In 2009 the administration’s
stimulus package put aside $19 billion dollars in the first two years and an
extra $50 billion dollars over the next five years to stimulate and subsidize
the adoption of Electronic Medical Records (EMR) to further development of
Health Information Technology (HIT).
must do their part by reengineering care processes to take full advantage of
efficiencies offered by health IT, in the context of redesigned payment models
that favor value over volume.”
In the meantime annual health care expenditures in the United
States have grown by $800 billion.
The new RAND study blamed the underperformance on several
“Including: sluggish adoption of HIT systems, along with
balky systems that are hard to use and aren't interoperable; and a failure by
providers and hospitals to adjust care processes to better benefit from
The RAND corporation is looking at the EMR problem
from 30,000 feet. On the ground many private practices and hospital systems had
previously installed information systems that cost them dearly and eroded those
providers’ net revenue.
Money is the main
impediment especially when reimbursement for physicians and hospital systems is
decreasing. Presently, physician groups and hospital systems are struggling to
remain solvent. This is partly from decreased reimbursement and partly from the
cost of ineffective non-functional information systems.
A new capital expenditure
of $65,000 dollars per physicians and $200 to $500 million dollars for hospital
systems is unrealistic even with the government’s partial subsidy. The cost
increases when maintenance fees are added.
Many hospitals simply do not have the capital
to buy systems that can cost $20 million to $200 million, especially when so
many are struggling to remain solvent. Hospitals also worry about high
maintenance costs, an uncertain payoff on their investment, a lack of staff
with adequate technical expertise and resistance from doctors.
In 2009 only 1.5 percent of
3000 hospitals had a comprehensive and fully functional electronic medical records
system “ comply with meaningful use criteria.”
The meaning of meaningful
use is all major clinical units in a hospital must perform 24 functions deemed
important by a panel of experts.
The EMR should incorporate
data points. It should include physicians’ and nurses’ notes in data point
The EMR must have the ability
to order laboratory and radiological tests.
It must include clinical
guidelines defining criteria for treating various conditions. It should contain
alerts to avoid dangerous drug interactions and 20 other functions.
It is cookbook medicine all
over again. The goal is to eliminate physician judgment.
On January 1,2013 only 11
percent of the hospitals had even a basic EMR system in at least one major clinical
unit that performed 8 of the 24 functions.
Physicians have been slow to cooperate. Intuitively they
know that a functional EMR might collect data that will be used against them,
The question is will the data improve medical outcomes,
result in less medical complications and less morbidity and mortality? Will it
increase or decrease physicians work hours or increase or decrease physicians’ net
“Pamela McNutt, senior vice president/CIO at Dallas-based Methodist
Health System, says HIT advocates were a little naïve early in the
process. "There was a bit of over-simplistic thought that if we just purchased
and installed some software that suddenly everyone would start connecting and
talking and it is premature," McNutt says. "Even people who have met
high levels and are ready to meet Meaningful Use Stage 2 still have to work to
says the whole idea of "efficiencies" in HIT is undefined.
have to talk about what are the efficiencies we are looking for," she
data to judge performance should not be the goal. Judging performance does not necessarily increase
EMR should improve the physician-patient relationship. It should be for the
patients’ benefit. It should not be for data collection to commoditize medical
ideal EMR should be constructed through the eyes of practicing physicians and
not through the eyes of bureaucrats and computer software companies.
should be an EMR that is interoperable and compatible with physicians and
patients needs not the administration’s needs.
EMR should be cloud based.
should be secure and protect patients’ privacy.
should not result in a capital expenditure by physicians or hospital systems.
would pay by the transaction.
should not provide a financial burden to physicians and hospital systems.
could be updated and maintained at no cost to providers.
would turn an expense into a profit center for the government.
Why can’t the
administration’s healthcare policy makers figure this out?
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.