The Digital Doctor: A reasoned look at the state of health IT

Following the recession, the Obama administration sought shovel-ready projects.

One unlikely shovel-wielding aggregate demand was health information technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 percent of the stimulus towards digitizing medical records.

Computerization of medical records doesn’t induce the images of public works as building freeways during the Great Depression does, but the freeway is a metaphor for exchange of information between electronic health records with the implication that such an exchange is a public good and so government intervention is justified.

Robert Wachter, voted the most influential physician by Modern Healthcare, sums the optimism and frustration with the electronic health record (EHR) in The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age  — which stands to be a classic.

It was Bush Jr., not Obama, who started the digitization. Seeking bipartisanship after the war in Iraq, Bush was inspired by his closest ally, Tony Blair, who was wiring the National Health Service (NHS) — a $16 billion initiative which has since failed, spectacularly.

Bush founded the Office of National Coordinator of Health Information Technology (ONC) and appointed David Brailer — a physician, quant and entrepreneur — as head. Brailer wanted interoperability so that hospitals shared information. It is because of interoperability that we can use our debit cards in New York and Singapore. The market must agree on a common language, such as the TCP/ IP for the internet, to achieve interoperability.

Patients suffer when systems can’t talk. Were patients, not a third party, bearing the full costs of care — a free market — they might have forced hospital information systems to talk. Rightly or not, health care is not a free market and hospitals have little motivation in making cross-talking simpler.

Brailer wanted the ONC to be an enabler not dictator of common standards. Fearing that market innovation would be ruined by regulatory overreach, he drew a fine line. A budget of $42 million suited his libertarian ethos. Following the HITECH Act, the budget for ONC increased to $30 billion and Brailer’s line was wiped.

With unabashed Keynesianism, the government subsidized the purchase of EHRs by physician practices from certified vendors. The logic was sound. Expecting practices to digitize voluntarily is like expecting people to buy roads to make Interstate-95. The cost of digitization is high, yet all will, one day, benefit from the wiring, not just practices which choose to be wired.

The reformers wanted a Goldilocks system in which doctors delivered neither too much nor too little care. To pay doctors for doing the right thing, not just for doing, an electronic repository was necessary, so that payers knew which doctors followed guidelines, encouraged prevention and practiced high-value care.

If only payers could measure doctors, they could reward the good and punish the bad. EHRs would be the treasure trove of that information. If mandating health insurance was crucial to reforming insurance, the EHR was essential to reforming physician payment. Thus, the EHR transmogrified into an electronic version of Bentham’s panopticon.

The government could not subsidize physicians unconditionally. The conditions were named, with unintended irony, “meaningful use.” Regulators no longer were concerned just with interoperability but how the technology was being used. It was like Steve Jobs and Bill Gates selling computers only if used for activities they both approved.

In a dialectic not odd in health care, HITECH is a success and disaster. The adoption of EHR, which increased from 10 percent to 70 percent of practices, would not have happened so quickly without the subsidies. The Blitzkrieg has consequences — many physicians loathe EHRs, viscerally.

The paradox of automation is at once diminution and magnification — fewer but more catastrophic errors. Wachter narrates how a young male received an obscenely high dose of an antibiotic because of a user-unfriendly prescription interface. The bad tool might blame the workman. Whether the tool or the workman is at fault is a distinction without a difference.

Why are doctors deskilled by EHRs when they use iPads, PowerPoint, and Yelp? EHR is like a library that throws all books all at once at you when all you wish to read are books by Herman Melville. The information overload fatigues.

EHRs serve many masters including administrators, payers, risk managers and researchers. EHRs must also capture the nuances of a doctor-patient interaction. By bloviating the EHR with information rather than trimming the interface with context, the vendors have pledged their servitude to the comptroller not the foot soldier; which would be fine but it is the foot soldier who uses the EHR predominantly.

Wachter is no Luddite. He speaks in measured tones with subtle angst, and his sharp analysis will please Luddites as well as Futurists. He occasionally invites the reader to disagree. Wachter believes EHRs, though flawed, have improved health care delivery. I might argue with that. The loss of clinical context is tangible. But would I return to paper records? Truthfully, probably not.

Computerization of records was inevitable. Had it emerged organically, through dispersed agents and trial and error, the way advised by Friederich Hayek in his landmark essay “Use of Knowledge in Society,”, arguably we might have interoperability. The precocious adoption of EHR may have stunted its growth.

Imagine if the government had subsidized the purchase of cars in 1896. Perhaps all Americans would have owned cars before the twentieth century, and horse buggies would have disappeared sooner. But would Henry Ford have innovated beyond the quadricycle?

Mr. Ford might have envied the EHR-vendors. I do. They enjoy a rare carapace which shields them from unhappy customers. Disgruntled doctors are summarily dismissed as change-phobic dinosaurs. Hospital administrators don’t admit that they have misjudged costly technology. Some contracts forbid doctors from shaming vendors openly, even as taxpayer’s money flows to the vendors. Free market advocates will protest that this is not capitalism. To be fair, neither is this socialism. Whatever this innominate political economy will be named, it seems quite unique to US health care.

John Maynard Keynes famously said that in a recession there was value even in the government burying bottles with banknotes and luring private enterprise into retrieving them. HITECH didn’t exactly bury the bottles but handed them out, with $30 billion in them. In return for the bottles, we have strategic plans, shared goals, pages and pages of rules but no interoperability. Instead, the ONC is remonstrating with hospitals not to block information. Might the stimulus have been better spent on tinkerers? Brailer believes so.

To quote Seneca: To be everywhere is to be nowhere. The reformers may have asked too much, too soon of electronic health records, which may deliver too little, too late. Time will tell, of course, and in twenty years either the tinkerer or the central planner will have the satisfaction of “I told you so.” But both will applaud Wachter’s tome.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad. This article originally appeared in the Health Care Blog.

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