When technology “disrupts” it creates winners and losers. Hello smartphone! So long camera, encyclopedia, newspaper, book, CD, courtship, attention span. Disruption isn’t just inevitable, it’s righteous. Question tech and you’re not only a relic, you’re a job-killer and a Luddite, and possibly a Unabomber.
The information technology tsunami has hit so fast that most of us haven’t had time to think about what we might be sacrificing by trying to ride it. And that’s particularly true when it comes to the delivery of health services.
With the best of intentions, the Obama administration six years ago launched the HITECH Act, a $30 billion program to put electronic health records (EHR) in every hospital and doctors’ office. It offered incentives for docs who bought and “meaningfully used” the technology, and penalties—which start to kick in this year—for those who failed to adopt the new technology quickly enough. The goal was to get doctors to store patient data and share it electronically with the patients, other physicians, public health agencies, laboratories and other players in the vast health care enterprise that accounts for one-fifth of our economy.
There was just one problem: Medicine may have been in dire need of a high-tech revolution, but the Obama administration did not think hard enough about whether the technology was ready for medicine.
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Doctors certainly seemed like a tech-friendly bunch for whom computerization would come naturally: They prescribed new drugs and prodded and inspected and sliced at us with increasingly sophisticated gadgets. But they still listened to our organs with a quaint 19th century device called the stethoscope, and wrote our prescriptions in illegible long hand. And when Obama took office, most of them still kept their patients’ records on paper, in manila folders with multi-colored tabs. Only 17 percent—the early adapters, the tech-savviest—relied on electronic health records.
Now, doctors spend many of their working hours in front of a computer screen. And they aren’t happy about it.
In principal, computerization could be a good thing. For years, the consensus of the experts was that health care lagged unconscionably behind other parts of the economy when it came to computerization and electronic records were seen as a crucial element in any plan to tame the health care monster swallowing our economy. To make health care better, cheaper and more accessible we needed to stop paying doctors for the number of things they do, and instead reimburse them for maintaining or restoring health. This could only be done when doctors, hospitals, insurers, nursing homes, psychiatric institutions—and patients themselves—got better at sharing information. And that would happen only when the data flowed electronically.
This cheery flow-chart hasn’t really materialized—not yet at least. And for that, several players—including the Obama administration—are to blame.
“The simple narrative of our age—that computers improve the performance of every industry they touch—turns out to have been magical thinking when it comes to healthcare,” writes Robert Wachter, a physician who teaches at the University of California.
According to David Brailer, the first chief of the Office of the National Coordinator for Health IT (ONC), Prime Minister Tony Blair had bragged to President George W. Bush about a since-failed British health IT initiative and Bush wanted one of his own. His vision, Bush said recently, was, “there’s a car wreck and the EMT takes a tag off the victim, plugs it into the computer and uses his records to make medical decisions.” Brother Jeb has a similarly magical view of health IT. On the campaign trail recently he pointed to his Apple watch as a potential tool in a “consumer-directed model” of health care that he would like to see replace Obamacare. “Five years from now … we’ll be able to guide our own health decisions in a way that will make us healthy … we have to get to a health system and away from a disease system.”
President Bush’s dream only started to flower when Obama started cutting big checks. His first ONC director, the patrician David Blumenthal (brother of Connecticut Senator Richard Blumenthal) had the idea of giving doctors and hospitals cash to buy electronic health records. Two other health staffers, Ezekiel Emanuel and Bob Kocher, wanted a set of “meaningful use” yardsticks to assure the incentives were properly absorbed. Obama’s transition team saw it as a unique chance to transform health care, according to Wachter in his new book, The Digital Doctor.
There were warnings that this wouldn’t be as easy as it sounded. In 2008, “disruption” guru Clayton Christensen predicted in The Innovator’s Prescription, one of his best-selling takes on how to turn the world upside down, that the key obstacle to data sharing would be the lack of a profit motive for doctors. It was foolish to expect physicians to invest in electronic records systems that “make it easier for other caregivers to care more effectively for their patients,” he wrote. “While providers are expected to bear the cost of implementing an [electronic records system] most of the benefits—such as improved patient safety, data security, care coordination and disease prevention—accrue to patients, insurers and payers but not the providers.”
Brailer thought the “meaningful use” incentives were a bad idea because they encouraged purchases of tech that wasn’t ready, for medical practices that weren’t ready to share patients or their data. “I never would have spent money on direct subsidies to providers,” he told Wachter. Without them “we would have a much more innovative IT sector … . It would be people competing on their systems’ new features and functions.”
While no one knows whether Brailer’s invisible hand would have done the job any better, his words sound prophetic. The health IT revolution turned into a mess, producing angry doctors, hospitals that were unable to coordinate care because their computers didn’t talk to each other and massive thefts of databases laden with some of our most intimate secrets.
In most areas of the economy computers do what they are supposed to do rather well, and are considered labor-saving devices. In hospitals, ERs and clinics, medical software tends to be a clunky, infuriating, labor-adding device. On average doctors spend an extra hour each day dealing with the tasks assigned by their software, according to recent surveys. Tending the computer cuts into their caseloads and sometimes requires new office staff.
In surveys, doctors describe the EHR as the biggest cause of job burnout—worse than long hours, billing and other nuisances. One frequent complaint is mental strain. In the computer, the doctor’s note goes from being an almost literary narrative of the patient’s condition to a series of checkboxes. Each visit reads much like the last because the computer software provides exhaustive information with the object of satisfying billing needs. The doctors can’t tell one patient from another in the absence of idiosyncratic impressions. The memorable rash or symptom a patient reported is buried in screen after screen of seemingly trivial data. In an ER or ICU, with time of the essence, this can become a critical safety problem.
Overall, EHRs are probably improving patient safety—they have replaced illegible medical scrawl with typing, for instance. Yet EHRs are inevitably listed among the 10 top safety concerns for doctors because they introduce new kinds of errors. Wachter outlines a whopper in his book—a sick boy in his hospital who received a 40-fold overdose of a powerful antibiotic because of a chain of assumptions leading from the mistaken belief that the computer was measuring the dosage by weight.
The risk of such errors adds further strain and distraction. “All the clicking saps intellectual power and concentration and blocks normal conversation,” says Dean Kross, a cardiologist in western Pennsylvania. “The device has become a disease requiring as much intellect to manage as does the patient.”
Despite the new dangers, many EHR vendors’ contracts contain a “hold harmless” clause that protects them from legal responsibility for errors to which their software may contribute. The vendors’ argument, writes Wachter, “is like a version of the ‘guns don’t kill people, people kill people’ argument: errors reflect poor implementation practices or screw ups by users. This is certainly true at times, but…there are scores of errors that are all but inevitable given clunky software.”
Congress hasn’t paid much attention to health IT. When it checks in, the usual drill is to parrot what industry is complaining about. The “don’t let regulation smother innovation” camp inevitably catches more attention than the Cassandras who bemoan a vanished sense of stability or call for more regulation. Overseers in the Energy and Commerce committee have been leery to fund a health IT safety center, although everyone who studies the software thinks it needs one.
Rep. Mike Burgess (R-Texas), a physician who obviously has gotten an earful from other physicians, was an exception to this rule, recently introducing legislation to penalize EHR vendors whose computers discourage information sharing and care coordination among doctors. The bill has few friends because many feel it doesn’t really get at the problem—a complex system built on vested interests and labyrinthine privacy rules.
“Someday,” Wachter writes, “the computerization of medicine will surely be that long-awaited ‘disruptive innovation,’” but “today it’s often just plain disruptive: of the doctor-patient relationship, of clinicians’ professional interactions and work flow, and of the way we measure and try to improve things.”
And the expense! The $30 billion in taxpayer funds doled out so far was but a down payment. Hospitals and medical practices have spent hundreds of billions on systems that require billions more in maintenance, upgrades and training.
Guarding against cybercriminals—hacks reported in March alone yielded 91 million patient records—adds additional cost. In Boston, according to one account, there are 1½ people writing software for each hospital bed. No wonder the latest Fortune 400 includes five health IT billionaires—Cliff Illig and Neal Patterson of Cerner; Judy Faulkner of Epic; Patrick Soon-Shiong of NantHealth; and Terry Ragon of InterSystems.
The story isn’t entirely negative, of course. There’s a lot to be said for organizing patient information in a portable record, for databases that help pinpoint the sickest patients, for nurses and pharmacists not being forced to interpret a doctor’s scribbled handwriting—or a junkie’s forgery on a stolen script pad. In some efficient practices, patients now find that a copy of the X-ray taken in the podiatrist’s office or the ER is hanging on the wall when they arrive later that day at the family practitioner. Further, most doctors recognize that there’s no going back, and look forward to the day when their software is more reliable.
And of course there’s the seductive future of health IT—that beautiful day when scientists and their wonderful machines will harness masses of data to compare and analyze all the trillions of tiny facts in our bodies and our records, employing complex math to craft meaningful information about how to prolong and enrich our lives.
For everyone tantalized by these visions yet disconcerted by the current cacophony of the digital clinic, the question comes down to this, somewhat exaggerated dichotomy: Is there something about medicine that computer technology simply can’t sort out? Or can the problem more conveniently be blamed on a government policy that incentivized doctors to buy poorly designed EHRs—providing “cash for clunkers,” as athenahealth CEO Jonathan Bush memorably put it.
Despite the missteps of the HITECH Act, some of its biggest critics believe that the way out of EHR problems is to push past them to a more total technological embrace—more algorithms that tell doctors how to practice, more analytics that predict a patient’s future health, more sensors to track the patient’s every move and murmur in the blood. In other words, they think that a mixture of automation and permanent data collection will lead us through the craggy peaks and icy fjords to health Valhalla.
Among the leading proselytizers of this religion is Eric Topol, a San Diego cardiologist and the author of two recent books about health IT: The Creative Destruction of Medicine and The Patient Will See You Now.
Topol believes passionately in data: DNA panels, blood sugar readings, EKGs and the gadgets that allow individuals to use and interpret them. “For the first time in history we can digitize humans,” he writes in Creative Destruction. “We can dissect, decode and define individual granularity at the molecular level from womb to tomb.”
Well, we can’t, really, he admits, but the day is coming. And once individuals can monitor their bodies and compare their molecular makeup with everyone else’s, doctors will become mere technicians. No longer, he states in The Patient Will See You Now, must the patient be “subservient and dependent” on the doctor, whom he compares to a truck on the highway that has been “out in front, dominating the road, and unwittingly obscuring our vision.”
The word “empowerment” bubbles up like sulfur in Topol’s books. Doctors constitute a “tyranny of experts” who “can be likened to that of religious leaders and nobility.… To say …information has to be routed through your doctor is a little like the Middle Ages, when only priests could read the Bible.”
This kind of advice appeals most to those with a strong need for a sense of control. Perhaps not surprisingly, the rich have been most attentive. A group of tech entrepreneurs have handed over millions to scientists whose research, they hope, will allow them to live for 150 years. Some pay concierge services that provide doctors on call to scan and monitor their health. Mark Cuban, the owner of the Dallas Mavericks, set off a Twitter firestorm in April by urging “anyone who can afford it” to get his or her blood tested every three months to look for tell-tale signs of disease.
It took a radiologist to diagnose Cuban’s statements as symptoms of an underlying condition—futurism. “Futurists,” wrote Saurabh Jah, “are a combination of entrepreneurs and physicians who are distinguishable by certain traits. First, they use the term ‘disruptive innovation.’ … Second, they’re ‘solving’ problems. It’s unclear exactly what is being solved and why. Third, they oppose the status quo. But what’s on offer instead of status quo is never mentioned.”
In the real world, the doctor-as-paternalistic-power figure is unrecognizable. Doctors are overworked, harassed and humiliated as never before. They no longer have enough of the authority that patients bombarded by pharmaceutical ads and conflicting health information might want and need. Doctors are usually too distracted, overwhelmed by red tape, network mergers, Medicare requirements, falling reimbursements and Yelp reviews to contradict what a patient says.
To be sure, gadgets that allow us to measure vital signs at home could give doctors a rounder picture of our health, lead to better adherence to medical treatment, quicker responses when problems develop and at the same time prevent unneeded ER and medical visits. That could save the health care system money—or at least transfer money from insurers to medical device makers—and improve the lives of the ill.
But there’s a coercive element to all this.
Under former Secretary Kathleen Sebelius, and now Sylvia Burwell, the Department of Health and Human Services has worshipped at the altar of innovation, encouraging techies to crack open and tap into public databases, setting ambitious goals for transforming the health care system from a fee-for-service model to one that places a value on good health care. It all sounds very innovative and entrepreneurial. It can also lead to a kind of change-for-change’s sake—call it changeism—and the loading of resources into policies before their value is clear. HHS has repeatedly watered down the EHR “meaningful use” program to deal with screaming from doctors and IT specialists. Some argue that the damage has already been done, by locking physicians into expensive technology that frustrates more than it advances.
The original Luddites, remember, didn’t actually despise machines for their newness. They hated ugly, dangerous machines that were stealing the food out of their mouths. And in that sense, the American health care system gives birth to new Luddites every day.
Date: June 12, 2015