The Machinery Behind Health-Care Reform

This weekend, The Washington Post published an investigative report entitled “The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records.” The reporter, Robert O’Harrow Jr., clearly hit a nerve when he exposed the origins of the EHR funding portion of the Economic Stimulus Bill—The Washington Post received so many comments that it had to stop accepting responses! I am sharing my comments here, along with the original article.

Dear Mr. O’Harrow:

Thank you for exposing the behind-the-scenes efforts that led to the creation and funding of the Economic Stimulus Plan’s EHR incentives program. Industry insiders have long-recognized these inherent conflicts of interest, but have been reluctant to make them public.

It is important to understand that the situation is being perpetuated—the people now charged with developing the specific regulations regarding how the money is to be dispersed and the standards which will determine to whom it will be given are the very same stakeholders who were behind the legislation. One has only to listen to the recent “meaningful use” hearing in Washington and look at the appointments to the HIT Policy and Standards Committees for evidence.

First, to clarify your premise—it is not the entire industry that lobbied. It is the traditional EMR vendors who are positioning themselves to receive the benefits. Only the big, CCHIT companies have been invited to the table to be part of the conversation in any significant way other than through very limited opportunities for public comment. No vendors of alternative technologies, i.e., non-CCHIT-certified products, have been given any formal role, regardless of their successful adoption rates and greater physician satisfaction.

It is no wonder that CCHIT is the presumed set of standards which will be used to qualify EMR software for Stimulus Plan payments. The legislation was rushed through with such a short timetable for implementation that it is hard to dispute the conclusion that there is no time to develop new standards. The HIT Policy and Standards Committees are predisposed to CCHIT—the vendor community representatives on each committee are from large, CCHIT companies, and at least one committee member is a CCHIT commissioner. It does not seem to be of concern that these EMRs are the very ones that have experienced miserable adoption track records, (see Landmark EMR Studies), particularly among specialists, nor that evidence does not exist to show that CCHIT certification has improved this adoption record.

In an effort to push the implementation along, the interests of high-performance, private-practice physicians are not represented in the process. There are no full-time, private-practicing physicians on the Standards Committee, who can appreciate first-hand the impact the wrong EMR can have on a provider. The seven physician members spend most, if not all, of their time in informatics-focused positions at their respective institutions. Furthermore, the needs of non-primary care physicians are being ignored. By virtue of its composition, the Committee will focus on primary care—of the physicians on the Committee, five are internal medicine-certified, one is a pathologist, and the vendor representative trained as a neurologist. For primary care physicians, CCHIT-type software may be more usable than it is for specialists.

In the era of transparency, it is important that all of these issues be understood and then addressed before the enormous sums of money are dispersed with limited potential to achieve the desired outcomes.

3 Responses to “The Machinery Behind Health-Care Reform”

  1. Mary Stroupe May 22, 2009

    Mr. Steele, While I certainly have compassion for your position, the fact remains that systems such as yours that rely on scanned images cannot talk to other healthcare data systems in any meaningful way. Thus, while it is undoubtedly true that an individual physician may have an easier time with scanning paper and the like than implmenting a truly electronic medical record, if any records need to be shared with anyone else, the best it can get is either printing the scanned images or faxing or emailing them. No opportunity to SHARE data without re-entry by the second provider, or paper storage is possible. All this re-entry, inability to read paper records, etc., costs MASSIVE amounts to the healthcare system as a whole, although the costs are spread out among many physician practices vs. concentrated.

    The other factor you fail to take into account is learning curve. While it is undoubtedly true that there have been major failures implementing EMRs, the failures (a) are NOT LIMITED TO CCHIT-certified products and (b) have as much to do with physician reluctance to adopt the technology as anything else. People do not like change. My own experience with EMR implementations (about 20 of them, but not in a research study) is this: (a) if the practice is owned by a physician who has a financial stake in the outcome, the implementation typically succeeds; (b),
    if the docs practice ahead of Go Live, they typically love the system ~ although it depends on the system and its friendliness, of course, its ability to be tailored, etc.) and (c) the young physicians who have used EMRs from the beginning or since near the beginning of their careers, are quick to adapt.

    Your arguments, while equally self-interested as the big CCHIT companies, do not take into account that any change of this magnitude in ANY industry takes years and years to accomplish. In an industry that is 1/6 our GNP, as you point out, I think it’s absurd to expect that all attempts at innovation will be successful. Your facts may be correct (EMR implementations have met with widespread failure) but the CONTEXT in which you interpret the facts is extremely narrow and self-interested. Anyone who has spent any serious time in the health records field knows better.

  2. Hi Mary:

    Thank you for your blog comments.

    First let me clarify your misconception regarding the SRS hybrid EMR—it is not merely a scanning system, but rather a physician-driven EMR that does not reduce productivity. The fact that we have not chosen to construct our EMR around CCHIT criteria does not mean that our product is not an EMR. The SRS hybrid EMR has many areas of optional data entry, data management, and interoperability—including ePrescribing, PQRI management, treatment recommendations/decision support, discrete data-based problems and procedure lists, and databased lab values. Our clients have successfully shared data with RHIOs, etc.

    When I write about EMR implementation challenges, I’m referring to the high-performance, high-volume physicians where CCHIT-type EMRs have had a dismal track record—particularly in the larger, physician-owned, non-academic group practices. Many in the industry talk about EMR successes, but the body of research does not support the financial benefits to physicians of traditional, point-and-click data entry EMRs. There have been many landmark studies that conclude that traditional EMRs cause financial harm to physicians, but I have yet to find just ONE landmark study performed by a venerable institution that is non-vendor funded that concludes otherwise (if you find one, please forward it to me).

    There are certainly physicians that have worked their way up the learning curve and implemented traditional EMRs—but these tend to be primary-care practices where productivity losses stemming from EMR use are not as magnified as they are in the high-performance segment of the market. They remain, however, the vast minority.

    I believe it is naïve to expect that a class of products (i.e., traditional, data-entry EMR)—that has an unproven and unsubstantiated track record of success in addition to returning no financial benefit to physicians—will be implementable on a nationwide scale. The interoperability and sharing of data is still far from a realistic capability of even CCHIT-certified EMRs. These are the facts that form the basis of my skepticism.

  3. AndrewBoldman June 4, 2009

    Hi, good post. I have been wondering about this issue, so thanks for posting. I’ll definitely be coming back to your site.

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