Dr. One

Dr. One has his own practice and is the sole physician in that practice.  He strides into the room with his new laptop balanced precariously on his L arm my chart in his right hand.  It was awkward for him but he finally got settled.  The other thing that was very noticeable was that  he had this microphone hanging from his tie which looked out of place.  He sits down, hits a few keys and announces we are ready.  “Hello” he announces, “I have this new medical record system” so bear with me since I am trying to figure out how it works.  We start to talk a bit.  He stops me and types a few things into the computer.  “I’m sorry” he announces-”Go ahead-you were telling me about the nights you don’t sleep well”.   On and on this goes, i.e. the starting and stopping, as we cover symptoms, medications, and what needs to be done.  Talk, stop, talk, stop, it is irritating that he is mainly concentrating on the computer.   He now has much less eye contact with me.  I sort of feel like the odd man out-so to speak. 

When we have finished our review and he made his recommendations, he stops again without saying a word to me, plugs his microphone into the computer and begins….”The patient is displaying signs of having………..”  He dictates the notes from our meeting and when he finishes he stands up and says his nurse will be back with instructions.   With that he stands up re-cradles the laptop on his L arm, grabs my chart with his R. hand and clumsily slips out the door.  It all seemed very painful to him.  To me, the tool got in the middle of the patient doctor relationship rather than helping it.  But then again, I cut him some slack since it was a new system for him. 

The followup visit about two months later was much the same as the first visit, only the paper chart was gone and the attention to the computer was just slightly diminished.  Progress. 

Dr.  Two

Dr. Two is a member of a treatment team within a large University setting.  I am signaled that something is new by the pretty balloons at the front desk.  “Looks like someone had a birthday!” I declare.  “On no” says the receptionist, “we just went on-line with our new Electronic Medical Records”.  “How do you like it?” I ask.  “It really good she replies, it is so much better than paper charts.  But I do need your picture ID and insurance card so I can scan them into the new system” she declares.  She goes on without prompts “But we are still going to keep the paper charts around even though everything has been scanned into the computer”. 

I think to myself, never hurts to be safe although I personally don’t practice safe scanning, i.e. the policy of keeping papers around for awhile just in case something went wrong with the scan.  I scan everything into my computer and promptly shred the original.  My line of thinking is, if you are going digital, go digital, don’t mess around with halfway measures.  But then again, I am not a big University. 

Dr. Two come into the room and greets me with his usual friendly greeting, we are friends as a result of the painful hours we spent together trying to unwrap the mystery that is my health condition.  I always sit at the foot of the examining table, he sits next to the examining table but facing me, and my wife sits across the room from us.  She is there to remember what is said since I seem unable to accurately recall what I heard just two hours ago.  It is an affliction that I understand is common to most men but in my case at least, short term memory loss is a verifyable part of my disease. 

But this time things are different- the little data entry station that held the monitor, keyboard, and processor would not swivel far enough for the doctor to turn around and look at me!  Oops, someone forgot to check with the doctors before installing the data entry station facing a wall.  He asks if I would mind sitting by my wife since he can more comfortably turn to see me that way.  This was my first clue that this was not going to be a model demonstration. 

Pardon me for failing to mention the redshirts.  These were IT staff people who hang around each department to help it get used to the new way of doing things.  They are noticeable by their bright red shirts, their clipboards, and their general techie appearance.  They lurk in the hallways waiting for a nurse or doctor to have a mental or technical breakdown.  “How long are they in each department?” I ask.   Two to three weeks depending on how many physician’s and staff there were to train.  Cha Ching, that’s gotta cost big time. 

My doctor friend is a young guy- maybe just 30 but already has landed a full time appointment at a Center of Excellence department in a major university.  So he is about as bright as they come, a quality I recognized in him early on in our relationship and part of the reason I asked if he would oversee my care.  He is no dummy.  He struggles out loud with the categories for data entry-what do they mean?  He mumbles to himself, then out loud.  The drop down menus for the IDC code that he is required to enter does not contain my disease.  What to do?  He calls for a redshirt.  There is no drop down menu to help him locate two of my medications’ names.  He calls for a redshirt.  He does a good job of keeping the dialogue regarding my health issues going while he types into the computer.  It is clear he is from a different generation than Doctor One.  But still, the appointment is interrupted 3 times by the need to bring in a redshirt to answer questions. 

“Is it going to be good” I ask, “you know, when you get it all mastered?”  He shakes his head negatively but doesn’t explain and we don’t have the time then to get into it, he has a whole day of patients already backing up and an even younger resident tagging along that day. 

When we finished the appointment he asks me to hold on.  He leaves and comes back with a copy of the notes he took during the appointment as well as a renewal Rx.  The printed document was nice, but it was printed, and on a system that will likely be seen only by other physicians at the university, not by others who treat me.  I will feel better when he makes his entries into my own personal EMR that is universally accesasable by anyone to whom I grant permission.  But for now, I leave the appointment as I always do with this person, feeling that he has given me the very best medical care he can give. 

Isn’t that the real point of it all?

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. 

 Babylonian Lessons: Healthy Information Technology and The ARRA

There has been a lot of attention in the media recently regarding the passage of the ARRA stimulus plan in regards to two major cost items, Health Information Technology (HIT) and Comparative Effectiveness Research (CER) 

The Senate Finance Committee released for public use a number of Qs & A’s which were inadequate to deal with these issues. Those who simply brush off the very real problem of the government overseeing the development and implementation of HIT is a gross error in my opinion. So lets’ look at the HIT issue first and deal with Comparative Effectiveness Research in a separate commentary. 

There is a lesson in the Old Testament in regards to the building of the tower of Babel. In so much as God was angry with the people of Babylonia, he caused them all to speak different languages during the building of their monument. Consequently the tower couldn’t be built. Confusion and disarray resulted from the language mess.  A poor analogy to today’s HIT status, but in many ways, not that far off. 

CONFLICTING PRIORITIES

Today’s equivalent are the many technologies and more specifically, programs that make up HIT. Each provider of HIT uses a proprietary system, so a perfectly workable program for a chain of 15 hospitals may not be compatible with the Center for Medicare/Medicaid Services CMS for billing purposes, or with physicians’ offices for the exchange of critical patient information. Everyone is on their own system. There are conflicting proprietary interests and billions of dollars at stake. Everyone thinks they have the best answer. Everyone is speaking a different language and using different computer systems in their own worlds.

The result, according to authors Carol Diamond and Clay Shirky writing in Health Affairs in the August 18th 2008 issue…Health Information Technology…A few years of magical thinking..is that health planners must stop the magical thinking that HIT is going to improve health care.  There is simply no evidence to support that by pouring Billions of dollars into this field the US will save any money, let alone improve care.

REFORM HEALTH CARE FIRST

What seems like an intuitively good idea, i.e. computerizing records and data, is only part of the solution to our health care problems. What is needed of course is a major reform in the way health care is delivered and how it is financed. Simply working on IT does nothing to solve the underlying problems with our health care system.

One of the most critical errors made by many is that they seem willing to accept that the government as a perfectly harmless entity to carry out the mission of building and implementing HIT.  Nothing could be further from the truth.  What if the government developed the Internet?  Would it be as free and open as it is today?  I am sure politicians would have figured out a way to put a fee on each e-mail or web visit as is often the subject of unsubstantiated web folk lore.

OPEN SOURCE SOFTWARE

The HIT system that we do need and can benefit from must come from private enterprise working on open source software that is free to all wish to use it.  The second consideration must involve control of key standards by a non-profit board comprised of HIT specialists, physicians, hospitals, the pharmacy industry, government representatives, and most importantly, CONSUMERS.  Consumers should be the focus of the entire system and have complete ownership and control of all their Electronic Medical Records (EMR) or what is often referred to as Personal Health Information or PHI.  Without the strictest of systems built by a non-governmental agency, people will be reluctant to engage new government sponsored technologies that post and track personal information.

The nature of a government designed HIT system seem clearly nothing more than a method to pursue ownership of the entire health care delivery and payment system.  Once the Federal Government has forced all the medical providers into their system of HIT, it is only a matter of time before they will control what doctors and hospitals do, or put more clearly, they will control what health care you and I receive.

I hope that those who support the Obama administrations’ incursion into this arena  will step back from the precipice on this issue and get into the problems that are related to health care first such as how to serve more people at a lower cost, how to keep access to health care open and fluid, and how to keep Americans covered by the private insurance plan of their choice.

Kirby V. Nielsen, M.A. CLU

Delaware, Ohio

knielsen@insight.rr.com