The Unhealthy Side Effects of Meaningful Use

Author’s note:  This article appears in Townhall.com Finance today, co-authored by Dr. Hal Scherz and myself.

Imagine a world where fossil fuel vehicles are gradually outlawed in favor of electric cars. The government would at first give incentives to those who purchase electric cars and then gradually replace those incentives with penalties for cars that use fossil fuel. As implausible as this appears, it is already happening with light bulbs, toilets and wind turbines. The government fancies itself as entitled to decide what works best for everyone.

A similar process is currently ongoing with health information technology (HIT).  The Feds have appointed themselves as the final judge of how HIT should be used. The American Recovery and Reinvestment Act includes a set of  “Meaningful Use” (MU) guidelines for the use of HIT by physicians and hospitals.  Beginning in 2010 the Act offered physicians financial incentives for MU compliance; by 2015 the incentives will be replaced by penalties for failure to comply with MU.

The benefits of HIT to patients and doctors appear to be obvious.  The potential for improved medical record legibility, ease of access and reduction of medical errors is easy to appreciate. We all enjoy the advances that information technology has brought to our phones, cars, banks and airports. So a program meant to accelerate the adoption of HIT would seem benign enough.

But physicians who care for patients every day understand what no one else does – that the benefits of HIT are not a forgone conclusion.  To us HIT has as much potential to harm patients as it has to help them.  We also understand that the fund of knowledge required to safely and effectively implement HIT has not yet been adequately developed.  It is therefore foolish, even dangerous, to force HIT into widespread use before it is well understood.

There is surprisingly little evidence that the electronic medical record (EMR) improves quality of care. There is in fact some evidence to suggest that EMRs currently in use may actually reduce quality of care and raise health care costs.  There are also no established EMR implementation strategies for medical practices.  Implementing a complex EMR system into a busy medical practice is like replacing an aircraft’s engines while it is still flying.  During implementation there can be no reduction in patient volume and no errors in patient care.  Information technology is the only medical technology that has been given a “free pass,” with apparently no need to prove itself the way we prove the worthiness of new drugs, medical devices and surgical procedures.

HIT is also the only business technology in the entire economy that has been exempted from the need to show a return on investment. There is no recognized business model that makes HIT profitable, or even revenue-neutral.  Like any business a medical practice must survive financially. A practice cannot purchase and maintain HIT without a strategy to recover the investment.

Health information technology will change the practice of medicine more than any drug, imaging modality, operation or minimally invasive endoscope.  It will profoundly affect the care of every patient.  No other past or current medical advancement can make that claim.

Any new technology, including health information technology, produces unexpected adverse consequences.  For adverse events in health care government mandates create a frightening multiplier.  What if the government had required all overweight patients to use Fen-Phen before its cardiac side effects were discovered?  What if all patients with arthritic hips had been required to receive cobalt-containing implants?  In an environment where every innovation is rightfully scrutinized before it is placed into widespread use, why do so many accept the unproven claims of HIT as unchallenged fact?

The alliance between government and the HIT industry has replaced critical analysis with blind enthusiasm and has replaced innovation with mindless regulatory compliance. What would today’s technology look like if the government had decreed back in 1984 that we had to purchase 4 MHz PCs or first generation brick-sized cell phones? They would still be “state of the art” today.  Had there been government-mandated demand for these early technologies there would have been no reason to build smarter phones or faster computers.

Within the HIT industry Meaningful Use now dominates the discussion at the expense of creativity.  MU incentives have sucked all the oxygen out of the room where original thought once took place.  In a healthy environment, demand drives technology, not vice versa. If there were an electronic medical record that allowed physicians to provide better patient care and run their practices more efficiently, we docs would line up around the block at 4 AM to get our hands on it, just we all did for iPhones and iPads?   No incentives would be necessary.  Someday that will happen…but only after the government incentives are gone.

About the author

Dr. Michael Koriwchak

Dr. Michael Koriwchak

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery.
After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations.
Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia.
With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

8 Comments

  • Dr. Koriwchak,

    I recognize that this is an opinion piece, not a study or analysis. However, the number of non sequiturs is remarkable. If this were not enough, there is also an admixture of ideology – government bad, private sector good – without anything to back up the claim.

    Add to this, there is the staggering presumption that the authors speak for all physicians who care for patients every day.

    Examples:

    “For adverse events in health care government mandates create a frightening multiplier.”

    This statement’s basis is a series of what ifs, rather than even anecdotal experience.

    And,

    “MU incentives have sucked all the oxygen out of the room where original thought once took place.”

    I think, though it’s really hard to know, that this is the government kills private sector innovation argument. Ideology meets bad metaphor meets data free analysis.

    One of healthcare scene’s great values is the extensive coverage of HIE issues without the cant in this post.

  • From personal experience, a working knowledge of the medical literature and innumerable interactions with EHR vendors, I can say that Dr Koriwchak has pretty much nailed it.

    You can find some references
    http://thebreastcancersurgeon.files.wordpress.com/2012/07/miamibeyond-the-ehr.pptx

    But I would be happy to provide more.

    MU ( I believe it is pronounced Moooooooooo) has centrally mandated that 300 plus EHR vendors all do the same 25 things. It is obvious that this has styfled innovation. If you do not think this has stifled innovation, go to any EHR vendor or hospital with an idea that is not one of those 25. You will be told bluntly that they have no resources beyond meaningful use. I have done this exercise as a physician, as a software developer and as a representative of major societies, and this is always the result.

    Read the Stead Report:
    http://www.nap.edu/nap-cgi/report.cgi?record_id=12572&type=pdfxsum

    In 2009, this report said:
    These multiple sources of evidence—viewed from the committee’s perspective—suggest that current efforts aimed at the nationwide deploy- ment of health care IT will not be sufficient to achieve the vision of 21st century health care, and may even set back the cause if these efforts continue wholly without change from their present course.

    Basically, the committee felt deploying the substandard IT available would lock hospitals into that substandard technology for a decade.

    They saw it coming, we are seeing it happening.

  • This is one the the better articles on Health IT in recent times. I completely agree with Kevin’s views above… Sharing several comments exchanged on this in a chat on twitter..

    nrip: Meaningful Use now dominates the discussion at the expense of creativity. http://t.co/T2Fhwng3 #hcsm #healthIT | That is so true
    2:10am, Jul 15 from Visibli

    CMIOblog: @nrip I don’t know if I agree with that assessment. We need MU metrics to open up our minds to further innovation.
    2:19am, Jul 15 from Web

    nrip: @cmioblog well MU is ok. but focus only on MU is curbing innovation twds better #ptcare now some sols in h/c outside US are more meaningful
    4:27am, Jul 15 from HootSuite

    CMIOblog: @nrip #MU is a start but u need some baseline info 2 start innovating. U don’t know what u don’t know. Can u innovate without info?
    4:30am, Jul 15 from Twitter for iPhone

    nrip: @cmioblog what u say is valid but not the only way. curation, crowdsourcing , creativity are all possible. read my comment.. cntd…
    4:41am, Jul 15 from HootSuite

    nrip: @cmioblog focus only on MU is an issue. offers the opportunity 4 vendors to stay simply within specs .. ok.. done.. but now lets open minds
    4:41am, Jul 15 from HootSuite

    CMIOblog: @nrip agree. #innovation is different for the clinician and for the vendor. I do agree with your comments though.

  • Without getting into debate about ideology, meaningful use requirements are compatible with an older model of software development favored by government and defense organizations: the waterfall model. They are less compatible with modern alternatives.

    Here’s one recent critique of the waterfall approach:

    A Better Project Model than the “Waterfall”

    http://blogs.hbr.org/cs/2012/07/a_better_project_model_than_the_waterfall.html

    Getting a bit more ideological (in the sense that an ideology is an encompassing worldview):

    “There is a dream dreamed by engineers and designers everywhere that they will someday be put in charge, and that their rigorous vision for the world will finally overcome the mediocrity around them once and for all. Resist this idea – the world does not work that way, and the dream of centralized control is only pleasant for the dreamer.” (Clay Shirky, An Open Letter to Jacob Nielsen)

    http://www.shirky.com/writings/nielsen.html

    Trying to channel Shirky (and apologies to him, if he ever reads it), I adapted his letter to apply to the EHR industry.

    Efficient and Moral Market-driven EMR and EHR Usability Innovation

    http://chuckwebster.com/2011/11/usability/efficient-moral-market-driven-emr-ehr-usability-innovation

    Efficiency, innovation, and morality. All hot buttons. Love the debate. Please keep it up!

    –Chuck

  • Nicely said. Enjoyed your thanksgiving post.

    I agree the proprietary format of EHRs and the lack of interoperability is holding back the type of progress you envision and that is sorely needed.

  • I’m glad to see the comments posted because they support their assertions with cites to back them up. This reinforces my first comment that the article posted from townhall.com lacks justification.

    Dr Hughes’ comments, for example, are based on his published observations and not simply assertions without backup.

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