Wednesday, March 25, 2009

There's HIT Dogs and Cats, and Then There Are the HIT Skunks

In the latest New England Journal of Medicine, David Blumenthal, who has been named the new National Coordinator for Health Information Technology (HIT), has a “Perspective” piece on the roll-out of electronic records throughout the healthcare system. It has a brief useful summary of the provisions of ‘HITECH’ (the HIT parts of the recently passed stimulus package). Dr. Blumenthal then goes on to make three telling points about how little time there is, the work necessary to define ‘certified’ and ‘meaningful,’ and Congress’ real intentions.

The first is that the National Coordinator is facing a daunting time schedule. Considerable regulatory and program infrastructure needs to be put in place in the next two years and the clock is counting. The bureaucrats will need to move at relative D.C. light speed.

Secondly, while the stimulus law is aimed at promoting the ‘meaningful’ use of ‘certified’ electronic records, no one is quite sure what that means. Dr. Blumenthal points out that yielding to temptation and setting regulatory bar too high may cause physicians and hospitals to ‘rebel.’

But the most important point is that Congress is filled with what my colleague, Vince Kuraitis of the e-CareManagement blog, has ably described as HIT ‘dogs.’ Not meant to be pejorative, this is in contrast to the HIT ‘cats.’ The canines believe health care reform aimed at improvements that are facilitated by HIT will lead to greater use of HIT. The felines believe that’s backwards. They favor reform aimed at directly promoting HIT, believing that will lead to greater healthcare quality. While the written law is decidedly cat-like (thanks to direct physician subsidies for adoption via Medicare and Medicaid, reduced fee schedule payments for the laggards and the financing of regional health information exchanges as well as regional technology extension centers), the DMCB gets the doggone impression from Dr. Blumenthal that this is just the opening scene of a far more involved three-fold Federal agenda. Washington is not only rabidly on the trail of 1) bringing costs to heel, b) licking the number of uninsured but (and here’s the dog part) c) taking a bite out of low-quality care. HITECH is a first step in that direction. No wonder there’s been no paws in Congress’ intense efforts to assemble a health reform package.

But enough of cats, dogs and puns. The Disease Management Care Blog would like to introduce readers to a third HIT species: the skunks. Like Harvard’s Drs. Groopman and Hartzband who decry elegant exercises in wishful thinking about HIT in their Wall Street Journal editorial ‘Obama’s $80 Million Exaggeration.’ Like Columbia’s Dr. Armstrong-Coben, who struggles with a clunky interface that impairs doctor-patient relationships in her New York Times editorial ‘The Computer Will See You Now.’ Like orthopedic surgeon Dr. Haig, who points out in a Time Magazine article titled ‘Electronic Medical Records: Will They Really Cut Costs?’ that the answer is no, because they enable docs to document more billable stuff without any commensurate meaningful increase in quality. Like the University of Minnesota’s Drs. Parente and McCullough who point out in an article titled ‘Health Information Technology and Patient Safety: Evidence from Panel Data’ in Health Affairs that electronic records by themselves outside of large institutions will likely have a small impact on patient safety.

The DMCB apologizes in advance to these and other writers that object to being associated with something so… stinky. But think of Looney Tunes’ Pepe Le Pew and his relentlessly inconvenient pursuits of Penelope. While he often failed, he nonetheless succeeded once in a while. More importantly, Pepe will always be remembered for being true to himself and refusing to accept the wrong answer.

The likelihood that Dr. Blumenthal and Congress will find the right HIT answer? The DMCB thinks that remote. However, if they mess this up, there will be no escaping the smell.

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