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By Emily Friedman. First published in Hospitals & Health Networks Daily on April 2, 2013
The pressure on hospitals, clinics, systems, physicians and other providers to get wired is profound. There are federal incentives and penalties, payer demands for quality data, and many other requirements. Yet some providers — especially physicians — are still resisting digitization. Why? And should we be taking their concerns more seriously?
My desktop computer crashed the other day — again. Had to buy a new one, which came fully equipped with the Operating System from Hell, a torture device within which everything is hidden (including the on/off command) and nothing is what it seems. I have spent hours just trying to learn how to do things that used to take five minutes. Don't even ask about its approach to managing photos, which I must do all the time. The experience has led me to postpone getting a new phone; I can only take so much technological torment at one time. Even the computer tech I finally had to call in said, "This system was designed for phones and gamers, not for business." Then why are PC computer manufacturers required to use it? And why did it reject my printer drivers? And why … . Oh, never mind.
All this is to say that I really understand change resistance. I am not opposed to change, heaven knows — I can't imagine living without the Internet, cellphones, computers, microwave ovens, turn signals and many other goodies that became available during my time on this earth. I would, however, prefer that the learning curve not be as steep as Mount Everest, nor as pockmarked with crevasses.
But there is more than simple change resistance underlying provider — especially physician — foot-dragging when it comes to e-prescribing, adoption of electronic medical and health records, and acceptance of other health information technologies. It doesn't even seem to matter that the non-adopters are swimming upstream in the face of countless powerful incentives.
Among these incentives is all that federal money being dangled in front of those who adopt e-prescribing and electronic health records and meet standards for meaningful use; pressure from private and public payers for electronic billing; constantly increasing requirements for reporting of data on quality to a variety of entities; growing payer and patient unrest with prescription errors; increased visibility for the serious problem of rogue prescribers, who often prey on addicts (and sometimes create them); and providers' need to reduce costs wherever possible in the face of payment cuts (real or imagined).
There certainly has been a widespread response. According to America's Health Insurance Plans, in 2002, 44 percent of claims were filed electronically; by 2011, 94 percent were. The Office of the National Coordinator for Health Information Technology reported last year that in 2008, 13.4 percent of non-federal acute hospitals had adopted at least a basic electronic health or medical record system; by 2011, 34.8 percent had done so. This varied greatly by state; in 2011, the highest adoption rates were in Florida, Hawaii and Virginia, whereas the lowest rates were in Montana, Oklahoma and South Dakota. Earlier this year, Level 3 Communications surveyed 100 health care CIOs and 56 percent reported that their organizations had fully implemented electronic health records, 33 percent were just starting to implement them and 11 percent were still considering the idea.
The ONC also reports that by 2012, 80 percent of physicians had computerized provider order entry systems, at least for medications, and 73 percent were engaged in e-prescribing. However, fewer than half had adopted digital approaches to clinical decision support and measurement of clinical quality.
A 2011 survey by the Centers for Disease Control found that 55 percent of physicians had adopted EHRs, but the rates were all over the map for specific situations. Not surprisingly, younger physicians were more likely to adopt; medical groups were as well — the larger the group, the more likely the adoption. Only 29 percent of solo practitioners had installed EHR technology.
And it wasn't always a happy choice — 40 percent of providers surveyed by CompTIA in 2012 reported that the implementation experience was worse than expected; only 27 percent found it better than they had feared.
I saw a fully wired system in 2011 when I visited Singapore, and it was alluring indeed — everything in one place; available to providers, payers and patients; and easily sent to where the patient was. Fully backed up, of course, and pretty much impervious to power failures. It was quite a contrast to what I and most other patients must endure when we go for outpatient tests or procedures: providing the same personal data, the same ID, the same insurance information, over and over and over again. And I can't help but get increasingly nervous when I see the piles and piles of paper files in physicians' offices, vulnerable to everything from fire to theft of patient information.
So I will borrow the title of Joni Mitchell's famous song and say that I have looked at (health IT) life from both sides now, and I think there are valid arguments on both.
What are those arguments, and do they hold water?
Let's take the numerous opposition voices first. As RAND researchers Arthur Kellermann and Spencer Jones wrote in the January 2013 Health Affairs, "Considering the theoretical benefits of health IT, it is remarkable how few fans it has among health care professionals."
Lack of ease of use. The CompTIA survey found that 58 percent of respondents' No. 1 wish was that these systems be easier to use and less complicated.
I understand this, not only from my own experiences, but also from what physicians tell me. They're busy, this stuff is a hassle and they often don't see the long-term financial benefits. It also doesn't help that many of those who advocate use of these systems deal in computerspeak and unintelligible learning approaches. If one were paranoid, one could believe that they do it on purpose, to retain turf and power. Here's an example from the ONC, illustrating hospitals' strides toward meeting meaningful use requirements. It looks like a horoscope to me.
Requiring busy people who might be technologically challenged to clamber up a steep learning curve is asking a lot, in or out of health care. And I remain cynical about developers' interest in making this stuff any more user-friendly; after all, an entire industry of techs and Geek Squads and such has arisen, and become successful, explaining this technology to its hapless victims. And the geeks often are employed by the people who sell it to the rest of us. Symbiosis is alive and well.
Cost. There's a reason solo practitioners are the least likely among physicians to adopt EHRs, and I don't think it's because they are a bunch of old fuddy-duddies. (I know a number of old fuddy-duddies who work in medical groups or are employed by hospitals.) These systems aren't cheap, and, as more than one physician I know has found out to his or her sorrow, there are vendors who are more than willing to sell unsuspecting physicians systems that are not only expensive and difficult to use, but that also make meeting meaningful use qualification difficult, if not downright impossible.
With the huge potential Medicare physician pay cut constantly hanging over their heads, practice costs rising, Medicaid fees being cut by states yet again, and a variety of other fiscal challenges staring them in the face, many physicians — especially primary care providers and those in lower-paid specialties — have to think hard about how they can pay for electronic systems, unless the hospitals with whom they are affiliated, or somebody, is willing to help defray the cost. Yes, there is federal money available, but it has a lot of strings attached — and it won't last forever.
Interoperability. I was visiting a physician friend who belongs to a decent-sized, single-specialty practice, and I overheard one of his colleagues asking a staff member to fax a patient's medical records over to one of the practice's other locations. This is a pretty high-tech outfit, so I raised an eyebrow and gently asked whether they were considering going digital (like so many other practices, they have thousands of paper records stored in plain view in the front office area).
My friend's first reaction, which I have seen before, was to roll his eyes and start reciting the litany: cost, difficulty of use, learning curve. I mentioned that they were soon going to be penalized by Medicare for non-adoption, and he smiled and admitted that they were in the process, but it sure was hard to get 15 specialists and several dozen staff to agree on anything. He said an added layer of complication was that they are affiliated with several hospitals, and those hospitals are not on the same system, so interoperability is a huge factor in the decision. (No one was shocked that this issue was front and center at the annual conference in March of nonprofit health IT organization HIMSS.)
I was reminded of a friend's experience when she was a patient of a health care system known to be very wired indeed. She lamented that her personal information could zip around that system safely and conveniently, but when she was referred to an outside hospital, its system couldn't talk to her provider's system. It is a story being told throughout health care, and it makes me wonder about the coming demands of administrative simplicity and health information exchanges and the like.
As Kellermann and Jones also wrote in the January 2013 issue of Health Affairs, "The health IT systems that currently dominate the market are not designed to talk to each other … . The lack of progress on interoperability is so stark that it has led some to speculate that major health IT vendors are opposed to interoperability." Well, duh, gentlemen; of course they are! That's on Page 1 of the Bill Gates-Steve Jobs playbook: Make everything proprietary, so everyone has to buy your stuff and not the other guy's.
Risk of erroneous information. I was having a minor outpatient procedure and was getting pretty woozy from the anesthesia when my physician decided to bring up our ongoing debate over whether he should go digital. I know he is intrigued by the idea, and I think he would be happy in a group practice that had EHRs, but in his present setting, he's still in the Paper Age. As I was entering LoopyLand, he said, "If an error is introduced, it will be in the electronic record forever!" I responded before I conked out, "But it will stay in a paper record forever, too — and it's harder to correct."
Still, his point has some validity. One of the dangers of having these records available to so many people is that a slip of the finger is more likely. I don't think that's a huge issue when it comes to medications, because the systems tend to have redundant safety features, but there is always the chance that a test result, a biopsy finding or some other key piece of information can be incorrectly entered, or not entered, with serious or even tragic results.
The human factor is always there. I picked up a prescription the other day and brought it home, only to find that they had given me the drugs for someone with a similar name. As it happened, no harm done; the drugs did not resemble each other at all. But what if both had been liquids, or pills, and what if the other patient was vision-impaired or demented? I returned the medications and read the pharmacist the riot act, and he admitted, "This is among the most serious errors a pharmacy can make." And all the digitization in the world would not have prevented it.
On the other hand, I believe electronic systems will — sooner rather than later — have even stronger built-in safety features, including intuitive ones, so that if a piece of information appears to be off the wall, alarms will sound.
After all, it's important to remember that these systems are supposed to help providers, not hinder or replace them — although that distinction is sometimes lost on certain elements of the health care enterprise.
Privacy. This is a biggie, and perhaps the greatest vulnerability of electronic systems. Yes, the data can be (and should be, and must be) encrypted, access should not be available to everyone in the organization, and the penalties for violation of patient privacy should be just as strong as those for employees who peek into paper records. As far as I'm concerned, it should be a no-strikes situation: You snoop, you're fired.
But electronic records make it so much easier to peek into them or get careless — and that is compounded by the brain-free behavior of too many people who have access to them. I mean, what doofus takes an organization's laptop, with hundreds or thousands of patients' files on it (unencrypted, of course) and leaves it in the back seat of an unlocked car? Can anybody here spell identity theft? Or the thumb drives containing sensitive private patient information that get lost, or any of the hundreds of other idiotic examples of health care folk playing fast and loose with sensitive data?
How about the heavily wired organization that contracted with a small vendor to store and scan 300,000 patient records, only to find that those records were being stashed all over the man's house and even in his car trunk?
The federal government reports that the personal medical information of some 21 million patients has been put at risk since 2009, and much of that information was being kept digitally.
Yet, the Health Information and Management Systems Society reported earlier this year that although 7 percent of health care organizations formally evaluate risks to the confidentiality of patient information every six months, 64 percent do it annually, 25 percent do it every two years and 4 percent do it at some other interval (if at all). Hey, folks, hackers are usually into a new Microsoft product in a matter of hours; biennial risk evaluation just won't do.
And if providers needed a push, on Jan. 17 this year, Health & Human Services issued the privacy rule required by the Patient Protection and Affordable Care Act, which builds upon the HIPAA protections of 2003. Although the jury is still out, we can hope that these new requirements will, in the words of HHS Secretary Kathleen Sebelius, "help protect patient privacy and safeguard patients' health information in an ever-expanding digital age."
But we have a long way to go before most physicians, and most patients, really trust computers to keep their secrets.
Clinical autonomy. Physicians don't talk about this a whole lot, but some have told me that this is a real worry for them. Having every move you make tracked is more than a bit unsettling, and some of these systems, clinically speaking, achieve something close to that. Physicians who believe (however much or little it is honored in practice) that the patient comes first, that doctors must be patient advocates, and that physicians must retain their clinical autonomy to achieve those two goals are often not exactly thrilled with being reduced to so much performance data.
Part of this, to be sure, is a new version of the "medicine is an art" argument, which I think is less and less persuasive in the era of evidence-based medicine and scientific quality improvement. There's a lot of room between allowing physicians to do whatever they want, even if it's dead wrong and produces poor outcomes, and reducing the sovereign profession of medicine to a lockstep checklist.
But, as we have seen with employment of physicians by hospitals, our system would be well-advised to remember that physicians train long and hard to do their work well and, when informed by evidence and experience, they can take care of patients much better than hospital executives or insurance actuaries can.
The fight will go on, but, in my opinion, in the end most physicians will join the fold, and most of the rest will retire or go do something else. But in the back of my mind, I am troubled by the words of Scot Silverstein, M.D. — a physician and professor of health care informatics — who has described the rapid adoption of EHRs as "a mania," and has warned that risks are being ignored. In response, George Lundberg, M.D., former editor of the Journal of the American Medical Association and an early advocate of digital health care, says, "It's too easy for those of us in medicine to get excessively enthusiastic about things that look like they're going to work out really well. Sometimes we go too far and don't see the downside."
But there are also powerful arguments in favor of universal adoption of electronic records and other health IT systems.
It's the law. This is not to say that because it's the law, it's a good thing — especially when it comes to the ACA, which remains controversial. But that's not the only law in play. There's the HITECH Act, which was embedded in the economic stimulus law, state statutes and requirements that might as well be law, from Joint Commission standards to demands from payers.
We are all aware of laws we're not crazy about — the Internal Revenue Code comes to mind, especially this time of year — but in the end, most of us comply with them. And I think those who continue to whine and jump up and down and scream and refuse to accept that health care record-keeping has entered the digital age for good are not doing anyone any favors. They — and the rest of us — would be served far better if they would examine the challenges, which I tried to elucidate earlier in this article, and sought to remedy them, so that the "mania" Dr. Silverstein warns us about does not envelop health care and leave us with a great big mess to clean up down the line.
Fighting against a fait accompli is the most useless of rear-guard actions.
Savings. Like everything from pill splitters to hospice, health IT has been sold as a big money-saver. Indeed, in 2005, RAND Corp. researchers predicted that it could save $81 billion a year if fully implemented; that has not been realized, for reasons ranging from the slow pace of full adoption to lack of interoperability to provider resistance to maximizing IT's potential.
But the savings are there to be had, from reducing the ridiculous amount of labor used to create and maintain paper records (and to transfer the information around) to the inherent efficiencies of streamlined billing and reporting. If, in an interoperable IT world, providers could deal with one billing form, one set of reporting standards and one panel of quality data, they could save a ton of money.
That is not even to mention what could be saved — not only in terms of dollars, but also in terms of human suffering and foregone litigation — by having errors in treatment identified earlier, or obviated completely.
In every sector of society, the adoption of digital technology has produced greater efficiencies, higher productivity and lower expenditures, whether that technology has taken the form of auto-building robots or computerized tax returns. There is no reason to believe that it won't happen in health care as well — and that the savings will increase as adoption accelerates. Let's just hope those savings are put to good use.
Improved quality. Patient safety and improved quality have become international holy grails in health care, pursued in almost every country by provider and payer alike. Yet, the United States continues to lag behind other nations in many key categories. Explanations are constantly put forth — different demographics, too many uninsured, a profoundly pluralistic system and so on — but a good part of the problem is that in many instances, we still don't know what's going on with patient care. We still prescribe and provide wrong medications, or wrong dosages of the right medications, sometimes with devastating results. Despite near-heroic efforts in most hospitals to promote hand washing (I sometimes think the next step will be to hire people to run after employees, waving bottles of Purell), infection still spreads because of lack of hygiene. Reusable items are not cleaned or stored properly; sometimes disposable items are reused.
And the human factor raises its familiar head again: Physicians, nurses, techs or others who aren't keeping up with the latest knowledge, or who are overtired, or are overworked get sloppy.
Health IT can remedy much — not all, but much — of this, by identifying suspicious patterns, double-checking medication activity, reminding clinicians of proper procedure and nudging patients to stick with their regimens. Mistakes can be caught in their infancy, and potential harm never reaches the patient.
These would be worthy goals even if money were not being saved; as it is, this is a win-win just waiting to happen.
And a side benefit would be a lessening of the blame game and the damage it does. As the groundbreaking Institute of Medicine report, "To Err Is Human: Building a Safer Health System", pointed out in 1999, quality problems lie with systems, not individuals. And it will take systems to solve them, preferably without the heads of clinicians and employees being paraded around on pikes.
Catching bad guys. There are some heads, however, that would look very nice on pikes, methinks. They belong to the fraudsters, rogue prescribers and serial killers who lurk in health care, often undetected for years. What health IT systems can do — and are doing — to unmask these people and get them out of our field is nothing short of spectacular. HHS, in conjunction with the Department of Justice, has reclaimed billions of dollars lost to Medicare and Medicaid fraud; some states have met with equal or greater success (the attorney general of New York state, Eric Schneiderman, is catching both perpetrators of Medicaid fraud and peddlers of illegal narcotics with impressive regularity).
Had there been full implementation of systems that can detect suspicious mortality patterns linked to specific providers, could physician serial killer Michael Swango have gotten away with murdering as many as 200 people, usually with drugs, before he was apprehended? If we had health IT to monitor all infection rates and clusters, could the fentanyl-addicted radiology tech David Kwiatkowski have succeeded in stealing narcotics and tainting syringes with Hepatitis C in 19 different hospitals? If it took a matter of days to detect that some rogue physician in Kentucky was writing 100 prescriptions for oxycodone daily, wouldn't that be better than having it take six months?
However one feels about health IT, this is an unassailable argument for its use in the interest of patient safety.
Patient empowerment. Providers, I suspect, are more enthusiastic about this idea in theory than in practice, especially with the fear of malpractice litigation always hovering about. However, almost everyone knows that the era of the passive, compliant, "Yes, Doctor, anything you say" patient is over. Engaging patients in use of health IT means more than allowing them access to their medical records (which they still find difficult in many situations, and that is really inappropriate in this day and age). It also means involving them in their own care, helping them look at their own patterns, assisting diabetics in tracking their A1C levels, empowering stroke patients with voice-assisted technology, and a host of other ways of assisting people in protecting their own health.
I don't believe in having a do-it-yourself health care system — I'm not a trained clinician and have no desire to usurp those who are — but anything that aids patients in being more confident about their ability to help themselves is a good thing in my book. With all the (justifiable) worries about shortages of primary care physicians and nurses, the probability of millions of new patients entering the system courtesy of ACA next year (many of them with serious acute or chronic disease) and the difficulty of access that many Medicare and even more Medicaid patients are experiencing, a health care system that partners with patients is not a nicety — it's an imperative. And electronic systems can play, and are already playing, a big role in making it happen.
All in all, even if it weren't pretty much a done deal, I think health IT is a major improvement over how we traditionally did things. I still remember one health care job I had long ago. It consisted of taking piles of lab report slips and running all over the hospital, pasting them into patient charts — some of which were so voluminous that I doubt a physician could have looked at linear comparability of the data, even if he were masochistic enough to try. It was a far cry from my physician's saying, "I have your last five sets of test results here on the screen," or the ability of radiologists to compare digital mammograms over time. I think health IT is a boon to clinical quality, efficiency of record-keeping, reduction of costs, and preventing provider staffers from pulling their hair out over redundant, conflicting and incomprehensible billing requirements.
Will it produce nirvana? Of course not. And there are legitimate obstacles that strike understandable fear in the hearts of many: how hard some of this stuff is to use, the lack of interoperability (whether that came about through design or accident) and the persistent bugaboo of violations of privacy, among others. And even though I believe that they are overstated, I understand physician fears about "cookbook medicine" and data mining, and all providers' worries about IT making it easier for the patient's bar to cook up lawsuits. (With regard to the latter, however, good electronic record-keeping also can reduce frivolous litigation.)
And there will still be the pharmacy tech who hands over some other patient's meds, and the hospital employee who just won't wash her hands, and the change-resistant physician who still wants to get away with "my way or the highway" medicine. And Dr. Silverstein may well be right, that EHR adoption is a mania that will overtake us before we have resolved some basic issues.
But it wouldn't be the first time. After all, Microsoft detects problems with its software offerings by releasing them, half-baked, to an unsuspecting public, then providing back-end "patches" and "service packs" once it is obvious that a six-year-old with a can opener can hack into the thing.
I'm still excited about the potential for health IT systems, and I hope that those who are not can get over it and help usher in this new era.
You'll have to excuse me now. The dysfunctional operating system on my new desktop just burped and sent 23 copies of the same large email to a client, who is afraid I'm going to crash his system. Looks like another long night.
Copyright © 2013 by Emily Friedman. All rights reserved.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
First published in Hospitals & Health Networks Daily on April 2, 2013
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