“If you take their money, they’ll tell you how wide to make the door,” said W.R. Keith, seventh-grade math teacher, c. 1958, concerning federal aid to education.
“When you extend your hand to take the money, that’s when they put on the handcuffs,” said Robert (“Jag”) Jaggard, M.D., c. 1983, regarding Medicare and Medicaid.
“If you take the stimulus money to computerize your office, they will own your patients’ medical records—and possibly your practice,” warns AAPS executive director Jane M. Orient, M.D.
While most of the economy has gone digital on its own accord, physicians have been slow adopters, at least for their medical records systems. Hence the deployment of carrots and sticks (and sticks disguised as carrots) by the federal government, to drag the “Luddites” into the 21st century.
The American Recovery and Reinvestment Act (ARRA) of 2009—the Stimulus Bill—makes subsidies available to physicians for the purchase of health information technology. Starting in 2011, up to $44,000 over 5 years will be available to physicians who see Medicare patients, and up to $65,000 for physicians who see high volumes of Medicaid patients.
To get the money, you must make “meaningful use”—still undefined—of a government-approved system. The Office of the National Coordinator for Health Information Technology (ONC) has announced a proposed rule for a temporary certification program (ModernHealthcare.com 3/2/10); the 30-day comment period closes Apr 9. A 47-page file is available.
Expect stricter and more extensive criteria for demonstrating meaningful use over time, says CMS.
EHR (electronic health records) salesmen have been compared to car dealers (Gregg Blesch and Joe Carlson, “Zero Tolerance,” ModernHealthcare.com 3/1/10). “Sign today, install tomorrow, and pay nothing until next year when you get the government’s money.”
But remember that the government money is contingent upon successful use of the system. And the subsidy might not be enough. Although these days one can purchase a computer with awesome capability for less than $1,000, medical practices should expect to spend $25,000 to $50,000 per physician for hardware, software, and implementation costs, plus an additional 20 percent for ongoing maintenance and technical support.
There may also be substantial and ongoing losses from decreased productivity.
Blesch and Carlson warn of the hidden risks of buying the system with financing rather than cash, including possible loss of all patient data if the system is repossessed for nonpayment. Be sure the contract provides that the data cannot be held hostage for any reason, they advise.
Compliance must be 100% or you don’t get the money, and some of the requirements are probably not achievable, in the view of the American Academy of Family Physicians (AAFP) (HITS 3/8/10). For hospitals, the 23 measures are so daunting that even hospitals with established systems might not qualify (HITS 3/9/10).
An essential feature will be “interoperability,” the ability to “share information.” Some of the other requirements for physicians include:
- displaying body mass index (BMI) for patients 2 years old and older;
- recording smoking status for all patients 13 years and over;
- actual submission of data to immunization registries;
- generating lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach;
- reporting clinical quality measures to CMS, or to states for Medicaid recipients;
- implementing five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic testing, and tracking compliance with those rules;
- use of computerized provider order entry;
- providing clinical summaries to patients for each office visit; and
- maintaining up-to-date problem lists based on ICD-9 or SNOMED-CT (Health Freedom Watch, March 2010) .
Patients’ records could be shared with more than 600,000 entities without patient consent (ibid.).
Proposed rules for the Electronic Health Record Incentive Program are published in the Federal Register 1/13/10; comments are due by March 15. Sample comments from the Institute for Health Freedom are available.
The information technology (IT) resulting from this program “will be injurious to patients at an unacceptably high level,” states medical informatician Scot Silverstein, M.D. (Health Care Renewal 3/9/10). Unlike safety-critical aerospace software, HIT is not rigorously certified but will be overseen by new, potentially amateur bureaucracies staffed by personnel with conflicts of interest.
Silverstein urges heeding the experience of the UK. Norman Lamb, Liberal Democrat health spokesman said: “The Government needs to end its obsession with massive central databases…. The NHS IT scheme has been a disastrous waste of money, and the national programme should be abandoned.”
AAPS director Wayne Iverson, M.D., a San Diego internist, is a proponent of HIT—if it is physician-directed. He warns against “G3 EHR”—government and third-party directed EHR. The latter is designed to meet G3 goals—which are not the same as patients’ and physicians’ goals. With physician-directed computing, information remains under the control of the physician; HIT works for the physician, not for G3; and vendors and clearinghouses are bypassed.
“Interoperability,” by progressive semantics, means G3 access to patient information. Standards set by the Certification Commission for Healthcare Information Technology (CCHIT) are actually contrary to state-of-the-art usage in computerized information exchange, Iverson writes.
CCHIT, he observes, “is a self-appointed group, adopted by CMS to grab control over physicians’ computer systems, and increase the costs about five times for extra functions the government and third parties need to capture the physicians’ information.”
There is no reason for CCHIT certification unless one participates in government programs, Iverson states. And the need for it is another reason not to participate.
AAPS past president Ken Christman, M.D., warns: “Once a critical number has been reached, the resisters will be mowed down.”
Some AAPS physicians who were early adopters of electronic claims filing stopped using it when they found carriers were illegally altering their claims, states Dr. Orient.
Physicians are invited to participate in the AAPS online survey. [polldaddy poll=2671539]
- Myth 32. “Information Technology Will Improve Efficiency and Safety,” posted Jan 7, 2010.
- Elizabeth Lee Vliet, M.D., “Obamacare’s Lethal Third Rail Shock to Come,” Feb 20, 2010.
- “The Syndrome of Inappropriate Overconfidence in Computing: an Invasion of Medicine by the Information Technology Industry?” by Scot Silverstein, M.D., J Am Phys Surg, summer 2009.