Babylonian Lessons Part 2 April 8, 2009

Posted by kirby8047 in HIT-Health Information Technology.
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HEALTH INFORMATION TECHNOLOGY: NO PLACE FOR UNCLE SAM

Perhaps the greatest difference between those in favor of the insertion of money into the ARRA for government run HIT and those of us that don’t see a thing wrong with what is happening in the Health IT domain.  It is currently struggling to find its core values and then its core program language.  With time, the proper HIT solutions will be implemented.  There are many who are saying on the other hand that this is the rightful domain of the Federal Government and that private enterprise has fiddled around long enough. 

 HURRY UP AND SPEND

The context of the HIT debate, centers partly on how it was brought about.  I see it as being jammed into a pork laden spending bill.  Along with CE, it was put in with little or no debate.  If HIT and CE were studied on their own merits, they would likely never have been funded at the astronomical levels they received.  Like so many other parts of the stimulus bill that really didn’t involve stimulus spending, it was an all or nothing offer on the part of Democrats and the President.  They conceded issues only to the extent that they could get the three needed votes.  This made a lot of people angry right from the start, it is hardly the Obama promised “new way of doing things in Washington”.

 CONSERVATIVE IDEALS

The second context is that HIT and CE are issues that might best be handled by organizations who have more expertise in this area.  For the National Association of Health Underwriters to advocate for something because it sounds good or has some face validity is the wrong reason to support the issue.  I hope to show here that the HIT issue is a can of worms with little hope of having positive outcome as a result the ARRA.  I realize that who represent health insurance agents inside the beltway must realize that the majority of the membership is probably more conservative than what is popular inside the beltway.  Many of us see a country deep in the financial hole and would not support the notion that spending for spending sake is the way to get out of this financial crisis.

 HIT SAVES MONEY AND REDUCES MEDICAL ERRORS

There are many things right with HIT but there is a great many problems as well.  I searched the internet and found a large number of articles that were both supportive as well as critical of HIT.  Let me begin by focusing in on two articles I found on Health Affairs (1) (2).  Both articles question to some extent, the overly optimistic opinions that HIT will make for better health care and will save us money.  There has been a growing body of evidence that HIT not only does not save money, it does not necessarily reduce errors.  In fact, one study showed that medical errors increased using HIT.  Although all the things often bantered about as HIT positives are potential benefits of a properly implemented HIT program, we are years away from that ever happening. 

1. The group Connecting for Health presented evidence to the Office of the National Coordinator for Health Information Technology (A body that is supposed to make HIT standards) and the Certification Commission for Health Information Technology (the body that is supposed to certify that the standards have been met) that three years of work has resulted in none as in 0 standards being met. 
2. Another report by the Merkle Foundation suggested that there were no clear goals in HIT.  Nor were there were “incentives to implement HIT”.  The point being perhaps that although there are potential savings, the cost of implementation is too high. 
3. Sidrov (1) reported that using Electronic Health Records (EHR) increased cost and that there was no indication that it would ever save money.  She also reported that documentation time increased by 17% in facilities that implemented HIT.  Those that implemented Computerized Physician Order Entry (CPOE) saw a 98% in documentation time.  Even more critical in physicians’ offices that implemented EMR’s there was no decrease in staffing after implementing EMR’s.  The time that was saved by having EMR’s was offset by the staff inputting into the EHR’s. 
4. The Agency of Healthcare Research and Quality (AHRQ) does support the idea of HIT measures but does not list HIT as EHR’s as a way to increase safety or reduce errors. 
5. The United States has already spent $900,000,000 on all of the above via money appropriated in 2004.  The purpose of that money was to prove that HIT could work.  Obviously, it has failed to ensure its widespread adoption. 

 

PRIVACY AND DATA SECURITY

I am concerned about those who setting aside concerns about “big brother” having access to our personal health information.  I am sorry to hear that many people can set aside these concerns so quickly.  Apparently they are a big fans and supporter of my “Big Brother” but I do not trust him or like him.  Nor do I like or trust Microsoft and Google or Intel.  I love them all, don’t get me wrong, they provide me with the best place in the world to live and give me magnificent products and services, but I do not trust them.  I do trust my wife, my children, and God and that is about all.  My point is that liberals often run right past the very issue that concerns everyone the most “trust”.  It is wise to stop and consider one of the very most basic concerns people have before spending a few Billion or Trillion dollars on HIT.

 

Speaking of privacy, ARRA’s expansion of HIPAA privacy regulations ARRA did receive good comments from two consumer based watchdog groups.  They were the Electronic Privacy Information Center (EPIC) (3) and the Patient Privacy Rights (4) group.  Notwithstanding these endorsements it is interesting to note the following facts (5). 

Since 2003:

1.       There have been 35,000 HIPAA violations reported to CMS

 

2.       There have been zero as in none civil fine. 

 

3.       Approximately 200 cases were referred to the Department of Justice of which the status is unknown. 

Which leads us to the simple question of whether or not, HIPAA privacy standards are worth the millions of tons of paper they have been printed on?  The best of regulations mean zero if there is not enforcement.  This is not necessarily good news if you are asking people to “Trust Uncle Sam”. 

 

Or, how about the secret military files that recently showed up on a MP3 player?  Maybe the company that was taking 83,000 Johns Hopkins Hospital patient files to storage but instead left them on the loading dock of a flower company could explain how our electronic medical records are safe.  Finally, closer to home here in Ohio, we had a college intern student instructed to take the backup tape of files of 500,000 Ohioans (which included their name, address, Social Security numbers, and DOB) home with him.  He threw the tape in the back seat of his car from where it was stolen.  I believe we taxpayers got a $10,000,000 bill for that mistake.  I don’t think I need to go on although I could.  Security is not necessarily assured whether you are with the government or a private enterprise.  These things are a big concern to many of us.

 

THE FUTURE IS BRIGHT FOR HIT

I am one of the biggest advocates of HIT.  But as you can tell, not such a big fan of Government run HIT.  I believe in all of the positive outcomes as a result of implementing a sound HIT policy.  However, I believe that there are some principles that need to apply before we can reach HIT Nirvana:

1. The first principal is that HIT must implemented in conjunction with a reform of the health care delivery system.  The key is that the system must be reformed before HIT can produce the results we all desire.
2.  The second is that there must be clear goals for what HIT is to do and what information it is to provide.  Questions such as what do we want out of it are critical.  In one article I read, the author bemoans the fact that 4 medical doctors stood at the doorway of a patients’ room talking about the patient.  Not one of them referred to the information in their computer.  To this person, the conversation was not documented, the decisions were not based on empirical evidence, and therefore the HIT implementation had failed.  Apparently, this person’s goal is to replace talking to each other with a digital medium.  To me, 4 MD’s talking about a patient’s health care is a miracle in this day and age.  It is people being people, doctors using their minds instead of being robots directed by some computer “best practices” flow chart.  My point is if we want techs to do MD’s work then go to the hilt on HIT and live or die literally by “best practices”.  But if we want doctors to do doctors work, we should build the HIT to support the physician, not replace the physician or make more work. 
3. The third is that the goals in HIT should be measurable.  Like “best practices” in medicine, it will be important to monitor what digital tools work and which ones don’t. 
4. The fourth is that the machine language or computer software must be open source in both senses, i.e. in terms of the operating language as well as implementation programming.  This does not replace private enterprise but is developed by private companies seeking profits and efficiencies around which to build better digital tools. 
5. The fifth is that HIT should be consumer centered, not institutional or physician centered.  EHR’s should be completely owned by individuals who then grant access to the records to physicians, hospitals, or other care providers.  Each provider is welcome to keep what they need in their files, but all treatments, medications, and other medical information must be placed in the individuals’ EHR.  This is the only way to streamline the system down to a workable level.  It is also the only way to guarantee the privacy of the each individual’s EHR. . 

 Kirby V. Nielsen

Delaware, Ohio

knielsen@insight.com

 

(1) Health Affairs, Joan Sidrov Market Watch “It Ain’t Necessarily So..EHR and the unlikely prospect of saving money”.  Volume 25 Number 4

(2) Health Affairs Carol C Diammond and Clay Shirky Web Exclusive “HIT: A few Years of Magical Thinking”

(3) www.epic.org

(4)Patient Privacy Rights http://www.patientprivacyrights.org

(5) Wall Street Journal 08.08

(6) CNN http://edition.cnn.com/2009/TECH/01/27/confidential.mp3.player/

 

OTHER REFERENCES:

www.openehr.org for information on a group of people developing open source HIT.

www.eheathinitiative.org has a list of studies and other efforts to demonstrate the effectiveness of HIT.

http://www.health2blog.com Health 2.0 is a rapidly growing group of corporations and individuals interested in developing bottom up technologies that support consumer friendly services.  Many believe Health 2.0 like its cousin Web 2.0 is the future of health care delivery in America. 

https://openhie.projects.openhealthtools.org is another organization working on open source programs for HIT

http://www.connectingforhealth.org/decisionmakers/index.html An excellent site sponsored by the Markle Foundation.  Resources and planning information for HIT.