Thursday, May 30, 2013

Health IT – The Right Tool for the Wrong Job

Every article, discussion, blog post, comment and casual remark on the subject of Electronic Medical Records (EMR) and their prominent role in health care reform is never complete without stating that EMRs were designed for billing and hence are poorly suited to contribute to patient care. Most health IT apologists are either trying to refute these allegations or are pointing out to new products and paradigms that will be designed from the ground up for something other than billing. Let’s try a different approach.

To paraphrase Coach Green, EMRs are what we thought they were, and we shouldn’t let 'em off the hook! EMRs are designed for billing, and they should be designed for billing and as financial administrative tools, they are uniquely positioned to solve our health care problems, if properly utilized, because the health care crisis in this country is a financial crisis. It is a financial crisis at a national level and for too many people it is a financial crisis at a personal level.

The Meaningful Use program provides incentives to health care facilities and physicians to purchase and use EMRs, concentrating exclusively on the recording, exchange and management of clinical information. In its first proposed iteration, Meaningful Use included a couple of financial measures (i.e. electronic claims and eligibility checks), but those were dropped very quickly never to be seen again. So Meaningful Use EMRs are all about patient engagement, care coordination, clinical quality measures, safety, public health and population health. Meaningful Use EMRs are supposed to support, encourage and facilitate the current federal initiatives to promote care coordination, wellness, preventive care and patient participation in clinical decision making, all of which are presumed to counteract the rising of health care costs by reducing the volume of medical services. Two and a half years into the program, the discouraging evidence is beginning to surface.

The current issue of JAMA Internal Medicine includes an 8 years study of patient participation in decision making. It turns out that younger, whiter, more affluent and more educated patients prefer to be more engaged in medical decision making and that this participatory stance is creating longer hospital stays and higher overall costs. Hardly surprising to anyone but policy makers, who envisioned  selectively informed armies of consumers as the antidote to already wealthy, but still greedy, physicians who order all sorts of tests and procedures, with complete disregard for patients' well-being and for the sole purpose of further enriching themselves. Much of this thinking rests on the massive research coming from the Dartmouth Institute for Health Policy & Clinical Practice, which retrospectively examines Medicare's expenditures for people shortly before they die, and finds significant variations in spend across the country, which were subsequently attributed by Dr. Atul Gawande to geographic variations in doctors’ greed, and then classified as waste, and arbitrarily quantified as 30% of all expenditures, by Peter Orszag. A brand new research paper from the Center for Studying Health System Change, deals yet another heavy blow to the Dartmouth/Gawande/Orszag thesis, which has been criticized before, by finding that geographic variations in cost of care are mostly due to the simple fact that in some areas of the country, people are actually sicker. Shocking indeed, and even if (honestly) engaging patients in decision making could save money, there is no money to be saved. 

So if we come up empty on the patient engagement front, how about wellness and prevention? Meaningful Use EHRs are continuously modified to collect increasing amounts of structured clinical data, and required to have capabilities for exporting these important data points. The idea is to be able to conduct health risk assessments, evaluate population health, trigger preventive screenings and perhaps we can reduce the volume of medical services by simply keeping people healthy, or at the very least leave the door open to charging more money, or withholding services, from those whose illness (or lack of adherence) may be attributed to “lifestyle” choices. An exclusive article published by Reuters on May 24th, reports a brief sighting of a RAND Corporation report commissioned by the administration, as part of the health reform law, to examine the effectiveness of workplace wellness programs. The RAND report, which seems to have been delivered to the appropriate government agencies in the fall of 2012, found that these wellness programs save no money to employers and have no significant beneficial effects on employees’ health. Unfortunately, the RAND report is not available for anyone to read because “Reuters read the report when it was briefly posted online by RAND on Friday before being taken down because the federal agencies were not ready to release it”. Well, perhaps after today (May 29th) they will be ready, because the said federal agencies just released the final rules on employment-based wellness programs, to “ensure flexibility for employers”. So the hunt for more patient data from EMRs is on, and “health-contingent wellness programs” will be replacing health-contingent insurance premiums (a.k.a. preexisting conditions). Never mind that these “federal agencies” were appraised months ago that these programs don’t work.

In addition to contributing to these worthy endeavors, Meaningful Use EMRs were supposed to reduce duplication of tests, reduce medical errors, reduce disparities in care, facilitate clinical research, and a host of other great things that could reduce costs of health care, all of which are yet to materialize. Instead, the onerous and expensive requirements to collect structured clinical data are taking away time from direct patient care (decreasing quality of care), forcing small practices out of business (increasing costs of care) and generally speaking turning clinical documentation into “pure torment”. Should we just write off EMRs as useless nuisances and revert to paper? Not at all…

In a beautiful essay also in this month’s JAMA Internal Medicine, Dr. Robert S. Foote is calling on physicians to take responsibility for “the separation of the clinical record from the nonclinical uses to which it is increasingly being put”. Considering that those nonclinical uses are yielding no benefits whatsoever, we should all share in this responsibility. Let doctors take care of the clinical record and let health IT concentrate on what it was built for and what it does best. Last year, in another JAMA article, Dr. Berwick introduced a model that defined and estimated the various sources of unwarranted health care expenditures, two of which were administrative in nature, fraud and abuse, and administrative complexity, potentially amounting to over half a trillion of wasted dollars every year. EMRs, if you recall, were built for billing, so let’s unleash that particular power, instead of foolishly trying to convert them into something they cannot be at this point in time.

Administrative complexity is bogging down every physician in every office. Why do doctors need to credential with every insurer separately? Why do they need different “provider numbers” for each payer? Why should every claim undergo “payer edits”? Why should every eligibility request return answers in a different format? Why should every rejection of a claim have one of hundreds of different and unclear explanation codes? Why should “medical necessity” rules be different for every payer? Why does it take months to have your lockbox switched to another bank? Why should people have to spend hours on the phone trying to figure out what happened to their claims? Why can’t claims be adjudicated and electronically paid in real time? While bemoaning the lack of standardization of clinical vocabularies, how can we justify the abysmal lack of standardization of simple financial transactions? Do we really believe that that’s how banks and ATMs are working? Is this how electronic trades are made on our beloved Wall Street? Do we think that Walmart or Amazon would tolerate hundreds of millions of dollars in fraudulent charges from their suppliers? Do we know what systems they are using to prevent those abuses before they even happen?

These types of questions have been asked and answered in every computerized industry that health care is being compared to. Fiddling with esoteric clinical decision support algorithms when we can’t even invoice and pay our bills in a common format is beyond negligent. Devising ways to shift risk and expenses to unsuspecting citizens, by keeping taxpayer funded research results from the public, and by using novel interpretations of the English language to cover up true intent is borderline criminal. Health IT needs to wake up and understand that although billing and financial management software is not as sexy as software that practices medicine, standardizing and simplifying administrative tasks for physicians is where “fixing” health care can realistically occur. There will be no support for this effort from our "fee-for-service" government, but try to remember that every dollar you save on administration could translate into one extra minute a pediatrician can spend with a baby.

Addendum 5/30/2013: Right on schedule, the RAND report has now been released for publication - Link to Report


  1. THANK YOU! You expressed my sentiment perfectly, and with a lot more knowledge than I could ever bring to it.

  2. Very good article, Margalit. It's an interesting addition to my inquiry about technology in healthcare. Thank you very much.

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