EHRs - evidence-free medicine?

I wasn't going to write another EHR-related post.  Not yet, time for a change.  But this article just came out online first in the Annals of Internal Medicine, funded by the Robert Wood Johnson Foundation and the Commonwealth Fund.  The conclusion of the abstract really says about as much as we all need to know, since we already all know it, except for ONCHIT, it seems:

Few physicians could meet meaningful use criteria in early 2012 and using computerized systems for the panel management tasks was difficult. Results support the growing evidence that using the basic data input capabilities of an EHR does not translate into the greater opportunity that these technologies promise.

And many large sites, like academic medical centers, have not just one, but several EHRs, along with perhaps a data repository or two, plus all the systems they have to interact with.  I guess the HITECH Act is good for the economy, guaranteeing that a bunch of people will have IT-support jobs that pay reasonably well into the indefinite future, and low risk of offshoring.

Or, to paraphrase the famous line from Treasure of the Sierra Madre (which I'd give more than 8.4/10 stars), "Clothes?  We don't have to show you no stinkin' clothes!"

I'll try for more variety in my next post.

A strong vote of confidence in our EHRs from current users

I just ran across a blurb today pointing to this article on the web discussing changes in EHR purchasing between 2010 and 2013.  I acknowledge that I have not done full due diligence to examine their methodology and biases, but I see no reason to believe that the figures they present are grossly distorted for any obvious reason.

Briefly, what caught my attention is that the proportion of those looking to buy an EHR in 2013 vs. 2010 who are replacing an existing EHR jumped from 21% to 31% (but this article suggests it could be as "low" as 17% in 2013).  My first thought was that maybe these were people changing from discontinued/unsupported systems; this is why a couple of community health centers I know of here in Massachusetts made that move, because they had MISYS and AllScripts bought and shot it.  However, a bit farther down, data are shown that by far the largest reason for switching was dissatisfaction with the old system and this was more common in 2013 than 2010, with >60% citing this as their reason for switching in 2013.  Given the issue of EHR lock - the systems are very expensive and vendors make it as hard as possible to get your data out to move to another EHR (generally not even providing users a data dictionary to understand how their own patient data are stored) - jumping ship to another EHR because of dissatisfaction means you really hate the one you have.  Then think about all the costs of retraining clinical and support staff for the new EHR, the lost productivity as they go through another learning curve - the costs are likely not much lower than buying an initial system, though I've never seen any articles with data about the costs of switching.  You truly have to hate your EHR to switch because you don't like it rather than because it is no longer supported or doesn't qualify for Meaningless Use incentives.  (And let's not even think about the poor schmoes who bought an "EHRMagic" EHR and learned that the magic was that their MU certification would disappear.)

Strong incentives to buy black box products with penalties coming soon for not using them (e.g., not using e-prescribing), when there are huge exit barriers, bears no resemblance to the assumptions of a "free market."  I really wish that the "anti-big government" forces in Congress would go after this one.  Unfortunately, as we all know, they are quite happy with a forced subsidy to big business, even at the price of more expensive, lower quality health care and worse health for Americans.  But nobody gets elected, or voted out of office, on the basis of their positions and votes related to EHRs, do they?

And I can think of no better way to end this rant than with a turkey photo or two.

More EHR crankiness - parallel evolution or just unacknowledged copying?

I just bumped into this letter submitted as commentary to Congress from the "Healthcare Innovation Council" of Antheliohealth.  The members are certainly more prominent than I, and while Antheliohealth is clearly in the business and hence potentially biased, they make very similar comments to those I made in the Health Affairs Blog post I linked to in my previous posting here.  It is interesting that they used virtually the same title as I did (though I could not believe I somehow sent mine in as "The EHR Has No Clothes" and not "The EMR Has No Clothes"), without any attribution and, more importantly, without sending me a large check.  But it could just be parallel evolution.

They went all the way to suggesting an end to the "Meaningful Use" program (I believe that is referred to in the trade as an act of MUtiny).  I had wanted to do that in my HA Blog piece but figured that would make it truly unpublishable - and it was already an incredible thrash to finally get it published anywhere.  And there is the issue of fairness - those adopting EHRs now are counting on the MU payments to help them cover the frequently obscene costs.  Even I think that abruptly ending the program would be unfair and unwise.  But there are, er, fair and balanced options that could be chosen.  E.g., the MU Stage 2 rollout could be put on hold while the specifications could be revised to focus on truly meaningful use - helping providers deliver higher quality, more patient-centered care.  One could even put a freeze on eligibility for MU incentives - e.g., no contracts for an EHR by an organization not already using a certified EHR signed after a specified date would be eligible for MU payments until the freeze was lifted when the new MU Stage 2 requirements were issued.

And I still don't understand the incredible resistance to adopting VistA.  Sure, it needs installation and support, but all EHRs do, and the software licensing cost is $0, which leaves a lot of money on the table for installation and support.  (I've offered to cover the entire software acquisition cost for my clinic if we dump NoxGen for VistA.)  It actually has evidence for improving care and, for an enterprise-level EHR, is relatively well-liked.

But, I know, I know, it has no glitzy GUI and is written in that truly archaic language, MUMPS.  As is Epic...

Ok, for you non-geeks who accidentally clicked on this, here's a picture of a white-breasted nuthatch in our backyard for your troubles (those are maple flowers in the tree):

Your HIT parade - Problem lists!

As some know, I think our national electronic health record (EHR) policy is woefully misguided - providers/organizations are being pushed hard to buy an EHR, any EHR (I think the official title of this strategy is, "Let 1,000 EHRs fester"), with the costs of acquisition and barriers to exit so high that most purchasers get locked into whatever they buy, even after discovering it is a POS and most of what they were promised was vaporware.  These complex systems are devoted to charge capture/justification, not patient care, and are chief suspects in increases in Medicare coding intensity/costs unrelated to any actual changes in care. (Here's the NY Times article.)  Well, duh!  They are NOT, in general, focused on helping clinicians actually provide better care (except for the few that were actually developed by clinicians to help them practice).  However, I can think of few ways to make this clearer than the email I received today:

Health Resources and Services Administration

Health Information Technology and Quality Improvement Webinar

Friday, May 17, 2:00 PM ET

“Using an Electronic Health Record to Create Patient Problem Lists”

This webinar will focus on how safety net primary care providers can meaningfully use electronic health records (EHR) to create and maintain patient problem lists.  Created by EHRs, patient problem lists are a core requirement of Meaningful Use. This function serves as a powerful tool for maintaining a patient’s medical history while also helping to engage patients to better track and manage their health care.  

Presenters will demonstrate how patient problem lists are created and maintained by EHRs, and share their strategies on how providers can use them for quality improvement and patient engagement.  Lastly, staff from the U.S. Department of Health and Human Services will discuss the importance of patient problem lists in achieving Stage 1 and 2 of Meaningful Use.

Register here: https://cc.readytalk.com/cc/s/registrations/new?cid=3g2cm558x3gp.

Previous HRSA Health IT and Quality Webinars can be accessed at the HRSA Health IT and Quality Webinar website: http://www.hrsa.gov/healthit/toolbox/webinars/.

Questions for presenters are welcome prior to the event and may be emailed to healthit@hrsa.gov.

If a webinar is needed to help people learn about creating problem lists in their EHRs and discuss how they can be useful in patient care, we are in seriously deep trouble.  After being sure you are looking at the right chart, the problem list is typically the first thing you look at.  How can it be possible that we are pushing people to buy and use such useless crap where conducting such a webinar does not seem utterly nonsensical?  And that people are paying many thousands, and often millions, of dollars for these pieces of crap.

Don't get me wrong - as a geek, I think the EHR has huge potential for increasing the efficiency and effectiveness of health care.  I just think we are squandering nearly all of that potential with our current, misguided policies and driving costs up substantially with little or no payoff.  Except to the EHR companies, who are making billions.  "Free market" Republicans should be up in arms over this forced subsidy - except, of course, they really care about helping businesses make money, not free markets, competition, efficiency, or saving taxpayer money.

Stay tuned - I hear that next year, HRSA and ONCHIT are planning on cosponsoring an advanced-level webinar, "Creating a Progress Note Using an Electronic Health Record."