A recent article published in the New England Journal of Medicine by Dr. David Blumenthal, newly appointed National Coordinator for Health Information Technology, has raised quite a stir. It clearly outlines the real intent of the major funding initiative placed in the new budget for health care, in particular for implementation of a “wired” health information system. This site has consistently applauded efforts to assist in the adoption and implementation of e-health systems to make better use of information. Many of the initiatives, time lines and incentives are outlined in the brief excerpt below (but in much greater detail in the article). There is much to commend, but equally much to raise major concern.
- The continued lack of basic uniformity in what data is really needed for effective care remains a major hurdle. These guidelines must be codified and continuously updated.
- The major cost associated with implementation of these systems nationwide. The current proposed incentives are below market costs and therefore unlikely to spur extended adoption.
- Who will determine what is what is a “certified EMR”? How will that determination be applied across the many specialities within the medical profession?
- Who will control use of the data and information within the system? If they are covered by HIPPA regulations, does that still mean the government may “mine” the data, not only for public health purposes, but for provider, or even patient profiling?
- Most worrisome of all, who will determine what is “meaningful use”? It would seem that the getting to the true intent of this final area is most troubling. If “meaningful use” is interpreted as adoption, implementation and integration within the system that will be one thing. If on the other hand, it is “double speak” for oversight of medical options, patient choices, medical opinions, medical decisions and medical judgments, then that is quite another thing.
- Perhaps the most chilling comment buried in Dr. Blumenthal musing is as follow: “That means taking advantage of embedded clinical decision supports that help physicians take better care of their patients.“ In other words, providers beware, you may well need to follow the embedded prompts and suggestions which will be built into the system or your profile may indicate that you are not providing quality care. This one comment sums up all the fears of seasoned physicians and surgeons. That medical training, experience and judgment will have to be surrendered to health policy determinations about what is and what is not appropriate care. The unprecedented amount of data collection that this project entails, could, if unchecked, potentially allow the federal government to use that data to mandate tests and treatments. Perhaps not directly, but by coercion via the monitoring and payment system. The resultant control will be the same.
- This fear needs to be addressed on the front end, not as an afterthought, if adoption of e-health systems is to become robust and fulfill it’s true potential for improvements in the health delivery system . . . obi jo
Stimulating the Adoption of Health Information TechnologyThe HIT components of the stimulus package — collectively labeled HITECH in the law — reflect a shared conviction among the fledgling Obama administration, the Congress, and many health care experts that electronic information systems are essential to improving the health and health care of Americans. However, proponents of HIT expansion face substantial problems. Few U.S. doctors or hospitals — perhaps 17% and 10%, respectively — have even basic EHRs, and there are significant barriers to their adoption and use: their substantial cost, the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers’ and physicians’ concerns about the privacy and security of electronic health information. HITECH addresses these obstacles head on, but huge challenges await efforts to implement the law and fulfill President Barack Obama’s promise that every American will have the benefit of an EHR by 2014.
Still, major hurdles remain. The infrastructure to support HIT adoption should be in place well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses. Meeting this deadline will be challenging. It takes time to develop and implement innovative federal programs, and it will take even more time to create the local institutions needed to support HIT implementation.
Second, much will depend on the federal government’s skill in defining two critical terms: “certified EHR” and “meaningful use.” That means taking advantage of embedded clinical decision supports that help physicians take better care of their patients.
N Engl J Med. 2009;360(15):1477–1479
GE Healthcare – http://www.gehealthcare.com/usen/about/commitment.html
Macy Foundation – http://www.macysinc.com/community/applicationprocess.aspx
HHS/HIT Home – http://www.hhs.gov/healthit
FOJP Service Corp – http://fojp.com/default.html
Partner’s Healthcare – http://www.partners.org
www.condron.us
HIT Adoption, Implementation, Control – Caution Ahead
ByObi Jo
Apr 15, 2009
[…] in the adoption and implementation of e-health systems to make better use of information.” Article Obi Jo, Real Health Reform, 15 April […]
“The unprecedented amount of data collection that this project entails, could, if unchecked, potentially allow the federal government to use that data to mandate tests and treatments. Perhaps not directly, but by coercion via the monitoring and payment system.”
I have been tracking your site for about a month or two since I stated doing my homework on health care reform. I’m only an old guy blogging in my retirement (food service career, not medical) and my medical background is limited to what the US Medical Service Corps taught me OJT forty-plus years ago.
That said, it seeme to me you spend a lot of time combing contemporary reports and opinion pieces looking for minutia impeding meaningful reform. Ours is a generation that witnessed the collapse of the Soviet Union as well as the Juggernaut of global capitalism. I think everyone is cognizant of the potential threat of Big Brother gone wild or the excesses and abuse that can come from too much control and command at the political AND PRIVATE business tops.
As I read the summary above, your highlighted quote was unmistakable. Oddly enough, it struck me as a strength rather than a weakness. Just as everyone in America can probably furnish anecdotal personal stories about substance abuse, mental health, or gambling addiction issues — either their own or someone close to them — my guess is that just as many can cite cases of people under the care of a hospital or physician getting worse or dying, not due to a bad judgment call but simply as the result of mixed signals, poor communication or lost information. I see nothing in our current “system” aimed at eliminating this problem. I put the word in scare quotes because the system now in place is no more systematic than urban sprawl is the same as urban planning.
Fear-mongering about unintended consequences leading to socialist or fascist extremes strikes me as too little, too late in the aftermath of Big Pharma and/or Big Insurance Gone Wild. As soon as that first flap about comparative outcomes research was conflated by someone in a Wall Street Journal piece into “rationing care for seniors” I suspected this was gonna be a tough, uphill journey past many political kickbacks and well-funded business interests to get anything done.
Please know that I’m tracking your site now not to learn anything new (Information is now flooding out) or in search of constructive suggestions, but to find out where the weakest chinks in the debate may be leading to defeating meaningful reform.
Thanks for the comment. Sorry you feel that we are in anyway obstructionist. Really feel you need to re-read our “plan” which by any fair measure is certainly not mainstream and certainly not something the current health insurance industry would necessarily choose to embrace. It is critical to point out these items of “minutia” because it is precisely these seemingly innocuous phrases which over the years have had unintended consequences. Clinical embeds and decision trees are nothing new in medicine. These types of systems have been used throughout most delivery systems in the US in one form or another. The beauty of real e-health reform is that these things, properly instituted, could indeed create the kind of communication, data retention, information sharing and the like that you seek. The caveat we have raised is a REAL one that could IMPEDE implementation. We have raised it not to impede but to warn so that these concerns can be addressed on the front end so as NOT to impede the progress of e-health initiatives. Hope you do keep reading, but think you can actually learn more here than you think. Thanks again for the comments . . . keep ’em coming.
Very thoughtful reply and thanks for that.
I took (another) look at your plan, which is presumably the link in the sidebar, and realized I came across it when I first added your blog to the aggregator. I very much like the ideas advanced there, but at this point they strike me as politically unrealistic. Two items in particular are guaranteed to raise a stink, increasing the minimum wage by two bucks and mandating universal participation. Now THAT comes across as Big Brother’s heavy hand far more harshly than helping physicians remember details that may have been forgotten or overlooked.
“Clinical embeds and decision trees” ? I never heard these terms before but they sound like helpful tools, not the edge of slippery slopes or camel noses under the tent. Maybe your concern that Dr. Blumenthal’s quote “sums up all the fears of seasoned physicians and surgeons” is what made me misread your words. A more constructive approach might be to allay those fears instead of underscoring them.
I heard poor Peter Orszag this morning in an interview dancing as fast as he could to put spin and sugar answering every question the interviewer brought up, because any meaningful reform will mean fewer procedures and prescriptions. That hard, cold reality is a tough sell to a public accustomed to pleading with the doctor “My (fill in your favorite relative here) is dying! Do everything you can to save him!” Never mind that places other than Mayo are also getting better outcomes for less money. Neither doctors not in those loops nor sick patients and their families want to hear any of that.
Doctors, meantime, are having a hard time swallowing the notion that the less they do the less they make. With revenue trumping outcomes, what else can we expect?
Congress and the Senate will savage whatever goes into the grinder bad enough without those of us pushing for change as hard as we can throwing stones at each other. And Orszag’s ticking bomb is still under wraps. If you think health care reform is a hard sell, wait til we get to the Diamond-Orszag plan to tinker with Social Security.
http://www.brookings.edu/views/papers/orszag/200504security.pdf
Thanks and back at ya! It is true that some of the ideas outlined in “the plan” would be highly controversial and likely not make the final cut. That is ok, as we are aiming for different goals in the short term. Open access to health coverage to end health insurance discrimination. Issues of finance, as you point out, are very complex and are being addressed in an ongoing fashion. Changes will have to be made if the system is to evolve (read the most recent post just made today). As for the Social Security referral (thanks for the link!), read it, and agree it will be a hard sell. However, will have to leave the Social Security debate to another blog (if time permits!) . . . thanks again for the comments and staying tuned to us!