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The Difficulties of Health IT

Earlier today, I had the unexpected pleasure of chatting with Contessa Brewer's cardiologist uncle on MSNBC. Her uncle made two main points: First, that rising health-care costs are primarily the product of medical malpractice. That feels true to a lot of doctors, but it's not something that's really backed up in the evidence. Second, that health information technology was just an added cost that would complicate the lives of doctors.

On some level, this is actually true. Installing a new IT system is a costly, time-consuming project. So is learning to use it. And anyone who has ever taught a parent or a grandparent to use e-mail knows that this stuff isn't necessarily intuitive. That was pretty clearly where Contessa's uncle was coming from. But the fact that a lot of doctors don't want to learn a new technology doesn't mean patients can afford to let them avoid learning a new technology. It's evidence of the uncommon autonomy we afford doctors that they've been able to delay this transition as long as they have. The Washington Post, after all, had a lot of people who were used to writing longhand, but we file electronically now. Banks use computers, even though many tellers were trained using ledger books.

These transitions weren't painless. In many cases, they were forced. But they were important. Information technology really is a step forward. And it's likely to be a particularly big step forward in medicine, where the stakes are higher and a lost chart or an illegible prescription can be deadly. But there are a couple of caveats. Doctors shouldn't have to bear the full cost of this, because they're not likely to see the savings. And we have to get the technical side of this right. See Phil Longman for more on that.

By Ezra Klein  |  July 21, 2009; 5:19 PM ET
Categories:  Health Reform  
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Comments

Where exactly do the savings come from? Most records stay in the doctor's office, but I think the cost of the filing cabinets is not really driving medical expenditures.

Traditional IT savings have come from automation of manual processes- such as balancing ledgers as you describe. Electronic insurance submissions are already the norm. What else is there where we are going to be able to reduce staff by using machines? If doctors could save money by using health IT, they'd already be doing it.

The security required for health records and the expense of protecting them properly actually make me feel better with this stuff on paper. Cybersecurity is a huge issue to get HIPAA compliant systems deployed in every doctor's office in the country.

Someone's going to be taking a lot of money.

Posted by: staticvars | July 21, 2009 5:36 PM | Report abuse

Phil's got the right issues, but the wrong focus.

1. The concern should be more about proprietary data, not proprietary software. If we aren't able to consolidate data across multiple database to get meaningful analyses, the lion share of health IT promise will be limited.

2. The issue with the proprietary companies is that they are looking to water down the "meaningful use" condition for federal funding of a given IT system, because most of them could not meet the right standard from a policy perspective. The companies look to be winning on this score, meaning that government will be paying for doctor's systems that don't really offer the benefits that have been espoused about for health IT. Which gets at the caution of government-centered health reform. Just like market-based solutions, government doesn't work in an ideal world either, and should analyzed as such. We may very well be looking at a multi-billion dollar subsidy to fatten the profits of companies that offer today's inadequate systems, rather than incentivizing development of the right ones. Despite what Emmanuel and Obama may think, just passing the bill isn't sufficient.

Posted by: wisewon | July 21, 2009 5:50 PM | Report abuse

I worked for a surgeon years ago. We got a new voice mail system in the hospital, and he and the other surgeons actually rallied a frickin' petition because they didn't want to learn how to use it.

Now, I don't want to impugn all doctors. My uncle and 2 of my cousins are doctors and really very nice people. Surgeons are absolutely the weirdest kind of doctors. As you might imagine, the type of personality required to cut into people on a regular basis is only one step closer to sanity than say, a sociopath.

But still... a petition. Doctors are divas. Smart, worthy, critically needed... divas. They need to be dealt with firmly. They'll learn the new system and they'll like it. Or else.

Posted by: roquelaure_79 | July 21, 2009 5:52 PM | Report abuse

My mom is a nurse practitioner (APN) in family practice, and a new IT system has definitely hurt her more than helped. Rather than being able to dictate charts/orders from the car on her commute, or from home, she now has to stay at work after hours, after seeing all her patients, to type everything in to the new electronic records system. I get that electronic records are supposed to save money, but it's really not fair if it's at the expense of unpaid work hours for already overworked primary care providers like APNs like my mom.

Posted by: saraho1 | July 21, 2009 6:34 PM | Report abuse

"contessa brewer's cardilogist uncle"?

what exactly is important about his viewpoint?

it would have been more informative to have listened to george halverson, ceo, kaiser on talk of the nation on npr

especially at the point in the interview where he talked about the wages of doctors like contessa brewer's cardiologist uncle

halveson points out that the income of physicians is a major driver of health costs and that us docs are paid 1/3 more than docs in other industrialized countries

Posted by: jamesoneill | July 21, 2009 6:34 PM | Report abuse

jamesoneill: but how do the costs of an MD compare from US doctors to doctors in other industrialized countries? Our docs graduate med school with tens of thousands of dollars in debt, if not $100k.

Posted by: saraho1 | July 21, 2009 6:39 PM | Report abuse

Ezra, this illustrates what I have been saying. It will be very difficult to get physicians to practice more efficiently, to form clinics, to take a salary and, in general, to do all the things Dr Gawande wants them to do. That's why we have to go after the low hanging fruit--private insurance waste and high drug prices which we can do by law, i.e. pass HR676

sara, if I hear about the crushing debt physicians leave school with one more time, I swear I will run naked down the block screaming. Look around you. Are Docs driving in 10 year old Civics, living in two bedroom bungalows in poor neighborhoods, or do they drive new BMW's and live in multimillion dollar homes? The only physician I know that does not live in a luxury home is near retirement at which point he plans to more to his waterfront house at the shore.

And the docs have done it to themselves. Who requires 4 years of pre med which most seem to forget at graduation? Who requires years of involuntary servitude? Who restrict places at med schools and discourages financial aid so the only the "best" people become physicians?

Posted by: lensch | July 21, 2009 7:09 PM | Report abuse

As a person who implements medium- and large-scale software, including so-called "enterprise applications", for a living, let me deeply caution Mr. Klein (and other policy analysts of his generation who have not actually worked in the field): sometimes information technology works. And sometimes it doesn't. In 99.9976% of the cases even when IT works and has an overall positive benefit it also generates massive unanticipated side-effects and consequences, most of them negative.

And contra roquelaure_79 at 5:52, beating the field personnel harder until they fall in line with the Beautiful Vision(tm) seldom works for the organization in the long run.

Posted by: sphealey | July 21, 2009 7:11 PM | Report abuse

halveson points out that the income of physicians is a major driver of health costs and that us docs are paid 1/3 more than docs in other industrialized countries

1) Every profession in the US is paid more relative to their euro colleagues. Thats true for lawyers, doctors, accountants, etc.

2) Physician REIMBURSEMENTS are partly responsible for healthcare cost increases but NOT physician incomes. Physician incomes are basically flat against inflation over the past 15 years or so. Total reimbursements, however, go up every single year because every year there are more doctors ordering more tests.

Posted by: platon201 | July 21, 2009 10:27 PM | Report abuse

Could you talk a little bit more about why medical malpractice lawsuits aren't a significant cost-driver? The numbers certainly don't add up if you just look at the premiums (they're high but not so high as to explain cost increases). But I wonder if the "fear of being sued" is leading to a lot of overtreatment?

Posted by: jbrians | July 21, 2009 10:44 PM | Report abuse

saraho1, your mom would do better if she charted and made orders while seeing the patient and not at the end of the day.

Posted by: kazumatan | July 22, 2009 12:45 AM | Report abuse

What platon201 said with respect to physician pay. U.S physicians make, in comparison to U.S. household income, about what European physicians make plus or minus a little, depending on the country. See (note that French docs get an enormous tax break that is not reflected in these figure):

http://www.oecd.org/dataoecd/51/48/41925333.pdf

What jbrians said about fear of lawsuits. It may be an exagerated fear, but it's a real fear. I was recently dropped from a lawsuit that was a classic. A heavy smoker had a "vague infiltrate" on a chest x-ray which was not chased down with serial CTs. Four years later when she developed lung cancer, she sued. Never mind that there is no data that suggests that there is any use to detecting lung cancer early, there is no data that says that there are lung cancers that are that indolent, and there are no treatments for lung cancer that have been shown to work (she chose coffee enemas for her treatment). If the docs involved in the case had done any of those tests and treatments, half the people here would have condemned them for overtreatment and the other half are now condemning them for undertreatment.

As a person who wrote and installed large scale software, I also agree with sphealy. The docs I know all quickly adopted PDAs, personal computers, and cell phones. Medical software, although it has potential to be wonderfully helpful currently comes no where near that potential. It is not currently useful at all and hyper-expensive to boot. In short, it sucks.

Posted by: J_Bean | July 22, 2009 1:09 AM | Report abuse

Thoughts from a surgeon:

1. The fear of being sued does increase health care costs, but not to the extent that many physician groups claim. There are far greater opportunities for reducing health care costs by changing the way we practice, and in particular in modifying the way we are reimbursed. For example, the big trend among physician groups in my specialty (Otolaryngology) is to buy our own CT scanner and then bill for our own scans. As a result, the number of CT scans increases dramatically since those reimbursements are now going into our own pocket.

2. IT improvements will improve quality care but probably will not make a major dent in health care costs. It's wonderful to quickly and easily access patient information through a computer terminal; less chance of missing something and less hassle in tracking down information. They are expensive to introduce and there is a learning curve.

3. The two biggest hindrances to introduction of IT systems in health care are: 1) poor user interface and 2) lack of standardization. What doctor wants, or has the time, to type all his or her notes to get them into a computer system, or struggle with some lousy voice recognition system. And what about the thousands of different types of medical data? How do you standardize them digitally?

Posted by: rlplant | July 22, 2009 1:10 AM | Report abuse

I can walk into any military hospital in the world and my records for the last 20 years are instantly available to the medical personnel treating me. The US military have been using IT as long as I've known it, and it works well.

Recently I became very ill in Germany, and went to Landstuhl, a base I'd never been to. One reason I went there instead of a German ER was because I wanted someone to treat me who had access to my records. That way, the medication they put me on was also included in my records, so I can follow up with my physician here.

So tell me again why doctors resist this? It's clearly better for patients. Shouldn't that be their first priority?

Posted by: KathyF | July 22, 2009 2:36 AM | Report abuse

For jbrians et al

The defensive medicine argument is simple. Many studies (not only the CBO) show physicians order many tests that some feel are unnecessary. These studies show the frequency of these tests is independent of the restrictions placed on malpractice suits. This data seems to be as strong as anything in the field. So if there is "defensive medicine", it is not caused by fear of suits (no matter what the physicians say) and, more to the point, restrictions on these suits will not save us any money.

Posted by: lensch | July 22, 2009 7:19 AM | Report abuse


saraho1, it is utterly impossible to extract any meaningful data from dictated notes (today). That stuff needs to be hard entered into reportable fields to ensure quality of care yo.

Also, um, your mom shouldn't be taking protected health information off premises, the HHS OIG will take issue with that.

And, worth throwing out there that some of the IT solutions in the works sit on the back end of practice management systems and translate them to standardized HL7 format, so there's nothing new for the doctors/admin to learn.

wisewon's right on about meaningful use but I remain optimistic that the collaborative steering committees coming together around health IT can marshall a needs requirement document that will scare the holy living crap out of any corner-cutting folks.

Posted by: ThomasEN | July 22, 2009 11:57 AM | Report abuse

I'll echo the cautions of others. So where is there low-hanging fruit/best obvious courses?

1) Computerizing prescriptions first. This doesn't mess with the routines of keeping records, just transmitting prescriptions. Computerized prescription records will also make it easier to reduce prescription errors.

2) Computerizing primary care second. I don't give a hoot whether the Palm Beach cosmetic surgeon computerizes his/her records of lifts, tucks, etc. But it should be critical for public-health purposes to computerize records of ERs, public clinics, school clinics, Walmart & Walgreen docs-in-boxes, etc. No guarantees here -- the fact that the VA has computerized records hasn't eliminated all sorts of bad outcomes in VA hospitals (okay, I live in Tampa, where things have gotten particularly ugly) -- but the leverage and payoff are pretty high, here.

3) Computerizing Medicare-receiving doctors/locations third. Okay, second wouldn't be bad, either, but since the Great Ethical Questions on "comparative effectiveness" are about fuzzy questions around prostate-cancer and other treatments for older Americans (as one op-ed in our local paper put it, what if the most expensive prostate-cancer treatment does squat for extending life but quite a bit for quality of life?), that's where better record-keeping can give epidemiologists the data they need to keep our myths in check.

Posted by: ShermanDorn | July 22, 2009 12:21 PM | Report abuse

Does anyone know what language VistA is written in?

Posted by: BeatKing11 | July 22, 2009 12:32 PM | Report abuse

BeatKing11: I think it's MUMPS. There's a company in Carlsbad called Medsphere that's trying to modify it to make it work outside of the VA.

lensch: So what you are saying is that even though most of the docs who respond to these threads say that malpractice suit fears are one of the reasons that they find themselves overprescribing, you know of a study that says that "tort reform" doesn't actually result in a change in behavior, therefore, those docs aren't actually considering malpractice suits when they overprescibe? Any chance that your study is actually showing that tort reform doesn't help? Although there are clearly some docs who over-order, for instance, CTs because they own a CT scanner, there are many more docs who don't own a CT scanner, but who do over-order CTs. What's they motivation? Kick-backs? If so, where are my kick-backs from the CT scanner owners? We see mostly HMO patients in my practice, so CT/MRI scans actually cost us money. Perhaps you can tell me why we order a damn MRI for just about every headache that walks in the door? Further, perhaps you can explain why several of our docs recently won a malpractice suit that revolved around not ordering a CT for an asymptomatic patient who became symptomatic a few days later (and did not get a CT until he was, well, symptomatic ... because if you would just routinely scan everybody, no one would ever die!)

Posted by: J_Bean | July 22, 2009 12:53 PM | Report abuse

BeatKing11: VistA is indeed written in M[UMPS]. You can find out practically anything you want to know about it by starting at www.hardhats.org.

Posted by: wankme | July 22, 2009 1:54 PM | Report abuse

JBean - First of all if my study (studies actually) shows that tort reform doesn't help, why do it? Why take away the right of Americans to seek redress for their injuries?

Obviously I can't say why physicians order unnecessary tests. All I can do is to speculate, so here goes. While many people have other's lives in their hands from auto mechanics to crane operators, nowhere is this more obvious than in the medical profession. Thus it does not surprise me that physicians will prescribe every test under the sun even if they know that some of them are unlikely to produce results.

It really makes scant difference if you guys order extra tests because you really fear suites or because you fear screwing up, the point is that tort reform has nothing to do with it. It simply doesn't help.

Posted by: lensch | July 22, 2009 3:54 PM | Report abuse

Well, I wrote a long post and somehow it disappeared. However, what most docs call "tort reform" is the desire to do their jobs without having the threat of a lawsuit hanging over their head every time there is an unfortunate outcome -- whether or not they made a mistake. Those very efficient doctors at the VA can not be sued because they are federal employees. That's going too far, but there needs to be some way for doctors who are acting in good faith to be free of that fear. Everybody dies sooner or later and doctors shouldn't have to be constantly watching over their shoulder for a lawsuit. I've been sued and seen people sued for failing to prevent death from inevitably fatal cancers, crappy lifestyle decisions (oh, but the doctor didn't tell him that if he didn't take care of his diabetes he could die), and have even seen people sued by narcotics abusers (my colleague recently received an apology 22 years after the lawsuit from someone who had gone into a 12-step program and was making amends to everyone she had wronged).

Fear of malpractice IS part of the problem. No one has been able to quantify it. However, the fact that every doctor brings it up, tells you that it isn't a minor contributor. There are other reasons why we over order tests; cookbook medicine (order a "screening thyroid test" on everyone because it saves a few minutes of time), distrust of one's skills (it seems like a non-focal neuro exam, but maybe I'm missing something), patient satisfaction (a lot of people really like to get labs and imaging tests), once-burned/twice shy (I just saw a really rare zebra, maybe you have it too). It's hard to tease out how much each of those contribute. It's pretty easy to count up how many people own their own CT scanners (a small minority), but the other stuff plays a much bigger role.

Posted by: J_Bean | July 22, 2009 6:09 PM | Report abuse

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