What truly frightens me about HITECH is that it demonstrates the government’s enthusiasm for juxtaposing itself into the EMR movement. I am frightened, but obviously not surprised. Like any powerful technology, EMR can be used for benefit or harm. Used properly EMR can fulfill the promise of lower costs, improved efficiency and higher quality of care. But if controlled by sinister forces, EMR will become a vehicle to undermine the doctor-patient relationship by limiting treatment choices and covertly monitoring /controlling doctor-patient behavior. Make no mistake: there are elements within our government that have recognized the potential of EMR as an instrument to bring health care under their control. If you think that notion is a bit paranoid, consider the words of the new director of CMS, Dr. Donald Berwick: “It’s not a question of whether we will ration (health) care, it is whether we will ration with our eyes open.” Regarding Britain’s National Health Service (NHS), which rations care to British citizens, Dr. Berwick says, “I am romantic about the National Health Service. I love it.” The NHS limits spending on life-saving care to $44,000 per year.
It is not difficult to understand how a government EMR system could be used to control and ration care. Remember the FDA’s recent withdrawal of its approval of the drug Avastin for breast cancer? Although doctors are powerless to reverse this unfortunate decision, at least it was formally announced and subjected to public scrutiny and debate. And Avastin is still available to use “off-label.” If EMRs were government controlled, no announcements would be necessary. The “Avastin button” would simply be removed from the physician’s treatment option screen. And it would be easy to program a government-controlled EMR to enforce an NHS-type spending limit to extend life. When a patient’s spending limit is reached, the system locks out that patient’s chart and no more care can be given.
Ridiculous, perhaps? The HITECH program, through EMR certification, already has established a mechanism to force EMR vendors to make their products comply with government requirements. It would be a simple regulatory step to “upgrade” those requirements to include a method of government “back door access” to any EMR. Such access would allow the government to establish and codify within EMRs methods of limiting and rationing care. It would also allow the government to monitor physician-patient behavior and deliver sanctions if it so desired.
I am not suggesting we storm Dr. Berwick’s office with torches and pitchforks. But I would like to offer some thoughts to serve as a “moral compass” as we continue our work on the EMR movement:
- EMR should only be used in a manner that supports the doctor-patient relationship. EMR should be used to reduce costs, improve efficiency, improve quality of care, enhance doctor-patient communication and protect the physician’s ability to properly practice medicine. EMR and related technologies, such as health information exchanges, should be used to efficiently move data among providers and to automate those parts of health care workflow that are appropriate for automation.
- It is inappropriate to use EMR as a vehicle for the government or any third party payer to force itself into the practice of medicine and into the doctor-patient relationship. EMR must not be used to enforce any restriction of treatment choices. It is improper to use EMR as a tool for the government or any third party payer to covertly monitor physician / patient behavior.
- The HITECH incentives are a mixed blessing. While the incentives certainly encourage EMR adoption they may also deprive the medical culture of the necessary time to make a stable, controlled cultural change to an information technology environment. This increases the risk of failure and may paradoxically increase the time and resources that are ultimately required to complete the cultural transition. It will take extra time and money for some medical practices to recover from poor decisions made in haste.
- The HITECH incentives are also harmful because they create a paradigm in which government sets the goals and the medical and IT cultures follow. The result could be a health care IT system that serves the whims of politicians, not the needs of patients. This is unacceptable.
- Let’s start thinking about a better physician payment system than CPT. The CPT coding system was created by the American Medical Association (AMA) over 40 years ago and has become an antiquated, overly burdensome set of documentation requirements. The coding compliance industry must siphon billions of health care dollars away from patient care to help physicians comply with these incredibly complex guidelines. The AMA profits approximately 50 million dollars a year selling CPT and ICD-9 materials to physicians. Their support of CPT is not objective and cannot be trusted. The CPT coding system assumes paper-based documentation. Through EMR we have learned that a fully CPT-compliant chart note is almost useless to the clinician. The relevant data are buried in a sea of white noise: patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes. The result is lengthy documentation that is dedicated to CPT compliance rather than to communicating useful health care information. EMR gives us the opportunity to replace CPT with a new physician payment system based on information technology instead of paper charts. Such a system will allow us to re-direct limited health resources from regulatory compliance back into patient care.
- Technology always brings unintended consequences. Health information technology will certainly bring unintended consequences, including unintended and undesirable de facto changes to the standard of care. We must watch carefully for these changes and protect physicians from these unplanned changes in the standard of care until they are examined, modified if necessary and formally recognized.
Recent political events clearly demonstrate a significant change in the relationship between America’s government and her citizens. Those who work in health care information technology must be aware that EMR technology could be utilized as a government instrument to covertly take control of our health care system in the name of “social justice” and cost containment.