Why wonks should read physician written blogs

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Category : Medical Rants

Obviously this post is a bit self-serving. However, it does involve some first guessing, rather than second guessing.

Talk to practicing physicians and these two concepts really drive them crazy. (There are others, but today I am just focusing on these two).

Performance measurement has grated on our nerves for a long time. This blog and many others have screamed about the flaws in the concept. We have pointed out the problems repeatedly. Finally the “leaders’ are seeing the light.

Experts in quality improvement developed an important paper for the RWJ (I blogged about this on June 6) – Achieving the Potential of Health Care Performance Measures In that paper the authors point out many of the flaws that bloggers have noted for many years. Our concerns now are getting serious attention.

Now in the Annals of Internal Medicine, Koppel writes “Demanding Utility From Health Information Technology

Their results suggest that EHRs currently fail to meet the anticipated goals, an observation that is particularly disheartening when one recognizes that the study population likely reflects the views of more enthusiastic EHR users.

Duh!

They had to do a study. They could have read many blogs and suspected the same thing. Koppel finished his commentary:

In light of these findings, addressing health information technology’s Tower of Babel will require redirection of our focus on data standards and integration. The U.S. government pays approximately 52% of all health care dollars, which can provide robust motivation for such refocusing. Regulators already have authority to demand data standards and interoperability. Ideally, vendors will cooperate. Current policy puts faith in market processes, incremental changes, and regulatory hints to achieve data standards, interoperability, and usability. DesRoches and colleagues reveal that such faith is chimerical. The necessity to improve care and reduce costs is too compelling to allow the current chaos to continue. This study shows that if EHRs are to fulfill their promise, we must shift from cheering health information technology implementations to demanding health information technology utility.

The wonks should talk to some real physicians to get an idea about unintended consequences. The good physicians who see patients daily understand practice very well. Why don’t the beltway boys listen to them?

Comments (4)

” Why don’t the beltway boys listen to them?” When you don’t understand something and it does not make sense to you, follow the money. It makes sense to someone.

Maybe, just maybe, the whole concept of Electronic Health Records is wrong. Maybe there is no good way to have the type of information a general practitioner in rural Montana uses is transferable to the surgical record of a transplant patient in Manhattan. Because they are incompatible purposes.

Maybe the best thing to do is go back to written doctors’ notes and nurses notes, a medical record (not a health record) which can be scanned and faxed, and use the computer for the things it’s proven for- medications, labs, electronic images and things like discharge summaries. A sort of hybrid system. After all writing down a patient’s information by hand seemed to work for 200 or so years. A well-known doctor asks publicly does anyone want to go back to the old system and assumes no one does. but if you modify the question slightly and ask if anyone wants to go back to the best parts of the old system and use only new modifications I suspect most experienced doctors would.

Now I say that because I know it won’t happen for two good reasons, which come back to the point of this blog.
First, newer users and younger people don’t know any other way and expect Electronic Health Records because that what they have been indoctrinated with. They wouldn’t know how to use a hybrid system (go ahead- ask for a pencil on the wards these days). Second, and more importantly, making the patient’s information understandable and accessible is not the real primary purpose of the Electronic Health Record – it’s to facilitate billing, reimbursement and monitoring of healthcare workers. That’s why it makes sense to someone as weakanddizzy put it (and I suspect the EHR has rendered him by his moniker).
And its why we can’t put the genie back in the bottle. Somewhere along the line we got co-opted and sold a bill of goods. And we bought it. Now we have buyer’s remorse -and there isn’t much to do about it.

As a former “wonk” I wholeheartedly agree.

In defense of the boys in the back room, I remember one occasion a senior VP told us to do a certain minor project – and specifically told us not to go to the affected department, he wanted to present it as a “TA-DA” surprise showing what could be done for them. Nor were our own suggestions acceptable. Even we could predict what followed – it was never used by the people for whom it was supposed to be a marvelous thing, yet we continued to use computer time and resources on it for a couple of years.

What I find troubling is that we have done all of this before, Ronald Reagan laid the foundation and Bill Clinton then build a very good welfare reform movement that did much to improve people’s lives and reduce cost. A large part of this was improving child support, eliminating the ability to move across state lines to avoid payment and coming up with an economic model that was fair to all involved, most importantly children.

The basis for all of this was a computer project called SETS. Knowing the American public would not allow the Federal government to have a file on half of the population, and with the money involved, state politicians would not allow the project to move ahead without their involvement, this was done on a state by state basis.

The results were predictable, with a vendor in our state who was already doing all of the major urban centers, being pushed out in favor of a politically favored vendor. Vendors with multi-state contracts divided the work among each group and then billed each state for all of the hours spent.

My attorney wife was told specifically they did not want her involved since she “would ruin their deal,” at one point she had no assigned duties and people were told she had left the department. After much pressure she was given a small module to complete, the vendor brought in a cell phone tower programmer to work on this big iron project telling him she was disruptive.

Quickly he discovered the truth and she learned enough about coding to guide him and his team to complete the technical aspects of the project while she, having been responsible for state wide training, developed and trained all of the staff so that they brought the project in on time and under budget, going live with no problems. They both were criticized; he left the area telling her he had never seen such a mess.

Today the Feds still reimburse 60% of a state’s child support expenses. Administrative process and DNA has cut out the majority of court cases, so the whole process is focused on computer systems and Federal dollars. Policy and program have no place in this brave new world.

The parallels to medicine are striking. Computers make the diagnosis, sets the time for treatment, and then very neatly bill the system. Vendors fight to keep their systems from interacting while always selling maintenance and upgrades. Politicians dangle the contracts as a means to gain contributions and support.

Like child support, doctors will be pushed out of the system with the major focus becoming the computer, not on treatment or the people whose lives are at stake. This will happen because “everybody knows” computer are a better way.

Steve Lucas

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