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Obamacare innovation: who does it benefit?

Obamacare innovation: who does it benefit?

The other day, when I was researching my post about Thomas Friedman and Obamacare, I contacted an old blogging buddy of mine – I was on the Watcher’s Council with him a few years ago – Scott Kirwin (aka The Razor).

Scott views Obamacare through the prism of his wife’s medical practice and his own experience in data processing.

While Scott hadn’t written the post I thought he had, our exchanges led to his own critique of the Friedman column, Electronic Health Records: The $6 Billion Cure For Bad Penmanship.

Being married to a doctor and an IT professional specializing in “big data” in the financial industry, I have watched the Wife’s experience with various EHRs with levels of amazement and dismay. It’s as if the lessons learned by the financial industry in the 1990s, such as poorly designed software that is incompatible with other software will cost more money to replace than it did to implement in the first place, have been completely lost by the lemming-like rush towards electronic health record (EHR, also known as electronic medical records EMR) systems.

The basic problem is that EHRs are not designed to suit the ways doctors practice. This is complicated by the fact that the way doctors practice varies between specialty, an orthopedic surgeon doesn’t practice medicine the way a primary care physician does, and by the additional complication that how doctors practice varies within the same specialty, often the same office. Even the same doctor will treat patients differently depending on what he feels works best for each patient. Yet these variances between specialties are only rudimentarily addressed within EHRs, and handle variance within specialties one of two ways, providing either a set workflow that dictates to the doctor the way she should practice, or one that provides so much flexibility that she is lost trying to get basic tasks.

The key decision in any software development is to address who the software is for and the key needs it is meant to address. Judging by the current EHR systems available none were designed for doctors. Instead they were designed for the employers of doctors such as large health systems, insurance companies and the federal government who are interested in aggregated data in order to answer questions such as “How many patients are uncontrolled diabetics?” or “How much is being spent on obesity-related illness?” These are questions which might be of interest to a doctor in general, but they are not what he’s thinking about when he’s facing his patient, say a morbidly obese, uncontrolled diabetic medicaid patient. Instead he is interested only in that particular patient’s problems. Is her agoraphobia contributing to her obesity, or is it the result of it? How can he wean her off HFCS soda and begin to move and diet when getting her into his office requires so much effort? Most of all, how can he encourage her to take an active role in her own medical care and help him treat her?

While I rejected Friedman’s premise that Obamacare spurred innovation, I accepted his premise that the innovations he wrote about would help improve healthcare. Scott’s well-documented response instructs otherwise. The innovations heralded by HHS and celebrated by Friedman are geared towards the government and insurers rather than doctors and patients. This is also a sense I got from a number of commenters.

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Comments

stevewhitemd | May 30, 2013 at 9:11 am

We use EPIC at my institution. It is flat out terrible: klunky, slow, confusing, poorly laid out and unsuited to the way most specialists practice. Of course, I’m required to use it for everything: write notes, look up labs and images, find consultation reports, bill, etc. It’s like a Swiss army knife designed by Hollywood actors.

The EMR indeed wasn’t designed for doctors: EPIC sure didn’t consult with me and our people, nor did our administrators. They imposed it and now I have to use it.

Sure would be nice if someone in the EMR industry read Apple’s “Human Interface Guidelines”.

    “…would be nice if someone in the EMR industry read Apple’s ‘Human Interface Guidelines'”

    Yes. But since most doctors are going to work for hospitals now, and all doctors are being forced to use EMR whether or not it works for their patients or their practice, there’s NO incentive for EMR companies to improve. Doctors have really no voice in this discussion.

    The EMR industry is very well-insulated from physicians’ concerns. Physicans aren’t paying the piper, so they can’t call the tune. Doctors complain, hospitals ignore, the EMR industry rakes in the Obamacare windfall $$$.

    Hospitals don’t care about (or even realize) how awful these error-generating systems are. But Obamacare creates enormous carrot & stick financial pressures to implement systems quickly and shoddily.

    “…they were designed for the employers of doctors such as large health systems, insurance companies and the federal government who are interested in aggregated data in order to answer questions such as… ‘How much is being spent..'”

    Exactamundo

    I went on a 20 minute rant with colleague this morning. (I’m a Cerner victim.)

    Ultimately, the mess is unlikely to be fixed because EMR is a win/win for everyone involved except the patient and the physician, who are the least important players in this equation. Plus, the problems are so arcane, nobody cares.

There’re good reasons they are referred to as “the healing arts”.

There is a fair amount of “art” employed by really good care-givers.

That does not lend itself well to the stolid regimentation of a Big Brother/IRS/HHS command and control system.

Join me in simply saying NO!

june beamer | May 30, 2013 at 9:31 am

I am another lady MD who is married to an IT guy who has watched me fume and complain through EHR decisions and implementation. After buying other EHR systems that we never implemented because they were so bad, I asked dear husband to search the internet for doctor friendly EHRs. He found it, it is Modernizing Medicine that uses adaptive learning technology to think exactly how I work. All done in an i-Pad!

    Fortunately, you apparently have a choice. And you chose a system specifically designed for surgical subspecialties. Not surprising that a good system could be designed for ortho, ophtho, et. al. Other specialities put much greater demand on complex CPOE and more extensive documentation. I have yet to hear of a system that yields itself well to the demands of hospitalists, for example. EMR technology simply isn’t ready for primetime. Too bad the free market wasn’t allowed to sort this out.

David,
Thanks for the write up on my piece. There’s so much I want to say about the integration of technology with Medicine that I’ll be writing more about it in the future. The abuse of IT is one of my pet peeves, and no industrial sector abuses IT more than medicine.

One thing I’d like to point out is the success of IT in the financial field. Medical professionals and administrators look at how IT has changed finance and want to do the same to the medical field. They don’t recognize that computers share the heart of the finance industry, the tabulation of numbers. The integration of IT and automation was a symbiotic at times and almost “natural” evolution, with finance pushing tech to do more, and the responding to what tech provides. Take today: the vast majority of trading on international stock markets are done by algorithms-based autonomous programs.

But this success masks the long line of failures, tech dead ends, and the hundreds of billions blown on software projects that never delivered anything beyond piles of floppy disks, cds, dvds and network storage drives.

The current push for IT in medicine is top-down and “big bang”, being pushed by the government as part of Obamacare and (so-far) failed attempts at controlling the costs of Medicare and Medicaid. Contrast this with the bottoms-up incremental approach of software development in the financial industry. In my experience the latter type projects are much more likely to succeed than the former.
And if a small $15 million project fails, you’ve risked much less than when a $1.5 billion project fails.

Sound like the United States Patent and Trademark Office, which FIRST had to develop it’s own record capture software (Windows compatible, only) instead of using the then-readily-available .pdf format. I tried that software, which would alter the text, pagination, and some symbols in a document. Naturally I never used it to file a client paper.

Now the USPTO accepts .pdfs for electronic filing. It took them years.

Lady Penguin | May 30, 2013 at 10:29 am

Medicine is an “art,” not a total mathematical science, at least not yet, and not totally. Part of what we’re seeing in the takeover of life by technology – if these technologies did not exist they couldn’t do this with the EHRs. Yet, now we see the health practitioner spending almost the entire patient interface time looking at a screen and not the patient. Impersonal and lacking in one of the key components of good medical practice – assessment. Everything is about the lab results, yet there are only “averages” causing the numerous exceptions to the “normal ranges” to be missed and inadequately treated.

I’ve seen my own practitioner try to order a simple TSH, but the program forces at least 3 other unnecessary thyroid tests. Unless a hand written lab order overrides the program, insurance is actually paying more not less because of the software design problems.

One other thought, I consider Obamacare a complete violation of HIPAA. While they make you stand so many feet behind the customer in front of you at the MD office or pharmacy, the government now has on file your entire health history, diagnoses, and treatment. You think the targeting of conservative(s) was bad with tax issues and the IRS, wait until the statist, Dem dominated bureaucracy has your personal info and the ability to control your healthcare…

As a finance professional for 15 years, I can support the amount of wasted money and time spent over the years as we continue to reinvent the wheel. Each new variant may add some new, unique and usable feature but they (IT meanies) always seem to simultaneously take away something that everybody used regularly. Net = sero improvement. Our current “new and improved” platform is rife with freaky, hidden new applications but nobody is effectively using them because the whole opeating system is still herky, jerky and finiky. My sympathies to all you medical professionals. JBB

dorsaighost | May 30, 2013 at 5:47 pm

This is a classic case of never measure and start cutting … it appears the only “requirement” they worked off of was what data was needed at the end of the chain … while that is certainly something that needs to be in the mix it should have been part of the “business requirement” that should have been done before a single line of code was written …
the fact is some pieces of data would never be part of a doctors daily routine (working with the morbidly obese, uncontrolled diabetic medicaid patient for example). Now because the government wants to measure something doctors (or their staff) will have to input it … more top down big data nonsense …

there is a faith that with “enough” data anything can be predicted in society (or finance)… that is a faith that has less empirical evidence than the existence of God but it never seems to stop the true believers …

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