Readers Write 2/12/09

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note: the first two articles were added as comments to previous articles, but because of the large number of links they included, they were automatically discarded by the blog spam-catcher, so I never saw them. I do not censor comments except in extreme cases (ones I’ve gotten include claims of past criminal records by named individuals, obvious vendor pitches disguised as a reader comment, and personal attacks – those I will either delete or edit). So, if you left a comment and it hasn’t appeared within a day or two, e-mail it directly to me.

Comments on MD Leader 1/27/09, Ministry Health and CattailsMD
By Pragma

Thank you for including links to back up your statements with peer review evidence. A good effort. It’s something we don’t see here often.

“EHRs Do Not Improve Quality” Your link to a study conducted between 2002 in 2004 (released in 2007) about ambulatory-only EMR systems, peer-reviewed, but disputed by many (even at the time). It is worth noting this is not a study referenced by… well anybody, in two years! And in medicine that wouldn’t hold up very well. Is it really that cut and dry? That clear?

http://www.bmj.com/cgi/content/full/bmj%3b330/7491/581
http://www.itif.org/files/HealthIT.pdf
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2253693
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=685103
http://www.cchit.org/about/casestudies/index.asp
http://www.fhin.net/eprescribe/Benefits/AdvantagesToProviders.shtml
http://www.fiercehealthit.com/story/ehrs-boost-quality-raise-costs-at-community-clinics/2007-01-22
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1479999

There are other studies. Often peer reviewed and indexed. I could go on and on and on … and on. But wouldn’t it be worth people doing the research themselves? This is medicine, the last time I checked it was a science. Let’s do the clinicians the service we expect of them.

Your basic statement is a truism, but it’s an obvious truism (or it should be). It’s not the EMR, it’s how it is used. How it is customized, and how the data is normalized and utilized. We must be cognitive of EMRs allowing the customer flexibility. EHRs do enable this. Paper does not. Paper and EHRs are just tools. And humans are pretty good at using them, when they are not given reason to not use them.

I am sure in Egypt there were many who railed against the failures of papyrus. Who advocated for more use of stone. Well they lost, and we as humans adjust. Cows? Not so much. I happen to think clinicians are better than cows. I have seen this. I have actually seen Doctors say they have seen the benefits and enjoy using an EMR! Wow! Kinda goes against everything people are saying here, right? Sometimes reading this site I think clinicians are cows. Who simply must have workflows duplicate their paper world exactly. So isn’t the question what are these people doing wrong? Because it can be right.

Wouldn’t a more constructive argument from the detractors be, “Which is the best EMR for quality, and why?”, not, “They do not work”, “There is no evidence”, “it’s a waste of money”? You wouldn’t know this from reading HIStalk, but there really is far more, recent, peer-reviewed empirical data to show they do. The truth is…. ahem.. out there?

Anyway, it’s an old and fruitless argument. They will be implemented, it’s just a case of how well. The people who care, and do not have an agenda, will ask questions such as “how do we make them better”, “How do we increase quality with available data”, “Isn’t all this data GREAT! What are we going to do with it!”, “Ok we have an EMR, now let’s try doing something for the Doctors, give a little back for the extra time they spend documenting”, “How can we make a logical thing like a computer, mirror illogical real life workflows?”, “How do we stop decision support annoying clinicians, so the continue to use it and not just click OK?”, “How do we take hospitals from hugely political organizations to ones that’s make decision to a truly best practice?”. The others often show their clear lack of objectivity.

Comments on the Interview with Glen Tullman, CEO of Allscripts
By Al Borges, MD

Dear Mr. Tullman:

Thank you for coming on HIStalk for an interview. This site is read on a daily basis for those of us with an interest in HIT, and having you come to visit is wonderful.

Didn’t President Obama pledge not to surround himself with lobbyists? Aren’t you, your company, and your coworkers the ultimate lobbyist group, showering Obama with donations for the past two years alone? From what little I could find on the Google, you personally gave President Obama at least $144,300.00 in donations in the two years prior to his election (1). Your employees gave $20,662 during the same period (2). Your company, Allscripts/Misys, also gave the possible future HHS Secretary Daschle $12,000 speaking fees on 8/2008 for a lecture (3).

Now this activity seems to have put you into the unusual position where you are the personal advisor of the President of the United States of America on how to channel money to your company, ultimately enriching yourself while the American taxpayer, and especially doctors have to foot the bill. President Obama has put the wolf to guard the hen house!

You can’t believe how much I resent the fact that you, a vendor selling a product, is now in a position of power where you can determine how Medicare pays me, a physician. I’m sure that I’m not the only doctor out there that feels this way. Unlike you, I don’t have the lobbying power to get Obama’s ear. You’ll be able to sign up in the short-term those who already have EMRs, but once you get close to 20% uptake of these incentives, you’ll begin to bump up against the less CCHIT-certified-EHR-hard-core, more knowledgeable physicians like myself who don’t want to buy into a multi-thousand dollar EHR to please the likes of the Medicare pinheads in order to be able to get paid adequately for our work.

What this bill will eventually do is to damage Medicare as physicians refuse to see new Medicare patients or dis-enroll altogether. It also will begin the process of destroying the small solo to group office over the next 10 years, offices where 75% of doctors work in currently. These offices won’t be able to survive under the burden of these unfunded, onerous, unneeded mandates that you are trying to promote to satisfy your agenda. Students will think twice before going into medicine if not only do they now have to pay off their loans but also pay for a $30,000.00 CCHIT-certified EHR, and worse yet, use it.

Lastly, you mention that “[CCHIT-certified EHRs are] a benefit to all of us in terms of quality and also in terms of cost reduction” without there being any real data showing such. In fact, there is data showing the opposite(13). Recently we’ve had alerts about data input errors from both the JACHO and the US Pharmacopeia (4,7-12). You have the National Research Council finding that HIT systems used by several major health providers has fallen short of achieving healthcare delivery goals envisioned by the Institute of Medicine (5). Recently, two HIT experts have penned an open letter to President Obama, warning him against investing too many federal dollars in existing electronic health records systems(6). David Kibbe, MD, a technology adviser to the AAFP, and Brian Klepper, PhD, founder of consulting firm Health 2.0 Advisors, stated that existing EHR systems are:

• too expensive
• difficult to implement
• disruptive to practice workflows
• not proven to improve patient care, and
• don’t do a good job of sharing information with each other.

So Mr. Tullman, do the right thing and stop the insanity of using taxpayer money to bail out a portion of the economy that doesn’t need the economic help, at least not in this way. If you can do me a favor — show this letter to the honorable President Obama so that he can get an idea of how the other side feels.

Sincerely,

Dr. Borges

Citations:

1) http://www.campaignmoney.com/political/contributions/glen-tullman.asp?cycle=08
2) http://fundrace.huffingtonpost.com/neighbors.php?type=emp&employer=ALLSCRIPTS
3) http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=389×4968435
4) http://www.jointcommission.org/NewsRoom/NewsReleases/nr_12_11_08.htm
5) http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090109/REG/301099965/-1/TODAYSNEWS
6) http://medicaleconomics.modernmedicine.com/memag/submitBlogEntry.do#blog_confirmation_anchor
7) http://www.ama-assn.org/amednews/2005/01/24/prsa0124.htm
8) http://www.jamia.org/cgi/reprint/14/3/387.pdf
9) http://www.nytimes.com/2005/03/09/technology/09compute.html?ei=5089&en=402b792e748d99a2&ex=1268110800&adxnnl=1&partner=rssyahoo&adxnnlx=1150474153-xVix1BcYkvTKJpuLyHStrQ
10) http://jama.ama-assn.org/cgi/content/abstract/293/10/1197
11) http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm
12) http://www.usp.org/products/medMarx/
13) see my 2 slideshows located here (~130 slides full of data)- http://msofficeemrproject.com/Page3.htm

Why Doesn’t Someone Propose a National EMR?
By Winston T. Goode

While I appreciate the commitment to healthcare that "billions a year for x years" represents, I can’t help but think that we’re trying to plug leaky faucets with fistfuls of money. Electronic Health Records are not a goal, Electronic Health Records are a tool, and they will only realize their potential if they are installed in the pursuit of a loftier goal.

The Apollo program was not funded as a $135 billion exercise in building rockets. Knowledge is the most powerful and most capricious tool we can bring to bear on our health. The ethics of healthcare often prevent controlled, double-blind studies, meaning that often useful knowledge can only be attained post hoc and en toto. Sorting through the interactions of multitudinous variables and extracting a modicum of causality to use for the betterment of all is not a challenge that can be met by a single doctor, or often even a single health system.

The barest hints of the potential of EHRs we’ve seen already. How many years did we spend collecting information on tobacco use? How many patients died of Vioxx-related heart failure before we managed to make a
connection? We would have known more, sooner, if we had a nationwide EHR infrastructure.

As the benefits of EHRs are society-wide, so to should be the scale of the tools and projects used to implement them. Providing for the health of a population is not a project that can be funded piecemeal with
earmarks and pork, run through unaccountable cronyism, or bloated bureaucracies. Nor is it a project that can be handled by the private sector, or tax breaks, or ‘small government’ rhetoric. It must be above either party,
and across government agencies. 

We need a national EHR project to realize the benefits of an EHR. Otherwise, EHRs will continue to be yet another false idol of future technology on which we will have squandered our wealth and potential. This should be a grand endeavor, not limited only to healthcare, but spanning industries from agriculture and education, to law enforcement and government. We must exert control on those variables that correlate to our desired outcome,be they chemical,  behavioral or other. This must be a results-focused, not rhetoric-focused enterprise.

Privacy advocates rightfully fear the ways in which this information may be abused. There must be protections and opt-outs put in place, but it should not be a system that people will want to opt out of. No one is forced to use U.S. dollars as a form of currency. No one is forced to open a bank account or use a cell phone despite the obvious privacy risks these present. We should have the healthiest, and longest lived, population in world.  EHR’s can help us with this goal.

I sincerely hope there is someone in Washington with the vision and leadership to harness the vast potential of EHRs to better the health of all. But I’m sure not seeing it at the moment.