Update on CHIT

Since my last post on CHIT, the economic stimulus package has been passed, and includes on the order of $20 billion to support the development of electronic medical records.  A few observations:

- The UK had a nationalized health care system, with standardization at many levels, for decades before it embarked upon its still floundering efforts to create an electronic medical record.  The amount budgeted is far less than what the UK has spent thus far.  The population of the US is several times larger than the UK, our health care system is nearly completely decentralized, and there is little standardization outside of health care directly provided by the US government.  It is likely that several times this amount would be required to arrive at the same point as the British – which is close to nowhere.  In short, the amount allocated is not even close to enough to begin to deal with the US problem, let alone craft any functioning product.  If the US experience replicates the UK experience, then the amount of money budgeted is far, far short of what will be required. 

- How is this money to be spent? This is not a trivial question, but in fact a central question.  There are major vendors of CHIT in the US, but their business model is of proprietary software and databases.  The kind of portability and accessibility that proponents of the EMR (Electronic Medical Records) tout are anathema to the business models of these vendors. Are the feds to choose one (and compel the scrapping of the competitors)? If history has taught us anything, it is government granted monopoly to any private corporation is a prescription for delay, cost overrun, inefficiency, and corruption.  Are the Feds to start from scratch? Are they to stipulate some sort of standard? Either would have the effect of undoing a substantial percentage of the experience and investment in systems to date.

- Can we even find efficient use for the money that has been allocated? Quite seriously, no one has ever had this kind of money to spend on the development of an EMR before. We’re clearly not ready to commence production, and we may not even know where we are in development.  Can there possibly be enough researchers and developers to efficiently and effectively utilize $20 billion dollars in funding?  The most likely answer? Somewhere between doubtful and inconceivable.  Make no mistake: the funds at issue will generate a huge number of ‘instant experts’ and draw everyone with remotely relevant experience into the endeavor. Sadly, there is no one with a large scale success to be recruited, because no one has had success on a large scale.

Comments

[Mitch Keamy]

Hmmmmm. I have 20 random thoughts regarding this whole matter; let me share some of them. I am reminded of an old Eisenhower adage; "if you don't have a good solution to a problem, make the problem bigger." The problem here is 90% commercial and 10% clinical informatics, by which I mean that while there is a certain charm in being able to look up a patient's last abdominal CT from 2004 from an imaging system 4000 miles away, the instances where that is important are rare, and the instances where it makes a difference to patient well being are even more rare. So aside from the obvious telegenic potential of the idea, what drives it? Well, primarily, commerce; it's about claims processing, mostly. But honestly, from down here in the trenches, the inefficiencies in getting money for my services are not a matter of passing claims info; it's the "claims war." The insurance companies employ legions to deny legitimate claims because, for instance, my diagnosis (i.e. knee pain) doesn't match the surgeons (i.e. torn medial meniscus) which then adds $50 of administrative costs to a $200 bill. I employ people to fight with the people they employ to deny my legitimate claims. Nothing about CHIT will decrease this near fraudulent abuse of the reimbursement system, which at last estimate, was a $30 billion dollar a year industry. Nothing will stop that save the elimination of the health insurance industry...

I don't believe that $20 billion will do it either. This task is akin to the interstate highway system or the moon landing in terms of its scope; it will require legislation in every state, and a virtual redefinition of privacy rights, as well as an incredible technology effort and associated infrastructure. You have rightly indicted the plan on this basis. This project is so vast and intricate, that I don't believe it can politically co-exist on an agenda that includes meaningful health care reform; the plate isn't large enough. But that's ok, because I also don't believe that it's really on anybody's agenda for the forseeable future save the folks marketing their various products. I myself wonder what other uses we could put $20 billion (40? 80?) to; that would buy, for instance complete coverage for all medically indigent kids for a year or two. I just see this all as a high tech boondoggle; window dressing instead of an attack on the core issues surrounding inadequacies in our delivery system...

In the end, after the national economy recovers, some or another middle-sized progressive state (Minnesota? Wisconsin? Oregon? Massachusetts? Washington?) will implement a system. Until somebody demonstrates a state-level system that works, there will be no real national initiative; the states are the laboratories...

thanks!

[DocV]

We can't even develop a functioning system between the services within the Department of Defense. I cannot imagine how daunting a task it would be to try and develop a single EMR for all providers.

[Chris]

I have a friend high up in one of the companies that's made billions in EMR. He and I were just talking about the other day and I made the point to him that the whole ideas behind the EMR wasn't just legibility but the ability to interface with records systems at other hospitals. He insisted this was in the works, but offered no details or timelines. We've been had.

[Physician Assistant]

I had to bookmark this site, its awesome!