• Republican Senators want changes to meaningful use

    I think I need a macro for posts like this one. But here’s the gist. I love information technology, but am skeptical about its “imminent” widespread use. This is in part because doctors don’t like electronic records in general, and in part because the meaningful use requirements for EHRs don’t really address the problems they face. I have long maintained that the biggest problem is a lack of standards for such systems.

    It turns out that a number of Republican Senators agree with me:

    On Tuesday, six Republican senators released a 28-page white paper — titled, “REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT” — outlining their concerns about current federal health IT policy, FierceEMR reports.

    The white paper accompanied a letter that the six lawmakers sent to HHS Secretary Kathleen Sebelius. The letter requested information about the agency’s progress in promoting electronic health record adoption through the meaningful use program…

    In the white paper, the lawmakers acknowledged that the meaningful use program aims to improve health care quality and reduce costs. However, they wrote, “nearly four years after the enactment … we see evidence that the program is at risk of not achieving its goals and that $35 billion in taxpayer money is being spent ineffectively in the process.”

    I read the letter, and it asks for a lot of information from HHS. I can’t tell how much of it is due diligence and how much is just a painful demand for busywork. However, the white paper is interesting. It identifies five major issues:

    • Despite expectations of cost savings, the digital systems may be increasing unnecessary medical tests and billings to Medicare.
    • The government has not demanded that the various digital systems be able to share medical information, a critical element to their success.
    • Few controls exist to prevent fraud and abuse. Many doctors and hospitals are receiving money by simply attesting that they are meeting required standards.
    • Procedures to protect the privacy of patient records are lax and may jeopardize sensitive patient data.”
    • It remains unclear whether doctors and hospitals that have accepted stimulus funding will be able to maintain the systems without government money.

    I think a number of these are spot on. There’s evidence for the first. My anecdotal experience tells me the third is somewhat true. The fourth is always a concern, and the fifth is something I agree with as well. But it’s the second that I can’t endorse loudly enough. If there’s one thing I want out of meaningful use, it’s a requirement that data be potentially imported and exported in one standard format. If we just got that, EHRs would be so much more useful.

    I look forward to the administration’s response to this. Given the fact that these requests are coming from Republican Senators, I’m more optimistic than usual that perhaps the HITECH Act could be amended to include some of these requirements.


    • Strongly agreed, the lack of interoperability seems like the #1 barrier to effective EHR use. There’s little incentive for EHR manufacturers to make interoperable systems, since they want to keep people buying their technology. The later iterations of meaningful use may have stronger interoperability requirements, but we’re not there yet.

    • What’s on the horizon will make implementation of EMR look easy. It’s wireless monitoring of patients’ vital signs. And patients will expect it because it will give them the (false) impression of having a physician watching over them 24-7. Talk about information overload. It’s coming soon. Cardiologists and pulmonologists will be in the first wave.

    • extending digital infrastructure into healthcare is an enormous undertaking

      these two blogs provide a helpful way of following developments



    • I suppose rather than pointing out the irony of Republicans calling for more regulations on business in the form of mandatory EHR interoperability we should just be quietly grateful they are doing so.

      • Agreed. There should be room for bipartisan compromise on this issue, as long as their critiques are in good faith (and not about obstructing the process of ACA implementation)

    • Sounds promising. But will everyone adopt a universal protocol, something like HTML5 for the internet? And will the government be responsible for setting up such a protocol or will the market have to go through a battle like HTML5 and flash? I guess these are uncharted areas of HIT.

      Another thing struck me when I was talking to doctors. Some people are trying to develop adaptor programs to bridge different EHRs. Whether these programs will be successful in the market and how they fit into the larger picture, we shall see.

    • There are standards in the healthcare industry for sending/receiving health information (HL7, IHE, CCD/CDA etc…).

      I believe security for patient data is being finalized by the standards bodies now. From what I see, most of the time it is human error, exposing PHI.

      One of the issues is that some of the large inpatient HIS vendors and some ambulatory EMR/EHR vendors are not willing to “play nice” and most want everyone to buy/use their products only.

      There are many vendors that can “bridge” these connection and translate data into proper standards.

      Maybe it is more of a governance issue with the participating organizations in the healthcare communities wanting to exchange data.

      Important to note, that only a few years ago, most everyone was still on paper.

    • “There’s evidence for the first. ” –Could you point me to some papers that have been written on this? The concern that the electronic medical systems have been increasing unnecessary tests was raised at a hospital where I do research, so Im wondering what research has already been done on this.

      From what I’m told, this seems to be due to failure to consider doctors’ behavioral/psychological responses to the software interface. That is, the arrangement of various options in the software implicitly shifts the “overton window” of what is appropriate for the circumstances. For example, the hospital observed that when the software includes a prominently placed option to have a test (which is normally needed only once) repeated on a weekly or daily basis, doctors (young fellows and residents in particular) were much more likely to decide to order repeat (and useless) tests.

    • I agree that these things should be looked at but I don’t trust the Republicans who wrote the letter to be above an attempt to scuttle ACA.

      The lack of interconnectivity is huge — not only do EHRs not talk to one another they don’t talk to HIEs. I wish that had been part of the original requirements.

      That patient data can be more secure than anything else hacked or hackable on the web is fallacy and we should not pretend that it is possible — nor should healthcare providers be held accountable for what the industry itself cannot provide.

      • Agree on the trust issue with the people making the request. But disagree on the technical ability to electronically share information between EHRs and HIEs. This is being done securely all over the country today.

        Problem is the governance of the HIEs and getting the participating vendors all working together.

    • Agree with the Rob S comments. A single national health record would theoretically solve the HIE issues and is not only politically unfeasible, but unsustainable. Imagine a federal EHR system’s funding under a Republican administration. We might get started under a Dem, but it would quickly fall behind industry standards as it was fiscally gutted by the right.

      Equally concerning Is that each private vendor knows they have the solution and if everyone else would adopt it all would be well. This is the challenge with the HL7 standards and similar ! They kind of work for everyone but don’t really work for anyone