– Posted on the Healthcare Renewal Blog May 17, 2013 –
It seems to have taken awhile, but organized medicine seems to finally be recognizing that today’s commercial health IT is not quite the revolutionizing, transformative, plug-and-play panacea to healthcare’s ills it is often touted as:
May 15, 2013
AMA board chair: HHS should address EHR usability issues immediately
The government needs to act quickly to remedy the impaired usability
of electronic health records (EHR) if the technology’s touted benefits
are to be realized, AMA Board of Trustees Chair Steven J. Stack, MD
(left), told officials during a federal hearing last week.
“The AMA and most physicians believe that, done well, EHRs have the
potential to improve patient care,” Dr. Stack, an emergency physician in
Lexington, Ky., said during his 30-minute testimony.
“At present, however, these EHRs present substantial challenges to the
physicians and other clinicians now required to use them.”
He emphasized that many of today’s EHR systems require significant
changes before they can deliver the promised outcomes. Referring to
Medicare’s meaningful use program, he pointed to undesired consequences
of pushing EHR systems on physicians before the technology was
completely ready for prime time.
“Immediately” is strong language.
I note that the phrase “health IT done well” is a term I’ve been using since 1998 at my now-Drexel-based health IT teaching website at http://www.ischool.drexel.edu/faculty/ssilverstein/cases, as well as at this blog.
Penned by me at my aforementioned Drexel graduate teaching site, originally housed on AOL, in 1998 and still appearing in its main essay:
… While clinical IT is now
potentially capable of achieving many of the benefits long claimed for it such
as improved medical quality and efficiency, reduced costs, better medical
research and drugs, earlier disease detection, and so forth, there is a major
caveat and essential precondition: the benefits will be realized only if
clinical IT is done well. For if
clinical IT is not done well, as
often occurs in today’s environment of medical quick fixes and seemingly unquestioning
exuberance about IT, the technology can be injurious to medical practice and
biomedical R&D, and highly wasteful of scarce healthcare capital and
Those two short words “done
well” mask an underlying, profound, and, as yet, largely unrecognized
(or ignored) complexity. This website is
about the meaning of “done well”
in the context of clinical computing, a computing subspecialty with issues and
required expertise quite distinct from traditional MIS (management information
systems, or business-related) computing.
(I have more recently switched to the easier-to-parse terminology of
“good health IT” vs. “bad health IT” after discussions with Dr Jon
Patrick at U. Sydney during my visit Down Under last summer, http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html.)
I’ve also heard “not ready for prime time” before. It is a phrase I used in speaking with a New York Times reporter that then appeared in the Oct. 8, 2012 NYT article “The Ups and Downs of Electronic Medical Records” (http://www.nytimes.com/2012/10/09/health/the-ups-and-downs-of-electronic-medical-records-the-digital-doctor.html?pagewanted=2) by Milt Freudenheim, October 8, 2012, where I am quoted and this blog cited:
… Critics are deeply skeptical that electronic records are ready for prime
time. “The technology is being pushed, with no good scientific basis,”
said Dr. Scot M. Silverstein, a health I.T. expert at Drexel University
who reports on medical records problems on the blog Health Care Renewal. He says testing these systems on patients without their consent “raises ethical questions.”
The AMA Board chair went on to opine:
“Attempting to transform the entire health system in such a rapid and
proscriptive manner has compelled providers to purchase tools not yet
optimized to the end-user’s needs and that often impeded, rather than
enable, efficient clinical care,” he said.
He noted that physicians are “prolific technology adopters” but that
adoption of EHR systems has required federal incentives because the
technology still is “at an immature stage of development.”
My near-exact terminology has been that the technology is still experimental.
“EHRs have been and largely remain clunky, confusing and complex,” he said.
Perhaps he read my ten-part series on the health IT mission hostile user experience at this blog, at http://www.tinyurl.com/hostileuserexper.
According to a recent survey by AmericanEHR Partners, physician dissatisfaction with EHR systems has
increased. Nearly one-third of those surveyed in 2012 said they were
“very dissatisfied” with their system, and 39 percent said they would
not recommend their EHR system to a colleague—up from 24 percent in
A survey I posted about in Jan. 2010 is here: “An Honest Physician Survey on EHR’s“, http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html
Dr. Stack spoke at a “listening session” hosted by the Centers for
Medicare & Medicaid Services (CMS) and the Office of the National
Coordinator for Health Information Technology (ONC), a division of the
U.S. Department of Health and Human Services (HHS). The agencies
coordinated the session to examine how a marked increase in code levels
billed for some Medicare services might be tied to the increased use of
Dr. Stack noted that some Medicare carriers have begun denying payment for charts that are too similar to other records.
“In this instance, even when clinicians are appropriately using the
EHR, a tool with which they are frustrated and the use of which the
federal government has mandated under threat of financial penalty, they
are now being accused of inappropriate behavior, being economically
penalized, and being instructed ‘de facto’ to re‐engineer
non‐value‐added variation into their clinical notes,” he said. “This is
an appalling Catch‐22 for physicians.”
“Mandated under threat of financial penalty” has been one of my stated “cart before the horse” issues with HITECH (e.g., http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html).
Dr. Stack advised officials that three key actions are necessary to rectify these issues with EHR systems:
- The ONC promptly should address EHR usability concerns raised by
physicians and add usability criteria to the EHR certification process.
- CMS should provide clear and direct guidance to physicians concerning use of EHRs for documentation, coding and billing.
- Stage 2 of the meaningful use program should allow more flexibility
for physicians to meet requirements as EHR systems are improved.
The AMA will continue to work with federal agencies to improve EHR systems and the Medicare meaningful use program.
I’ve been calling for usability evaluation to be added to the certification process, including in comments during public comment periods to HHS, for some time.
What the AMA Board Chair is apparently missing, though, is health IT safety. They should perhaps read my post on the recent ECRI Institute Deep Dive Study on health IT risk – itself based on a report in their own AMNews (amednews.com) publication (“Peering Underneath the Iceberg’s Water Level: AMNews on the New ECRI Deep Dive Study of Health IT Events“, http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html).
I don’t think any prudent person would consider a 9-week study of 36 hospitals with volunteered reports of 171 health information technology-related problems, where eight of the incidents reported involved patient harm and three may have contributed to patient deaths, information to ignore.