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June 26, 2007
Health Wonkery in Everything
Matthew Holt writes:
Apple CEO Steve Jobs and filmmaker Michael Moore essentially are on the same mission. They both want to convince the American public to take another look at what they've been using so far hoping that the re-evaluation will be so dramatic that the scales will fall from their eyes and Americans will suddenly realize they can do much much better than what they've had to put up with so far.
The simple fact of the matter is that, like cell phones in the EU, health care works better over there. Why? Better use and management of the technology at hand. It's not entirely a coincidence that in most major European countries the use electronic medical records by physicians is much more common than it is the US. And we're not talking a minor distinction here. In countries like Denmark, Norway, the Netherlands, the UK and New Zealand the use of electronic medical records in the exam room by primary care physicians is almost universal. In the US despite years of hype, somewhere under 20% of doctors are using them.
To this day, I've never read a compelling explanation of why the nation's doctors and hospitals haven't broadly adopted electronic medical records. It's not as if they're allergic to technology. At this point, cardiovascular care employs every strategy but astral projection to keep our in rhythm. It's not as if it wouldn't be cheaper and easier for them. The man hours and costs from keeping track of files, printing out labels, finding lost manila folders, and getting sued because the nurse misread the doctor's handwriting are enormous. Theoretically, insurers should be pushing on this, but they seem behind the curve, too. And it's not as if there aren't tested programs in use -- not only does Europe do electronic records well, but the VA does them beautifully, and they've released their primary program, ViSTA, as open source, for free use by anybody.
That all these factors haven't spurred our private providers to incorporate such broadly appreciated technology should be one of our first signs that American medicine is not responding to the incentives we'd expect. But wait, no, can't say that, because Michael Moore sometimes stretches the truth...
June 26, 2007 in Health Care | Permalink
Comments
One reason for the slow pace of electronic medical recordkeeping is fear of regulators and legal/financial liability. The consequences of hacked electronic medical records are potentially catastrophic, whereas paper records are much harder to steal in the same quantity. The heavy-handed and extensive regulation of financial relationships between and among providers (kickback, self-referral, etc.) also inhibits providers from approaching bigger-picture benefits of electronic recordkeeping--sharing of records in community databases that can be accessed from multiple, unrelated providers.
Posted by: Joseph Hovsep | Jun 26, 2007 10:54:04 AM
Ezra,
Here's the explanation. Its a nightmare for the first six months. You're asking doctors to completely change the way the do their work-- and its difficult to do so, plain and simple. They hear the potential benefits, but are skeptical-- its much faster to just write things down, and while there may be back end savings in terms of lower office overhead, they are either happy with their current income (so don't need the hassle of changing) or they aren't and are convinced that higher reimbursement is needed. Remember, these people are practitioners of medicine, not business people. The downstream efficiencies that glean from EHRs just don't seem to outweight the nightmare stories they hear about from the initial implementation.
Here's an extreme analogy. Imagine a study comes out that says that Chinese is a much more effective an efficient language-- journalists are more able to communicate their points with readers, less grammatical errors for editors to clean up, and the print costs are lower for print newspapers/magazines because characters for words rather than letters use less ink.
Are you/Prospect going to transition from English to Chinese for your work (yes I am assuming readers know Chinese for this analogy)?
Posted by: wisewon | Jun 26, 2007 10:55:21 AM
That all these factors haven't spurred our private providers to incorporate such broadly appreciated technology should be one of our first signs that American medicine is not responding to the incentives we'd expect.
One other important point. The real benefits of EHRs are not gleaned by providers. As I described above, the incentives you laid out for physicians just aren't that compelling. Now if insurers were willing to share some of their potential savings (unnecessary duplication of lab tests, better decision-making due comphrehensive medical information due to interoperable EHR systems)-- then you'd start getting real incentives for physicians. Hence P4P initiatives on use of health IT in physician/hospital practices...
Posted by: wisewon | Jun 26, 2007 11:00:38 AM
Having worked with electronic documents systems since the late 1980s, I have to say that I have never seen one that comes even close to duplicating the ability to jot notes, sketches, and other free-form information that a paper file does. Just one simple example: I keep a record of my blood pressure in Excel with a graph and give it to my doctor periodically. He takes the graph and jots some notes, arrows, etc on it, then maybe staples in an article on folic acid, etc and sticks it in the chart for next time. How would this be handled with electronic records? Everything reduced to fixed format text? Some sort of digital ink format and a scanner sitting every place the doctor might need to talk to anyone? Besides the exponential disk storage and retrieval requirements for free-form document acceptance and management such systems are bulky, cumbersome, and an incredible irritant to anyone just jotting down some notes.
Cranky
Posted by: Cranky Observer | Jun 26, 2007 11:15:28 AM
It should be noted that wisewon's comments boil down to "the system isn't currently providing incentives for various kinds of improved practice and treatment."
Posted by: Meh | Jun 26, 2007 11:16:59 AM
wisewon's second post points out the issue-- converting to electronic records is an economic cost to the doctors and their practices, but the insurers and hospitals are the ones who reap the direct benefits. The VA can do it because the VA is a unitary system of doctors and hospitals. The financial incentive isn't there for the independent physician.
It's only going to happen if doctors get money to defray the costs of upgrading, since they have little incentive to spend their money for little return to their own businesses.
Posted by: Tyro | Jun 26, 2007 11:18:09 AM
Joseph had one of the key points. HIPAA put serious restrictions on how health information has to be handled. And it's not just having some information stolen that will get you in trouble. Certain preventive/protective provisions HAVE to be in place to protect records, and if they're not, you're in violation of the law, which would be devastating for many practices. Putting these provisions in place for physical records essentially requires locks on filing cabinets and file rooms. The requirements are much more substantial for electronic records and would force many providers to implement layers of technical security that are cost-prohibitive.
Posted by: mike | Jun 26, 2007 11:26:00 AM
Where did Matthew Holt get the idea that cell phones are better in Europe? They're more expensive, and adoption of data services is crawling.
This is part of the problem with EHRs . . . they're not better on all dimensions.
Unsurprisingly, I'm unconvinced that the problem is market financing. The reason EHRs haven't been adopted is that they're not as easy for doctors, and doctors have too much power in our system. That's not money, it's medical culture. Medicare could mandate EHRs, which would effectively force them on everyone in the country, but doesn't; hospitals don't use them even though the have ample correct financial incentives.
Posted by: Jane Galt | Jun 26, 2007 11:28:12 AM
The clinic I go to is associated with a hospital in Seattle. They've adopted a completely integrated, electronic records system. The doctors I've talked to love it. I can go to my doctor, and he can bring up the chest X-Ray I got in the hospital, right there onto the screen, in real time. He enters a prescription, it gets faxed to the pharmacy immediately, and when I went to the hospital, they knew exactly what meds I had been on. I didn't have to explain everything over and over again. There's no waiting around while someone goes and tries to find a piece of film, a piece of paper.
If we had a single-payer system, incentives to adopt a common EHR system like this would be easy. If doctors wanted to get paid, they'd sign up for the system. If they wanted to work for free, they wouldn't.
Posted by: me2i81 | Jun 26, 2007 11:34:47 AM
hospitals don't use them even though the have ample correct financial incentives.
This is not really true-- and it relates to the first half of your post-- that it's not easy for doctors and they have the power. In hospitals, putting a new system in place would then require physicians to use them. In most hospitals, physicians bring their procedures there by choice-- i.e. they are free agents and can take their business elsewhere (i.e. their patients) if they don't like the hospital. So hospitals may see the potential cost-savings if they implemented the system-- but they fear mass-scale defections from their doctors.
Mandates are a reasonable solution, the fight will all be about the upfront compensation for implementation.
Posted by: wisewon | Jun 26, 2007 11:36:27 AM
If we had a single-payer system, incentives to adopt a common EHR system like this would be easy. If doctors wanted to get paid, they'd sign up for the system. If they wanted to work for free, they wouldn't.
You can accomplish this via regulation alone, as Jane suggested-- you don't need single-payer to accomplish this...
Posted by: wisewon | Jun 26, 2007 11:38:13 AM
Closing italics.
Wisewon, that's true, but it goes both ways: prestigious hospitals offer reputational enhancements for the doctors they allow to affiliate with them. (My mother will only go to doctors at New York Hospital, forex. But I do take your point.
Posted by: Jane Galt | Jun 26, 2007 11:51:22 AM
Those hospitals typically do have a fair amount of health IT in place already, with EHRs being added fairly rapidly.
Posted by: wisewon | Jun 26, 2007 11:57:33 AM
You can accomplish this via regulation alone, as Jane suggested-- you don't need single-payer to accomplish this...
What Jane suggested was essentially the same thing: if Medicare mandates that doctors use EHR systems in order to get paid, then doctors have a large financial incentive to adopt EHR.
I suspect that basically all hospitals will move to EHR systems en masse soon enough, now that some of them have switched over, once the numbers start coming in. One question is whether they'll be balkanized or not. It would be unfortunate if individual hospital EHR systems were incompatible, but that's what will happen if we don't have some mandated EHR adoption driven by either Medicare or even better, some larger universal payer.
Posted by: me2i81 | Jun 26, 2007 11:58:53 AM
As it happens, I worked from 1999 to 2005 in a company that sold various medical systems based around electronic health records. The story of why they aren't being adopted more quickly is a fairly complex one.
First of all, Ezra is simply wrong when he states, "It's not as if they're allergic to technology." Most medical personnell are technophobic, and to a certain neophobic in general. Yes, there's lots of high tech stuff going on in hospitals, but it's usually operated by technicians, not by doctors or nurses, and they only have to receive the results. Also, don't underestimate the extent to which any new procedure is underused, ignored, or used only grudgingly by doctors.
(My father, a doctor, makes the claim that this is because malpractice rules in America make doctors extremely risk-adverse, which leads to a general reluctance to adopt new procedures).
Secondly, Cranky is right that there remain some serious UI challenges in the realm of electronic input. In most of the country, a primary care physician can spend only a few minutes per patient and maintain profitability. It's extremely hard to create an interface that allows a wide variety of input in the kind of time constraints that non-specialist doctors have.
Don't underestimate pure bureaucratic incompetence, too. Most medical businesses are not particularly well run as businesses (executive pay is not what it is in other industries, and executive ranks are dominated by both doctors (who may be good doctors but are not necessarily good businessmen) and nuns (similarly)). Any business has a good deal of bureaucratic inertia that resists major change. Hospitals and medical practices tend to have more than most.
While, in my experience, HIPAA requirements aren't actually very hard for a technological solution to meet, it can be hard to convince the non-technical people who make decisions for a given medical community that you aren't exposing them to additional liability.
And, finally, the real payoff for adoption for EHR's will be when everyone else has adopted them too. It's a bit difficult to sell the virtues of being the first community in your area to adopt them, because they don't get you much.
Posted by: Michael B Sullivan | Jun 26, 2007 12:47:23 PM
There is actually a simple explanation here. Hospitals have used computers for years. Because of the factors listed above, building a computer system for a hospital has always been a massive task. This gets even worse when some departments, like the pharmacy, are more driven than others, like housekeeping, to adopt new programs.
At the same time, hospitals have been extending into integrated clinic and health insurance institutions. Additionally, switching x-rays from actual film to digital imagery involves very large files. All of this must accept appropriate user commands and inquiries and reject the inappropriate.
For example, University Physicians, in Seattle, encompasses the doctors practicing at University Hospital, Harborview, Children's, and a number of clinics, as well as practice at affiliated teaching hospitals. The system that allows these doctors to record their notes digitally is like a medieval city, ringed with defenses against hacking. Once built, it is no simple task to connect such an electronic fortress to another larger one.
It's not quite as simple as launching MySpace and then dealing with the subsequent problems as they arise.
Posted by: serial catowner | Jun 26, 2007 12:53:10 PM
99% of doctors I know would have no problem using EHRs and would gladly implement them into their private practice.
But they are NOT going to spend 5 million dollars on such a system; the private vendors selling these EHRs charge RIDICULOUS prices. There's a whole slew of vendors who want to stick their greedy fingers into the healthcare pie and rape/pillage as much money as possible from it.
The solution is simple. We already have a very good FREE EHR called VISTA that the VA system uses. Medicare/Medicaid simply need to announce that they are going to move to the VISTA system and any doc who sees Medicare patients wont be able to get their records or get reimbursed unless they use this FREE system. That way doctors dont have to take a huge financial risk to implement their EHR.
So why doesnt this happen? Its not because doctors hate EHRs, its because the private vendors are lobbying FURIOUSLY to prevent the govt from doing this. You see, if VISTA was adopted nationwide as the standard EHR, they would go out of business overnight. They will spend any amount of money in Washington DC to lobby to keep that from happening.
Its the same reason why there will never be a single payer socialized medical system in the US. Private insurance companies would go out of business overnight if this happened, and they will spend ANY amount of money lobbying in DC to stop it.
Posted by: joe blow | Jun 26, 2007 1:10:46 PM
It's a simple equation. The benefits are mostly public, but the costs are mostly private. In the UK, the government is spending something like $50B per year to update IT systems in their public healthcare system. Here, we expect private providers to do it at their own expense, without even a set of guidelines and standards to ensure that they are making the right investments. The US government department responsible for EHR implementation can barely get budget for its own staffing. A BU study recently showed that we're wasting 50 cents of every healthcare dollar on administration and inefficiency (nearly $1 Trillion per year). In the face of that, a $50B public investment in technology would seem like a no-brainer. Not in America, I guess.
Posted by: robsalk | Jun 26, 2007 1:11:52 PM
Ha ha, Michael says it's complex and I say it's simple. His points are very right, but maybe not clear to the general reader.
The old style doctor sees you for about 5 minutes, writes a prescription in longhand for you to carry to your pharmacy, and spends about a minute dictating a recording that will be transcribed and inserted in your chart by a medical transcription company. From the viewpoint of the old doctor, it can't get much better than that.
The new style doctor often must type in a progress note to your chart, enter a prescription, etc, which you can often see them doing at the terminal in the clinic room where you are seen. To do this they must be logged in on a secure terminal and navigate menus and forms, which is about as much fun as it sounds like.
And the benefits are modest if the doctor isn't part of a system. If the end product is for you to leave the clinic with a prescription, the doctor doesn't gain much by putting the Rx through a system that eventually prints the Rx for you, which still must have his signature.
Don't underrate doctors as businessmen. They had a system in which the medical practice was a gold mine, and for them, a lavishly appointed one that literally waited on them hand and foot. Most doctors learn how to be financially successful as fast as they learn how to be doctors, and that's pretty fast. They'll change (most of them) when the financial incentives change.
Posted by: serial catowner | Jun 26, 2007 1:15:16 PM
me2i81,
Jane did say Medicare-- fair enough. My point is that the regulations can be provided by government, even without the need to link to Medicare and/or single-payer. You need a license to practice medicine, there are a slew of regulations on top of that, and the government could just as easily regulate health IT as you suggest right now without using Medicare as the vehicle.
Posted by: wisewon | Jun 26, 2007 1:59:12 PM
joe blow,
We already have a very good FREE EHR called VISTA that the VA system uses.
Um--no. Or at least, I really doubt it.
The code may be free, but code isn't a software system. To have a good system, you need (at a minimum) documentation and a helpdesk. That's why Linux hasn't completely displaced Windows.
Posted by: SamChevre | Jun 26, 2007 2:27:12 PM
the government could just as easily regulate health IT as you suggest right now without using Medicare as the vehicle.
Sure, anything's possible if you've got the votes...I just don't see it happening in isolation. If Medicare or the future Health Plan of America mandated it, there's a compelling reason to do it, i.e. you could directly save huge amounts of taxpayer money by reducing administrative overhead. In isolation, it's just handwaving in the face of powerful interests and momentum.
Posted by: me2i81 | Jun 26, 2007 2:40:26 PM
The code may be free, but code isn't a software system. To have a good system, you need (at a minimum) documentation and a helpdesk. That's why Linux hasn't completely displaced Windows.
Right, building out the infrastructure of systems like that is a large, serious, expensive effort. I'd be nervous about mandating it right now, because the current administration is so clearly, um, compromised in the way it contracts and administers work. It would be a many-year effort to get such a system built, even starting with the work that the VA has done.
Posted by: me2i81 | Jun 26, 2007 2:44:45 PM
Sure, anything's possible if you've got the votes...
Completely agree-- I think politically, regulating the industry as I've suggested is a much easier sell than pushing for a single-payer system. (Are you watching the Republican debates?)
In other words, both substantively and politically, single-payer is a less preferred solution.
Posted by: wisewon | Jun 26, 2007 2:54:29 PM
To this day, I've never read a compelling explanation of why the nation's doctors and hospitals haven't broadly adopted electronic medical records.
Because sometimes an illustration made by a doctor in a chart would take a thousand words to enter into an EMR. Because once you have the file in your hand, all the associated image studies are there without having to pull up a jpg. Because it's easier to tell somebody is in a file they have no business looking at if it's in a filing cabinet rather than on the same computer screen everything else is on. Because it is easier to ensure the physical security of files on paper than on a computer that is connected to the internet. Because some analysts consider Windows to be inherently non-HIPAA compliant. Because paper is cheap when you don't account for buying tons of it over the course of the years. Because it would mean most medium sized doctors office would have to hire an IT guy. Because some doctors don't think technology should change how your practice. Because they are deathly afraid of spending a lot of money on an EMR that will be rendered obsolete by the next upgrade of their operating system. Because they are worried about how easy/difficult it is to revise a record after the fact. Because without handwriting, it is almost impossible to prove who made a specific entry in a courtroom -- after all, every system has a superuser mode, and some passwords aren't very secure.
There are lots of little reasons you will hear bandied about if you hang around doctors. No big ones, really.
Posted by: ShortWoman | Jun 26, 2007 5:16:27 PM
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