Yves here. While this post on electronic health records may seem a big far afield of usual Naked Capitalism fare, it illustrates some of the themes we’ve seen in other contexts. The first is code is law, the notion that underlying, well-established procedures and practices are revised to conform to the dictates of computer systems, with result being crapification of the activity. Second is the distressing way that health care is becoming all about the money, with patient outcomes taking a back seat. This article describes in considerable detail how electronic health records, which in theory should reduce errors and allow for more consistent delivery of medical services, were instead designed only with patient billing and control over doctors in mind. As a result, they are if anything worsening medical outcomes.
By Informatics MD, a medical doctor, and medical informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine. Expertise in clinical IT design, implementation, refinement to meet clinician needs, and remediation of HIT projects in difficulty in both hospitals and the pharmaceutical industry. Former Director of Scientific Information Resources and The Merck Index (of chemicals, drugs, and biologicals) at Merck Research Labs. Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA.. Originally published at Health Care Renewal
The Citizen’s Council for Health Freedom (CCHF) is an independent 501(c)3 non-profit organization with a mission “to protect health care choices and patient privacy” (www.cchfreedom.org/about.php).
Its president, Twila Brase, wrote this piece about Electronic Health Records in the CCHF newsletter of June 18, 2014, observing some “inconvenient truths” and highlighting one of the most asinine statements I’ve ever seen about computers made by (of course) a venture capital official who happened to play a significant role in formulating the Affordable Care Act a.k.a. “Obamacare”:
The Truth about Electronic Health Records
Propaganda only works for so long. Pretty soon truth catches up to it. This is exactly what’s happening with electronic health records.
If you’re a doctor you know how bad the government-mandated electronic health record (EHR) is. But if you’re a patient, you may not realize that EHRs are endangering your life and jeopardizing medical excellence.
The EHR is nothing like what Big Government, Big Data, and Big Health said it would be. They promised convenience, coordinated care, fewer medical errors, more efficient medical practice, and portable medical records. They never meant it and it hasn’t happened. These data systems were created for billing, data collection and government control of doctors, not patient care.
From all I have seen over the years, I must agree with the last two sentences above. The pioneers who explored this technology back to the 1950’s warned against the nightmare that exists today, but I don’t think they believed we would ever get to where we are in 2014.
Further, while Politico did not explicitly mention risk to life and limb caused by these systems, Twila Brase did. “EHRs are endangering your life” is the elephant in the living room that the industry and its well-captured (and perhaps lubricated?) “regulators” simply will not address in a serious manner.
It has been my belief this reflects self-serving willful blindness, gross negligence and/or pecuniary motives, but I also believe that a fundamental malevolence on the part of people and organizations who know better increasingly needs to be considered as a contributor to the recklessness in the health IT sector. These are experimental technologies of admittedly (by the regulators) definite but unknown risk, due to impediments to that knowledge. Demanding their rapid diffusion under threat of penalty while knowing about the risks, and the uncertainty about magnitude, certainly does not reflect a benevolent disposition.
For more on the above points see my April 9, 2014 post “FDA on health IT risk: reckless, or another GM-like political coverup?” (http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html) and its 11 points and hyperlinks. This post and its linked brethren represents an indictment of sorts against the health IT hyperenthusiast culture and the unprecedented regulatory accommodation enjoyed by this sector.
Arthur Allen at POLITICO Pro eHealth (http://www.politico.com/story/2014/06/health-care-electronic-records-107881.html) says government-imposed EHRs are:
- Driving doctors to distraction
- Igniting nurse protests
- Crushing hospitals under debt
“In short,” he writes, “the current generation of electronic health records has about as many fans in medicine as Barack Obama at a tea party convention.“
I guess that’s Politco’s way of saying “not very many at all.”
Doctors forced to use these EHRs say:
- “They slow us down and distract us from taking care of patients.”
- “We’re basically key-punch operators, transcriptionists having to input the data ourselves. It has essentially tripled the time to complete a medical record.”
- “That’s why I’m retiring.”
- “Before I took notes, wrote what I wanted to say. Now I write and I click. If you just click, the person who reads the record gets no idea of what the patient was going through, your thought process.”
- “Anything that in a normal world would take at most two clicks, here it takes four or five.”
In fact, doctors and nurses forced to use this technology say far worse (e.g., see my posts on candid clinician feedback at http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html , http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html , http://hcrenewal.blogspot.com/2014/02/ehrs-real-story-sobering-assessment.html , and http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html).
Proponents falsely promised privacy. The real goal of Big Government, Big Data and Big Health was NO privacy. Data is valued as a tool of control and a means to profit. And today, 2.2 million entities today have legal access to your medical records without your consent because of the so-called HIPAA “privacy rule” and the 2009 HITECH Act. In addition, untold numbers of computer thieves, identity thieves and hackers have illegal access.
Not only that, but our data is sold in, in essence, data broker “back alleys” (e.g., see “Health IT Vendors Trafficking in Patient Data?” at http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html ).
Worse, the phenomenon of mismanagement of the “sales” is international in scope (e.g., see “NHS slammed for MAJOR data blunders as scale of patient info sell-off is revealed” at http://www.theregister.co.uk/2014/06/17/nhs_blamed_for_major_data_blunders_with_sale_of_patient_info_to_private_outfits/).
Every doctor and hospital must use EHRs by January 1, 2015 or face financial penalties. This was part of Obama’s 2009 Recovery Act, and the foundation of Obamacare. The sheer cost of the mandate has forced many doctors to shut down private clinics and become health system employees, susceptible to being told by outsiders how to practice medicine.
It has also led medical centers such as the University of Arizona Health System, about to undergo the stresses of mass immigration of South American children no less, to sink $30 million into the red in large part in trying to fix EHR bugs (see my June 2, 2014 post “In Fixing Those 9,553 EHR “Issues”, Southern Arizona’s Largest Health Network is $28.5 Million In The Red” at http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html).
Next Ms. Brase reveals a stunning fact about one of the architects of that 2009 Economic Recovery Act:
The arrogance of some EHR supporters is unpardonable. Bob Kocher helped write Obamacare, was trained as a doctor and is employed as a Venrock venture capitalist in health IT, but his credentials are those of a bureaucrat and profiteer (http://www.venrock.com/teammember/bob-kocher/).
Unpardonable arrogance indeed.
In other words, a speculator and profiteer in the health IT sector helped in the formulation of laws that pushed the technology onto physicians, nurses and hospitals with CMS penalties for non-adopters of “certified” systems. It would be interesting to know just how far such a potential conflict of interest went in the crafting of the ACA and HITECH itself.
Beyond that issue, this venture cap issues the following perverse statement, as cited by Politico and CCHF:
Per Politico pro eHealth, he says, “The reason so many [computers] are inefficient is that doctors are inefficient. If they redesigned their workflows, computers would work better.”
Readers of this blog are familiar with perversity in health IT, but that statement is literally stunning. It would make for a funny Saturday Night Live or Rowan and Martin’s Laugh-In (to us 60’s folks) skit if the topic were not so serious.
If they [doctors] redesigned their workflows, computers would work better?
Where, exactly, is the evidence for that assertion? Exactly how should doctors “redesign” their workflows, considering the poorly bounded, conflicted, highly variable, uncertain, and high-tempo nature of the field? 
How can one even have a well-defined and unvarying “workflow” in such a domain that would “make computers work better?”
Answer: it’s impossible.
(Perhaps patients should adjust the unpredictable nature of their illnesses and symptoms to make the computers work better, too?)
What Dr. Kocher seems to turn on its head is the recognition that:
“The reason so many [computers in healthcare] are inefficient is that they are grossly misdesigned for a domain like medicine. They are unfit for purpose. If they [the IT companies] redesigned their entire process in HIT production (from conception, design, implementation, marketing, and support) to be consistent with the needs of the field of clinical medicine and of clinicians, computers would work
better.” – Silverstein
The reality is that if the healthcare IT industry actually fired its ossified business-IT-oriented leaders (since business computing and clinical computing are two highly different fields, e.g., see http://hcrenewal.blogspot.com/2008/06/business-v-clinical-computing.html), or relegated them to managing accounting systems, and embraced the teaching of 50+ years of Medical Informatics in building good health IT (see definitions of good and bad health IT at http://cci.drexel.edu/faculty/ssilverstein/cases/), then we might actually get significant value and better safety from the technology.
Mr. Kocher, that’s an idea to consider.
As I wrote at that 2008 post on business v. clinical computing:
… The prevalent belief in MIS [management information systems a.k.a. business computing] seems to be that medicine is another area of transactional business subject to conventional modeling by generalists, to be followed by “business process re-engineering” and traditional information systems development processes and methodologies.
However, the belief that one could employ conventional business-oriented “analysis” in the clinical world always seemed to me to be oversimplistic, overoptimistic, and in fact not infrequently harmful to medical practice as a result of the simplistic assumptions. It is a belief that does not perform well even in the conventional business world where significant cost overruns, project difficulties, and project failures are commonplace, let alone in the unforgiving environments of medicine.
My fear is that many in business computing may lack the mental flexibility and capability to understand issues like that, that conflict directly with their linear-flow, business-oriented worldview.
In other words, Mr. Kocher wants doctors to practice according to the computer systems he helped impose, not the doctor’s patients. We must never let his agenda for medical practice prevail. State legislatures must act now to restore patient privacy rights and use Tenth Amendment powers to undo the EHR mandate.
Exactly. It’s certainly the simple way to big profits, and injured and dead patients be damned. Building good health IT is far more resource intensive.
Working to sustain an ethical patient-doctor relationship,
President and Co-founder
Thank heaven someone is working towards those ends.
 Per Medical Informatics researchers Nemeth and Cook’s “Hiding in plain sight: What Koppel et al. tell us about healthcare IT”, Journal of Biomedical Informatics 38 (2005) 262–263 available at http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf)