At The Moderate Voice Ron Chusid points out another brewing problem in the Obama Administration’s plans for reforming the healthcare system:
The original stimulus package after Barack Obama took office included a program to provide funds to medical practices to be used for conversion to electronic medical records. In order to qualify for the incentive payments, physicians and hospitals have to follow a set of Meaningful Use requirements which have increased requirements for each stage. Initially there would be incentive payments (which turned out to be far less than the costs of conversion to electronic medical records), and subsequently there are penalties for failing to comply. The first stage was successful in terms of getting large numbers of doctors to adopt electronic medical records, but it is more questionable as to whether this is really resulting in the desired cost savings.
Stage 2 was initially required by October 2014. This would have greatly increased the use of electronic medical records, possibly resulting in more medical cost savings, but the requirements were unrealistic. The law originally required that physicians comply with the requirements of Stage 2 for a 90 day period in 2014, which essentially meant that we could wait until October 1 to implement them. When it was apparent that most physicians could not comply with this, the government postponed this until January 2015.
It was quickly apparent that this was no solution, partially as the new requirements required a full twelve months of compliance with the Stage 2 rules. By requiring compliance by this January, this only gave an additional three months. The same problems which prevented compliance with the rules by October 2014 are still present this January.
Electronic medical recordskeeping has always been a slender reed on which to base dreams of reducing the cost of healthcare and the problems have been apparent since the very outset. A major problem has always been provider compliance and it remains a problem but not the only one.
I disagree with Ron, however, that the EMR matter is a greater problem than Healthcare.gov falling on its face at its debut. That was so public, so visible, and so highly publicized I believe that it’s hard to overestimate the damage that did to the notion of the competence of the federal government.
Not to put too fine a point on it but the EMR systems suck. As is all too common with computerized information systems the systems conform more to developers’ notions of what such systems should do and how they should operate than to providers’ needs. Furthermore, the standards for such systems are completely inadequate.
There has been a drastic change in the role of the federal government since the end of World War II. Seventy-five years ago the federal government actually provided goods and services and contributed to GDP, other than by expanding the money supply, of course. Little by little that role has transmuted into providing the funds by which individuals and corporations produced goods and services. That this might provide even greater vehicles for waste, fraud, and abuse than the federal agencies the approach has replaced does not seem to have occurred to anyone.
In theory you could produce a heckuva web application or hosted application for $10 billion. In practice we’ve lost the knowhow. So we pay providers to purchase systems that they can or won’t use from vendors who may or may not be in the electronic medical records business next year or five years from now.
I don’t think anyone has thought EMRs would be the major source of cost savings, but I think there were reasonable hopes it would contribute. If I could get access to pt’s care at other facilities, I could order a lot fewer tests. If I could actually know their medications list in a timely manner, I could save money. That said, all the systems i have seen to date serve largely as data sets to make administrators and insurers happy. Not very usable by clinicians. To be honest, I remain surprised that no entrepreneur has decided to really tackle this.
Steve
I’ve seen a half dozen different systems. Every one I’ve seen has been what I would call “naive”, i.e. they’re a solution that the proverbial man from Mars might have developed.
One of the issues is how computer systems are actually developed. In my experience proceeding from requirements gathering to design to implementation is actually pretty rare. What I’ve seen is that every system beings with a single customer and an attempt at solving whatever that client’s problem is.
The VA has an electronic system, and it has pluses and minuses. It was in place when I started going to the VA, and I am not sure how they handled the transition between paper and electronic records.
I am not sure if it has changed, but during Katrina, my records were not available because they were only kept on local servers. I had my the bottles for my meds to get them refilled, but I was surprised that they were not better integrated.
Mostly, the VA is a self contained system. Prescriptions, physicians, testing, hospitals, urgent care, specialists, etc. is all done in-house, and there is no need for the system to interface with other systems.
Nobody ever considers what to do with existing paper records or the transition. Scanning everything in is costly, and it takes a lot of hard drive space.
Optical Character Recognition (OCR) is when the computer converts the scan into text, but this is dependent upon the original documents. No OCR is 100% correct, and changing one character can have a large impact. $1,000,000.00 and $9.000.000.00 are only off by one character.
Then, you have a hybrid system. Some information is in digital format, and it is on the forms of the EMR system. Other information is still on paper, and the doctor, nurse, technician, has to know how to navigate two systems.
If paper is still used locally, will the EMR system have enough data for the user to make the correct diagnoses? There may be 3 months of digital data seen, but there may be 10 years worth of paper not seen.
If they started with simple systems, they may be able to make it work. Imaging, bloodwork, and medications might work, and they could build upon that.
The VA has a website for vets that you can get a lot of information, and they are slowly increasing the amount available. I can reorder prescriptions, and I can see my lab work from past years. (The VA is doing something with sharing information.)
Rather than one integrated system, there could be an option for the physician to log onto the patient’s system and view their records on that system.
The DoD has been working on EMR’s for over a decade and it’s still a work in progress. There is currently Request for Proposal (RFP) that should be awarded this summer for an $11 billion dollar contract for the next iteration. I’m sure it will work out great.