Monday, September 23, 2013

Why Doctors Will Never Ever Like EMRs and How to Change That

EMRs are not designed for patient care. Is there anyone working in health IT who can honestly say that he or she never heard this statement being made hundreds or thousands of times? Is there any clinician actually working with patients and EMRs who can state that such thought never crossed his or her mind? This includes health IT evangelists and physicians spearheading IT initiatives at the most excellent of centers of excellence. People complained that EMRs are not designed for patient care seven years ago, when the first EMR certification body was created. They said the same thing four years ago when billions of dollars were made available for the purchase of EMRs. They kept insisting even as use of EMRs was becoming widespread two years ago, and the chorus remains unchanged today: EMRs are not designed for patient care.

Seven years is an eternity in the world of computer technology. Seven years ago Motorola and Blackberry ruled the world and the iPhone was getting ready to be born. Seven years ago something called Twttr was released and Facebook launched a high-school version of itself. Seven years ago Ken Jennings was undisputed king of Jeopardy and IBM’s Watson was wrong 85% of the time. We’ve come a long way, baby, but EMRs are still not designed for patient care. Why is that? The most common explanation is that EMRs were designed for billing and cannot be changed. But if a program designed to play Jeopardy can be expanded to practice medicine, surely seven years is more than enough to refocus EMRs on something other than billing. The second most common reason given for the inadequacy of EMRs is the inadequacy of those who build them; because we all know that all great programmers work at Apple, unless of course, they work at Twitter or IBM or somewhere in Verona, Wisconsin. More seriously, the third explanation for EMRs failure to help with patient care is the onslaught of government regulations for EMR design.

Many, including yours truly, are arguing that EMR vendors are so busy meeting regulatory mandates that there are no resources available to make customers happy. On second thought though, are we saying that giants like GE that owns half the planet, or McKesson with its astronomic CEO compensation, or that one place in Verona, are unable to spring a few bucks for half a dozen developers to make EMRs better for patient care? Are we saying that a market chockfull of very wealthy customers railing for a solution cannot attract even one manufacturer willing to solve the problem and collect billions of dollars in return? Surely we are not saying that seven years is not enough time for writing an EMR that is designed for patient care. On September 12, 1962, President John F. Kennedy, in a speech at Rice University, officially launched the race to the moon. On July 20, 1969, Neil Armstrong and Buzz Aldrin walked on the moon. It took seven years.

EMRs are not designed for patient care because our medical system is no longer designed for patient care. Our medical system is being redesigned to provide health services to consumers, and EMRs are morphing into superb tools for a service industry.
  • EMRs are designed to collect increasingly detailed customer information.
  • EMRs are designed to facilitate market research.
  • EMRs are designed to standardize and automate transactional complexity.
  • EMRs are designed to smooth handoffs across the supply chain.
  • EMRs are designed to orchestrate and monitor production lines.
  • EMRs are designed to minimize production costs and maximize revenues.
  • EMRs are designed to provide quality assurance based on exact specifications.
  • EMRs are designed to prevent and quickly detect malfunction and non-compliance with specifications.
To be clear, most EMRs can’t do all these things just yet, but they are being redesigned along these lines, because these new EMRs are foundational to what David Cutler, a Harvard Applied Economics Professor and one of the most influential health care policy makers, calls the “information technology revolution”. In a surprisingly candid article Prof. Cutler is describing the future health care system as designed by him and his distinguished colleagues, and as currently implemented by our government. The title of his article is self-explanatory: “Why Medicine Will Be More Like Walmart”. It is very possible that as EMRs are being carefully repurposed, they will also be made more intuitive, more iPhone like, glossier, faster, more colorful, and generally more appealing, because it is imperative right now that physicians use them consistently, and preferably without much turmoil. Why? Let’s hear from Prof. Cutler: “The introduction of information technology into the core operations of hospitals and doctors’ offices is likely to make health care much more like the retail sector or financial services. Health care will be provided by big institutions, in a more standardized fashion, with less overall cost, but less of a personal touch”. And, if I may respectfully add, increased convenience and instant consumer gratification to be balanced by lower quality, lower wages, rampant fraud and mass exploitation of both workers and customers. A veritable paradise for well-adjusted proletariat.

Yes, physicians will be using EMRs in larger and larger numbers, but there is zero probability that today’s doctors will ever like using EMRs, because nobody goes to medical school (or any school) hoping one day to land a job at a Walmart lookalike. So the logical remedy for doctors’ dislike of emerging Walmart EMRs is very simple: get rid of doctors. Right now we are told that there is a looming shortage of physicians, so we must find ways to deliver medical services without doctors, and hence we must automate, computerize and delegate medical care. Very clever idea, because once we downgrade services and have people accept this new paradigm, we can make the circular argument that we need even fewer doctors. Indeed Prof. Cutler goes on to prophesize the demise of small independent practice and small hospitals along with most conventional doctoring, which will be replaced by computer-aided self-diagnosis and crowd sourced clinical advice (something to do with Amazon, I think…). He still sees a need for a few doctors here and there, mainly “to direct patients to the right specialized resources, to reassure those in need, and to comfort the terminally ill”, which we are told “is a noble calling nonetheless”.  Noble calling indeed, but it should not require an MD or fifteen years of preparation, and hence it will not command much attention or compensation. The Walmart “doctors” in David Cutler’s future of health care will be happy to like their EMRs, or whatever else they are told to like.

Oh, by the way, no need for panic... I am fairly certain that they will have separate little venues serving Dom Perignon and Beluga caviar with Harvard Medical School educated physicians on the side.

Monday, September 9, 2013

The Passion of the Health Care Fixer

The first President to take a shot at fixing health care was a Bull Moose trying to become President one more time. Unfortunately Teddy Roosevelt failed to win those elections and instead of providing “protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance”, America took the low road leading to the Great Depression. Fixing health care was on the minds of all subsequent occupants of the White House, from FDR to Barack Obama, to varying degrees, but as America’s circumstances and character evolved over many decades, so did the understanding of why and how health care should be fixed.

For Franklin D. Roosevelt[t]he right to adequate medical care and the opportunity to achieve and enjoy good health” were part of a second Bill of Rights to provide security at home for all Americans. It was a lofty attempt to “assure us equality in the pursuit of happiness".  FDR failed to implement his progressive fix for health care, and Harry Truman although even more passionate than his predecessor, achieved little in his own health care fixing attempts. It fell to Lyndon B. Johnson, a southern democrat, to create Medicare and Medicaid, taking the first step towards Truman’s vision of a “national system of payment for medical care”. Although much tinkering and heated rhetoric followed, the second step was never taken. Until now.

As our President expanded Medicaid to include a larger fraction of the growing masses of poor people, and created federal subsidies for unofficially poor people to purchase the now mandatory health insurance, an army of experts at everything from Toyota manufacturing systems to silicon chips design are professing their passion for fixing health care. But the passion of today’s health care fixers is different. When Harry Truman spoke of health care, he spoke of those who “suffer needlessly from the lack of proper medical care”. And FDR spoke of the dangers of being content when “some fraction of our people—whether it be one-third or one-fifth or one-tenth- is ill-fed, ill-clothed, ill housed, and insecure”.  John F. Kennedy spoke of “working men and women” subjected to the indignity of “being forced to beg for help from public charity once they are old and ill”.

Today, we speak of the imperative to cut health care expenditures and the need to balance budgets and reduce deficits. Our sympathies are with employers who are contributing too much towards workers’ health care, and we argue that freeloaders must be prevented from getting health care at our expense, and that the poor must be diverted from seeking care at expensive medical venues. The passion of contemporary health care fixers is not about human pain and suffering. It’s not about humiliation and social injustice. It’s not about preserving freedom and democracy or pursuing happiness. It’s not about the people at all. It’s about money.
It was a late evening sports injury resulting in a swollen ankle in fifty shades of purple. After nipping the ER idea in the bud, and dutifully waiting until the next morning, I made a same-day appointment with a reputable orthopedic practice and a doctor we never met before. There was no waiting and the sweet and friendly nurse breezed through all the meaningful use nonsense, which was not pertinent to this visit in any way, and then she and her laptop left the room. The doctor walked in thirty seconds later, with no laptop, no chart and nothing else in his hands. Soft spoken and businesslike, he examined the ankle, ordered the obligatory x-rays, walked out and several minutes later walked back in telling us that nothing is broken, but we’ll be getting a boot to help the healing process, and then walked out again. Exactly what I expected from a specialty visit. But then something strange happened. The nurse could not find a proper Ace bandage and while she was fumbling in the hallway, the doctor walked back in, pulled a little package from some drawer, sat down on the low stool and slowly and methodically bandaged the swollen ankle, making small talk about bandages always being the wrong size. So here was this distinguished orthopedic surgeon, specializing in knee and hip replacements, wrapping an elastic bandage around a little girl’s mildly sprained ankle. He was definitely not practicing at the top of his license, and neither was his nurse, and during those 30 seconds of pure waste, the aloof stranger became my daughter’s doctor. She would keep the boot on although it looked yucky, and she would make an effort to put weight on that foot, and she’ll come back in two weeks to see him, and the doc was smiling faintly as he was leaning against the door before we left.
If FDR had his way, fixing health care would extend the best health care in the world to all people “regardless of station, race, or creed”. If we have our way, and we will, this type of health care will cease to exist for most Americans, because there is no ROI for highly trained surgeons to tend to children’s falls and bruises, unless of course the child happens to live in the ruler’s palace, or Bel-Air, or Alpine NJ. Fixing health care today means learning from India or Nepal, or any random third world country mired in corruption or despotism. Fixing health care means spread of innovation where people who can barely afford breakfast dispense medical advice from mobile vans parked on street corners to those who are immobile in many ways, while calculating the exact dollar amounts of savings realized by such bold innovation. And fixing health care means cool technology.

Technology of the type recommended to fix health care is manufactured for pennies a day, by children existing in those countries we are supposed to learn from; children who were not lucky enough to be born in the greatest country in the world. Harnessing the wonders of technology to fix health care means giving all poor people a shiny blue button to click on, so they can see how well the mobile van driver cared for them, and perhaps share the information with the next mobile van that will be tending to their needs. I can’t begin to tell you how distraught my daughter was when realizing, that unlike the 60,000 former soldiers residing on park benches across the country, she had no blue button to click on. There were no open-notes for us to peruse the next day, and neither the doctor nor his team of people searching for Ace bandages, made any attempts at partnering with us, and we were not empowered to choose wisely. Nobody suggested that the follow up visit be with some “other care giver”, or be conducted electronically from the comfort of our home. I guess, my daughter’s orthopedic surgeon is not a passionate health care fixer, so he forgot to flip his clinic.

But more than anything else, today’s highly educated health care fixers are passionate about knowledge, because you cannot cut costs of things you don’t know about. Imagine how much more effective caring for a sprained ankle could be if I only knew exactly what the surgeon got paid for all the knee and hip replacements he performed last year, not to mention the ability to have a list of every prescription he wrote, every test he ordered and every pharmaceutical bagel he ate since the sun began shining. They used to say that knowledge is power, but in our fixed health care, knowledge is also money, and lots of it. As Robert Henley, 1st Earl of Northington and the Lord Chancellor of Great Britain observed in 1762, and as Franklin Delano Roosevelt, the President of the United States of America reiterated in 1945, “[n]ecessitous men are not free men". Since both “necessitous” and “free” are now relative terms, thus open to personal interpretation, perhaps it is unfair to criticize the abundantly necessitous passion of health care fixers yearning to be free. I therefore preemptively apologize.

Wednesday, September 4, 2013

Alternative Health Information Technology

Say you are a pediatrician in an average middle class lily white suburb and most of your little patients are either sitting stiffly in the pews next to you or are elevating your spirits with angelic voices clad in white robes on a blessed Sunday morning. Say little Johnny trips on his way down the altar and ends up taking a ride to the ER to have his forehead stitched. Does the ER doc need to know that the 13 year old altar boy is not a smoker? Does he need to know that Grandpa Joe died from prostate cancer, but other than that the family history is unremarkable? Does the nurse washing Johnny’s forehead need to be informed that the boy has a history of ear infections and had tubes put in when he was 3 years old? Not a fair example, right? Let’s cross the 8 Mile road and look at another Johnny who shows up at the other ER at 2 am with two gunshot wounds to the chest. Does anybody on his care team gives a damn about Mom suffering from depression and diabetes, or the fact that Johnny is a current smoker of tobacco products and has been counseled on cessation? Yes, I know, sometimes these things are pertinent, and sometimes even more details are needed, but not always, and not always the same details. Unfortunately, we are busy building a one-size-fits-all-circumstances infrastructure, which is destined to be too big for most, too small for some and ill-fitting for all but a random handful.

Leaving aside the troubled business side of medicine, electronic medical records are supposed to ease and simplify the capture, analysis and sharing of clinical information, by utilizing computer software tools. Computers have eased and simplified the capture, analysis and sharing of financial information, supply chain information, manufacturing information, transportation information, and every other type of industrial information you can think of, so why not medical information? Before you go pointing out that clinical information is highly variable and so very unique to the individual, please consider that computers have simplified and eased capture, analysis and sharing of personal information of all sorts from chatting and accessorizing outfits, to making friends and asking a pretty girl out on a date. Surely, nothing is more unique and personal than finding your soul mate. Not even health care.

If a physician practicing medicine in the U.S. today desires to ease and simplify the capture, analysis and sharing of clinical information, he or she can choose from a large assortment of computer software tools, better known as EHRs, all carefully examined and certified by government sanctioned entities to be capable of easing and simplifying these tasks, and as Pete Seeger might have said, “there's a green one and a pink one and a blue one and a yellow one, and they're all made out of ticky tacky and they all look just the same”. To the dismay of regulatory and certifying authorities, most physicians who are willy nilly adopting these tools, under threat of financial fines and penalties, continue to grumble that the capture, analysis and sharing of clinical information is neither eased nor simplified by EHRs, and quite the opposite is true.

This strange situation can be, and often is, dismissed as due to physicians being technophobes or just unwilling to do their share in promoting beneficial health reforms. To support these specious arguments, the regulators are constantly parading a handful of doctors who found happiness and efficiency in their EHRs. Unexplainable? Not really. There are always a few lucky folks for whom one-size tee shirts fit as perfectly as if the rag was tailored just for them, while the rest of us have to tuck it in, tie it in the back, cut it off, or pull at the sides to make it stretch, and in all cases it ends up looking like someone else’s garment. A quick look at what is driving health care costs up reveals that physicians as a group are cheerfully adopting things like magnetic resonance, computed tomography, image guided radiation, proton beam therapy, laser surgery, robotic this or that, and a host of other high tech tools that would terrify the average technophobe into crawling under the first available rock. So why is health information technology so different? Or is it?
  • epocrates, the drug reference software boasts 50% of physicians in the U.S. as its users. epocrates has been steadily growing since 1998 and is practically a household name when it comes to medications advice. It is available on iPhones, iPads and mobile Android devices and it has expanded far beyond just lists of indications and contraindications for prescription drugs.
  • UpToDate needs no introduction either. The widely used electronic clinical decision support system has been in existence for over 20 years and you would be hard pressed to find an academic institution that is not subscribing to its content and tools, both in the U.S. and the rest of the world. Like epocrates, UpToDate is available on the web and on all fashionable mobile devices.
  • Doximity is a relatively new kid on the block, and a very interesting one to boot. Only 3 years old and already claiming to have “crossed the 200,000 member milestone”. Doximity is a communications platform for physicians allowing members to securely exchange messages, including clinical information, and make referrals or obtain ad-hoc consultations from colleagues. Sort of like a social network on steroids, and of course it is available on mobile phones and tablets too.
epocrates never bothered to obtain Meaningful Use certification for its main product, because what it does and what clinicians find useful is not a certifiable activity. It did however certify its feeble attempt at creating yet another ticky tacky EMR, and then proceeded to quickly dump the resulting stillborn. UpToDate obtained certification only for its peripheral patient education module, and Doximity is nowhere around the target zone of what the government decrees as meaningful use of technology. While both epocrates and UpToDate had ample time to solidify their user base before the advent of Meaningful Use, Doximity experienced its meteoric rise in spite of Meaningful Use and that should give us some hope that any day now, a couple of MIT grads in some basement may launch Patximity and make information sharing between doctors and patients as simple and as easy as apple pie. We can imagine that somewhere far from the limelight a doctor laboring in solitude will come up with the simple and easy to use Charximity to effortlessly capture thought processes at the point of care. And then someone will come up with something better or different or faster or smarter or cheaper…

Sadly, this crescendo of innovation is very unlikely though, because unless the new software is a clone of some primordial EMR, or parts thereof, and unless it conforms to government devised ways of doing things, most prospective customers will be forced to choose between a new and unknown product and the piles of cash thrown at them by regulators. If say, our imaginary Charximity developers come up with a quick and elegant way to record a dynamically defined set of information, and package it in a small, nimble and universal format that lends itself to being securely moved around the private networks of the fabled Patximity and real Doximity, in a most expedient way, chances are great that this cool innovation will fail to thrive because it can’t inform regulators on Johnny’s smoking status or Grandpa Joe’s prostate trouble, in an exhaustive XML format passed around through interminable chains of certified intermediaries on the federally secured national health information network. The good news is that one day checkboxes and dropdown lists will only exist at the Smithsonian, and good technology will prevail in the end. The bad news is that the end is being pushed further and further away with each additional Meaningful Use stage.