Sunday, February 22, 2015

On Electronic Health Records and Meaningful Use Incentives

Many medical students, particularly pre-clinical medical students, do not understand the utter insanity and horror that is electronic health records/electronic medical records (EHRs/EMRs).  Instead, you will find many that endorse such programs as the be-all end-all and cure to the terrible days of handwritten records.  In such EMRs, we are promised, is the potential for limitless medical discovery and efficiency.  This ethos is shared by many in healthcare administration and others who are not clinicians.  The Federal government has bought this hook, line, and sinker and is poised to impose financial penalties upon any healthcare provider who does not use EMRs.  As an aside, this is not attributable to the ACA/Obamacare- the EHR companies have their tendrils into US Department of Health and Human Services, and it was under Bush that the first meaningful use incentives began to come out if I recall correctly.  However, Obama has continued this trend with his ACA, and his recently announced initiative to use large scale data collection from EMRs combined with genetic data- which he is calling Precision Medicine.

I fully support the use of big data, but I think EHR incentives/penalties are a terrible idea.


I'm a student of Dan Ariely, who is a behavioral economist at Duke. I mainly use his theories when I'm talking about/thinking about practical ethics and improving behavior, but it applies to a surprisingly wide field of human endeavors.

One of the things that's really stuck with me is to always analyze exactly what we're incentivizing, and to remember that profits and money are often very blunt motivating factors. Rather like using amphetamines for weight loss (which by the way is an FDA-approved indication)- it works, but it frequently has all kinds of bad side effects. If we tell cops "we will promote and pay you an extra $10,000 if your beat has less crime", what are they going to do? Some might work as hard as they can to reduce crime. Others will record that a murder was an accident, and that an rape was a simple assault to make their numbers look good without actually doing anything to reduce crime. (This happened in New York City, and the whistleblower who exposed it was sent to a mental hospital for four days by his fellow police officers, as chronicled in This American Life).

Think about it like this: in the 1980s, the Veterans Affairs hospitals came up with an EHR, that is still surprisingly good in retrospect. It wasn't incentivized, no governmental organization pushed for it- the doctors who worked there wanted a way to access records, and programmed the system themselves. It was beautiful and effective (for 1980 anyway). Why? Because doctors' only incentive was to produce and use a system that worked for them and their practice. It was adapted throughout the VA system because it was effective- not because anyone forced them to.

What are the incentives around EHR now? Physicians are told that if they don't adapt one of a very limited menu of EHRs, they will start getting fined (or won't get a bonus payment, same thing really). In other words, physicians aren't incentivized to pick an EHR that works for their practice, that is better than paper charts, and which helps their patients: they're incentivized to pick the cheapest EHR that they can tolerate. And what's more, companies don't have an incentive to produce a beautiful, usable EHR that is better than paper charts- they just have to be better than the other guys- who all suck. What's more, who's buying these systems? Hospital administrators- who want the ability to bill for everything. Not doctors concerned about working efficiently and safely.

How can we safely and effectively incentivize EHRs? Simple- we regulate the companies. We demand that companies produce EHRs that are compatible with a common standard set by an organization like the AMA, which has not been captured by EHR companies like the Department of Health and Human services has. Then, we let doctors naturally migrate to any company that meets their needs- once it meets their needs and expectations.

Yes, it will take longer but in the meantime: patient safety, physician satisfaction, and so many other things will be better. I fully believe in the dream of big data to solve healthcare problems. But the data that EHRs are now outputting is so flawed as to be useless- physicians clicking "wnl" buttons and blindly ignoring dozens of alerts for allergic interactions. Not to mention: blatant misinformation to satisfy the EHR's electronic demands (as someone who is on clinicals, as me how many physicians actually ask/counsel about tobacco use reduction, and how many click yes on the box that prompts them about it).  We need to stop this madness, and end the government/payer demands upon clinicians to use EHRs.  Doctors care about their patients, and more importantly hate writing things by hand as much as anyone else.  They will jump to EHRs with no incentives needed- once it meets their needs and expectations.