work for Medicare, as their presentation has many glaring lies. They state that 3/4 of physicians are using EHRs… the reality is that Medicare has put out of business many/most of the small offices that used to function well and physicians now are working within large networks or as hospitalists. Sure, they are “using EHRs” but this shift has made the practice of medicine more onerous and less competitive, and will eventually end up raising prices. Other physicians like myself have become NONPAR with medicare, so I don’t factor in anymore as an eligible physician that can participate with the Meaningful Use mandates. Many of the surviving offices are also NONPAR.

    In my physician building next to one of the large county hospitals in Virginia (Virginia Hospital Center), about 80% of practices have closed. I’ve lost many of my Medicare patients that I had followed for years due to my NONPAR status and for most of the initial couple of years it was difficult, but some have returned and I’m now seeing many more Obamacare patients which have no meaningless use mandates. These patients are younger, healthier, and easier to see. I may eventually get rid of my Medicare patient load altogether one day if I become booked more than a week ahead of schedule.

    I see that the article title is a lie- the (negative) spirit of meaningful use still lives on, and will be replaced eventually with more onerous rules and regulations. I was very surprised that THCB posted such a shitty article. Meaningful use needs to be abolished altogether, not replaced by another evolving government mandate.

31. Physicians will give Mr. Slavitt the benefit of the doubt and consider that the two missing links in the last paragraph are not a metaphor for this new era of interoperability 🙂