In Second Look, Few Savings From Digital Health Records

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    Jan 14, 2013 4:38 PM GMT
    Oops...

    http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html

    The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.

    Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.

    “We’ve not achieved the productivity and quality benefits that are unquestionably there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.

    RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

    The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.

    “RAND got a lot of attention and a lot of buzz with the original analysis,” said Dr. Kellermann, who was not involved in the 2005 study. “The industry quickly embraced it.”

    But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.
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    Jan 14, 2013 6:09 PM GMT
    Not oops, but there are reasons why the savings might not be there yet:
    http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/11/why-electronic-health-records-failed/
    Read the whole thing, but here's the relevant graph:
    F1.large-11.jpg

    For comparison, the UK, Australia, Netherlands and NZ has >90% doctors working with EMRs. You can't declare a thing a failure before it's used by the majority of people.

    The lack of interoperability is the bane of my life. I have to physically type in labs from companies that aren't compatible with our system (which is a fairly widely used one). Records from other doctors I still have to enter by hand.

    However, I know in my practice I've saved productivity and money, even after figuring in the price of the EMR itself. We're ordering fewer labs that other doctors have ordered. And another thing: my secretaries have fewer paper cuts and are grumbling less. icon_lol.gif
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    Jan 14, 2013 6:43 PM GMT
    q1w2e3 saidNot oops, but there are reasons why the savings might not be there yet:
    http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/11/why-electronic-health-records-failed/
    Read the whole thing, but here's the relevant graph:
    F1.large-11.jpg

    For comparison, the UK, Australia, Netherlands and NZ has >90% doctors working with EMRs. You can't declare a thing a failure before it's used by the majority of people.

    The lack of interoperability is the bane of my life. I have to physically type in labs from companies that aren't compatible with our system (which is a fairly widely used one). Records from other doctors I still have to enter by hand.

    However, I know in my practice I've saved productivity and money, even after figuring in the price of the EMR itself. We're ordering fewer labs that other doctors have ordered. And another thing: my secretaries have fewer paper cuts and are grumbling less. icon_lol.gif


    So the solution as it is with all failed government solutions you seem to believe and advocate for is to spend more money in the hopes that it will eventually work... good plan... how nice for you that this isn't your money.
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    Jan 14, 2013 6:47 PM GMT
    It is working for systems with no interoperability problems, namely, the VA.

    And no, it's my money too, and I'm already saving money. Without the government incentive to go for the EMR, we probably wouldn't not have made the jump.

    Nearly all the other industrialized countries have way more EMR usage than we do and I dare say their health expenditures are lower partly because of that. That's is a shame.

    You're declaring something a failure prematurely. The stimulus for adopting EMRs made many of us adopt EMRS just during the last few months of 2012 (even though we've had ours for 1 year already). So that RAND study is like really, really premature. Much of the requirements for interoperability won't even take place till 2014.
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    Jan 14, 2013 7:07 PM GMT
    q1w2e3 saidIt is working for systems with no interoperability problems, namely, the VA.

    And no, it's my money too, and I'm already saving money. Without the government incentive to go for the EMR, we probably wouldn't not have made the jump.

    Nearly all the other industrialized countries have way more EMR usage than we do and I dare say their health expenditures are lower partly because of that. That's is a shame.

    You're declaring something a failure prematurely. The stimulus for adopting EMRs made many of us adopt EMRS just during the last few months of 2012 (even though we've had ours for 1 year already). So that RAND study is like really, really premature. Much of the requirements for interoperability won't even take place till 2014.


    And yet, in the rush to dole out the cash for "stimulus" as the report shows, there was no push for interoperability of these systems - which suggests that even with greater adoption, how will this necessarily result in greater savings?

    Ontario has done something similar, massively bungling EMR and as have other provinces and countries. The problem with these initiatives - however well intentioned is that they are more about building systems to meet the needs of bureaucrats and providers who are pushed to choose between inadequate systems in a rush to avoid losing out on this gravy train.

    It's a no brainer that improved IT and information should result in savings and even saving lives - especially in healthcare - unfortunately in practice and how it has been implemented, this suggests this has been far from the case. Instead you have people who aren't responsible for the costs involved benefiting from the ability to spend other people's money.
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    Jan 14, 2013 7:11 PM GMT
    From the article:

    Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously.

    ¶ The 2005 RAND report helped Cerner executives and others sell the new systems, despite criticism at the time that the analysis was too rosy. RAND said that the report was not influenced by its financial backers and that, in fact, it disclosed the corporate sponsorship prominently in the report itself.

    ¶ The study was harshly criticized by the Congressional Budget Office for overstating expected savings.

    ¶ The new analysis was not sponsored by any corporations, said Dr. Kellermann, who added that some members of RAND’s health advisory board wanted to revisit the earlier analysis.

    ¶ Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.

    ¶ “The vast sum of stimulus money flowing into health information technology created a ‘race to adopt’ mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow,” Dr. Brailer said.
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    Jan 14, 2013 7:37 PM GMT
    The stimulus was not designed to be a cure-all. The carrot part of it did increase adoption rates of EMRs from 10 to 30%, and probably more in the coming years when the stick part of the deal comes (i.e. penalties for not having an EMR). It would have stayed at 10% without it.

    The problem with interoperability is a problem of the market itself. There are simply too many vendors. To mandate that everybody use a single standard is not going to work. The requirement for interoperability is in Stage 2 of meaningful use (i.e. it's coming) that vendors will have to certify. Nothing happens overnight, least of all something as complex as interoperability.

    As with everything else, buyers beware. We shopped for our EMR for a full 9 months before buying ours, and I was positively sick of the 6-7 presentations I had to endure at the end of the day from the vendors. I personally visited other doctors' offices to see how their EMRs worked in real life. But it paid off. (We specifically did not buy an Allscripts product)

    If the VA CPRS system had a billing system we would have used it. But alas, we're in USA with its myriad of insurances.
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    Jan 14, 2013 7:40 PM GMT
    Let me ask you a question: how would you have implemented it in real life?
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    Jan 14, 2013 9:24 PM GMT
    q1w2e3 saidLet me ask you a question: how would you have implemented it in real life?


    Subsidies and outright graft given how lobbyists worked with the US government to push for the parameters of these systems, invariably cause unintended consequences - particularly with vendors who were never ready in the first place. The right approach wouldn't have been to throw money at the random issue in hopes that by spending it by a certain deadline you would have a system that worked.

    Incidentally the convoluted classification system that forms the basis for nearly all health insurers in the US comes from ... medicare! If the savings are possible, it was necessary for the government to throw so much money at what individual firms would have done on their own as the return on investment became clearer. The one thing that the healthcare system truly lacks is transparency - particularly on costs. If an intervention is necessary, that's what I would regulate - ensure portability of medical records and the least number of mandated standards as possible - and if you insist that the government needs to spend money, spend it on results - not on the process and share on the supposed anticipated savings.

    Given that Medicare is the largest insurer and sets the standard for nearly all insurers, if there's truly a cost savings in paperwork, pass those savings along to participating practitioners who use online systems. Above all things, force doctors and hospitals to disclose the costs and outcomes in aggregate publicly if they want to accept Medicare/Medicaid.
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    Jan 14, 2013 10:28 PM GMT
    q1w2e3 saidIt is working for systems with no interoperability problems, namely, the VA.

    And no, it's my money too, and I'm already saving money. Without the government incentive to go for the EMR, we probably wouldn't not have made the jump.

    Nearly all the other industrialized countries have way more EMR usage than we do and I dare say their health expenditures are lower partly because of that. That's is a shame.

    You're declaring something a failure prematurely. The stimulus for adopting EMRs made many of us adopt EMRS just during the last few months of 2012 (even though we've had ours for 1 year already). So that RAND study is like really, really premature. Much of the requirements for interoperability won't even take place till 2014.


    He doesn't like it because it's being promoted etc by a Liberal gov't. You'll notice he says zip about Canada doing the same thing, because here it's being done by a federal Conservative party. icon_lol.gif

    http://northvanconservative.ca/index.php?option=com_content&task=view&id=12&Itemid=5
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    Jan 14, 2013 10:54 PM GMT
    meninlove said
    q1w2e3 saidIt is working for systems with no interoperability problems, namely, the VA.

    And no, it's my money too, and I'm already saving money. Without the government incentive to go for the EMR, we probably wouldn't not have made the jump.

    Nearly all the other industrialized countries have way more EMR usage than we do and I dare say their health expenditures are lower partly because of that. That's is a shame.

    You're declaring something a failure prematurely. The stimulus for adopting EMRs made many of us adopt EMRS just during the last few months of 2012 (even though we've had ours for 1 year already). So that RAND study is like really, really premature. Much of the requirements for interoperability won't even take place till 2014.


    He doesn't like it because it's being promoted etc by a Liberal gov't. You'll notice he says zip about Canada doing the same thing, because here it's being done by a federal Conservative party. icon_lol.gif

    http://northvanconservative.ca/index.php?option=com_content&task=view&id=12&Itemid=5


    Oh you beclown yourself again as you almost invariably do on any substantive public policy issue. icon_wink.gif

    No I don't like it because it has been a waste of money and of those who are implementing it now here, they also complain they are skeptical of the cost savings and if anything it has been driving up costs to their practices - at least in Ontario. In the US now we have a study that isn't paid for by the IT industry that shows that it may in fact be driving up costs. The subsidies in the US were somewhere in the order of $44,000 for each physician.

    You seem to cling to party lines and therefore think others do too. The spending and push in this area has largely been shown to be an abject failure. Incidentally I did mention Canada - ie Ontario above.
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    Jan 14, 2013 11:42 PM GMT
    riddler78 said
    q1w2e3 saidLet me ask you a question: how would you have implemented it in real life?


    Subsidies and outright graft given how lobbyists worked with the US government to push for the parameters of these systems, invariably cause unintended consequences - particularly with vendors who were never ready in the first place. The right approach wouldn't have been to throw money at the random issue in hopes that by spending it by a certain deadline you would have a system that worked.

    Incidentally the convoluted classification system that forms the basis for nearly all health insurers in the US comes from ... medicare! If the savings are possible, it was necessary for the government to throw so much money at what individual firms would have done on their own as the return on investment became clearer. The one thing that the healthcare system truly lacks is transparency - particularly on costs. If an intervention is necessary, that's what I would regulate - ensure portability of medical records and the least number of mandated standards as possible - and if you insist that the government needs to spend money, spend it on results - not on the process and share on the supposed anticipated savings.

    Given that Medicare is the largest insurer and sets the standard for nearly all insurers, if there's truly a cost savings in paperwork, pass those savings along to participating practitioners who use online systems. Above all things, force doctors and hospitals to disclose the costs and outcomes in aggregate publicly if they want to accept Medicare/Medicaid.


    Well, you could say the same thing in your first paragraph about any industry now in the US...they all have lobbies in Congress. It's just a matter of whether they have ears and deep pockets. The oil and gun industries certainly have their share of causing unintended consequences. icon_lol.gif

    Your 2nd paragraph deals with coding. I agree with you, it's convoluted, but Medicare isn't really the problem. ICD predates Medicare a lot (see the historical section in Wikipedia on ICD). The problem is the fee-for-service culture that's entrenched way before Medicare. But if we have to code for service, it's bound to be complex, because medicine is getting more complex.

    As for portability, it's in the meaningful use criteria 5 of Stage 1. So it's already in there.

    I'm not sure about your cost savings in paperwork being passed from Medicare to providers...because already we're saving lots of time with our new billing system, without the need for paper submissions.

    For cost disclosure, Medicare has a set rate for all procedures which is visible on their website. You'll have to ask the insurance companies to disclose theirs.

    Outcome disclosure is still in its infancy. Some measures (like giving antibiotics within a certain number of hours in the ED for pneumonia, or time to cath lab) are debatable and produce other unintended consequences. But I do agree with you, it's a worthy goal. Several of the Meaningful Use criteria actually ask EMRs to measure clinical outcomes (e.g. number of patients with Hgb A1c and BP within goal). And criteria 10 of stage 1 actually requires hospitals to be able to capture data with their EMRs to report quality measures to CMS and states.

    So see, they HAVE thought of everything...just not that they advertise it to everybody. icon_lol.gif
    https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MU_Stage1_ReqOverview.pdf
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    Jan 15, 2013 1:30 AM GMT
    q1w2e3 said
    riddler78 said
    q1w2e3 saidLet me ask you a question: how would you have implemented it in real life?


    Subsidies and outright graft given how lobbyists worked with the US government to push for the parameters of these systems, invariably cause unintended consequences - particularly with vendors who were never ready in the first place. The right approach wouldn't have been to throw money at the random issue in hopes that by spending it by a certain deadline you would have a system that worked.

    Incidentally the convoluted classification system that forms the basis for nearly all health insurers in the US comes from ... medicare! If the savings are possible, it was necessary for the government to throw so much money at what individual firms would have done on their own as the return on investment became clearer. The one thing that the healthcare system truly lacks is transparency - particularly on costs. If an intervention is necessary, that's what I would regulate - ensure portability of medical records and the least number of mandated standards as possible - and if you insist that the government needs to spend money, spend it on results - not on the process and share on the supposed anticipated savings.

    Given that Medicare is the largest insurer and sets the standard for nearly all insurers, if there's truly a cost savings in paperwork, pass those savings along to participating practitioners who use online systems. Above all things, force doctors and hospitals to disclose the costs and outcomes in aggregate publicly if they want to accept Medicare/Medicaid.


    Well, you could say the same thing in your first paragraph about any industry now in the US...they all have lobbies in Congress. It's just a matter of whether they have ears and deep pockets. The oil and gun industries certainly have their share of causing unintended consequences. icon_lol.gif

    Your 2nd paragraph deals with coding. I agree with you, it's convoluted, but Medicare isn't really the problem. ICD predates Medicare a lot (see the historical section in Wikipedia on ICD). The problem is the fee-for-service culture that's entrenched way before Medicare. But if we have to code for service, it's bound to be complex, because medicine is getting more complex.

    As for portability, it's in the meaningful use criteria 5 of Stage 1. So it's already in there.

    I'm not sure about your cost savings in paperwork being passed from Medicare to providers...because already we're saving lots of time with our new billing system, without the need for paper submissions.

    For cost disclosure, Medicare has a set rate for all procedures which is visible on their website. You'll have to ask the insurance companies to disclose theirs.

    Outcome disclosure is still in its infancy. Some measures (like giving antibiotics within a certain number of hours in the ED for pneumonia, or time to cath lab) are debatable and produce other unintended consequences. But I do agree with you, it's a worthy goal. Several of the Meaningful Use criteria actually ask EMRs to measure clinical outcomes (e.g. number of patients with Hgb A1c and BP within goal). And criteria 10 of stage 1 actually requires hospitals to be able to capture data with their EMRs to report quality measures to CMS and states.

    So see, they HAVE thought of everything...just not that they advertise it to everybody. icon_lol.gif
    https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MU_Stage1_ReqOverview.pdf


    Not really - given that not all other industries got billions in subsidies. But here's the problem - this rush to emr is one of the causal problems for the disastrous implementation. This is after all, a 30 billion dollar implementation. All is as was predicted:
    http://www.huffingtonpost.com/stephen-soumerai/dont-repeat-the-uks-elect_b_790470.html

    I am not sure that I would say that one system should have been built, but surely given the prevalence of Medicare - there could have been leadership there of a template of how the most basic systems should interact and leave other features to the demand of users/practitioners. It's the complexity that generally kills you and is a significant issue for implementation. Trying to "think of everything" is part of the problem in this regard - at least when it comes to specifications.

    And no, I'm not talking about cost disclosure, I'm talking about pricing in general - Medicare could require public disclosure of both prices without insurance and what they pay out for procedures. And no, it's not necessary to ask private insurers to disclose costs if that's the case.

    A lot of pricing can be disclosed right now but many hospitals and practitioners refuse/are resistant to do so because they fear that patients won't understand as there is only I imagine a very real fear of price competition - both price and quality disclosures are necessary for this to happen and in turn for there to be cost savings for both the users of healthcare and providers.

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    Jan 15, 2013 1:54 AM GMT
    I do like the open-source idea...the VA CPRS would be an example. However, medical practices and hospitals are busy places, and unless you have a dedicated, computer-savvy guru hired by each practice, you won't see adoption any time soon. (I had trouble initially convincing my colleagues to use the EMR we have right now, imagine having them beta-test stuff) Doctors are lazy people when it comes to change, but once they make the change, they tend to stick to it.

    "Meaningful use" is actually what you're talking about in terms of the "basic template" of what EMRs should have. Some of these "meaningful use" standards are really just common sense (e.g. EMRs should be databases that contain basic information such as allergies and med lists and be able to print out a summary for patients). The "standards" that are missing in interoperability have more to do with the technical details of coding for that information. That's where the complexity and interoperability problems come in--how to communicate the basic information that EMRs need to have between themselves.

    That's a problem of software. Right now, there is no .gif file for medical records, even though the 256-color standard for medical information is there. Also, there is no Microsoft in this market, and there is no Linux yet.

    On price disclosure: Prices are negotiated between hospitals and insurance companies. Some discounts might be trade secrets, both might say. If one has to do it, the other has to agree.

    My final thoughts on EMRs: It's not like you have to learn to play the violin at 5 to be a genius, but rather it's a marathon, and to declare a toddler a failure running marathons is premature.

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    Jan 15, 2013 4:44 PM GMT


    "You seem to cling to party lines and therefore think others do too."


    ROFL! Project much?
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    Jan 26, 2013 12:39 AM GMT
    q1w2e3 saidI do like the open-source idea...the VA CPRS would be an example. However, medical practices and hospitals are busy places, and unless you have a dedicated, computer-savvy guru hired by each practice, you won't see adoption any time soon. (I had trouble initially convincing my colleagues to use the EMR we have right now, imagine having them beta-test stuff) Doctors are lazy people when it comes to change, but once they make the change, they tend to stick to it.

    "Meaningful use" is actually what you're talking about in terms of the "basic template" of what EMRs should have. Some of these "meaningful use" standards are really just common sense (e.g. EMRs should be databases that contain basic information such as allergies and med lists and be able to print out a summary for patients). The "standards" that are missing in interoperability have more to do with the technical details of coding for that information. That's where the complexity and interoperability problems come in--how to communicate the basic information that EMRs need to have between themselves.

    That's a problem of software. Right now, there is no .gif file for medical records, even though the 256-color standard for medical information is there. Also, there is no Microsoft in this market, and there is no Linux yet.

    On price disclosure: Prices are negotiated between hospitals and insurance companies. Some discounts might be trade secrets, both might say. If one has to do it, the other has to agree.

    My final thoughts on EMRs: It's not like you have to learn to play the violin at 5 to be a genius, but rather it's a marathon, and to declare a toddler a failure running marathons is premature.



    http://dailycaller.com/2013/01/21/obamas-great-health-leap-forward/

    Again, it’s possible that electronic records will eventually pay huge benefits, once an entire network (or maybe a better, voice-activated entry system) is in place. Or it’s possible that Dr. Groopman and Dr. Hartzband’s skepticism will be borne out–and that the real purpose of the electronic database will not be to help achieve better, efficient care but to justify the government in stopping treatments deemed cost-ineffective.

    Some of the early software systems are apparently particularly kludge-y–but that doesn’t get Obama off the hook if, as Emailer #2 suggests, his $19 billion incentive encouraged hospitals to hurriedly adopt these inferior systems in order to get federal cash before the 2014 deadline.


    At this point it seems just as likely if not more that the the pressure to spend the cash at the behest of lobbyists has meant that the money has been spent poorly and will cost a lot more than it will ever save, and your experience seems to be the exception rather than the rule.
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    Mar 27, 2013 10:37 PM GMT
    "More on the Obamacare IT nightmare"
    http://washingtonexaminer.com/more-on-the-obamacare-it-nightmare/article/2524900