More than a decade ago the media were excited that Hillary Clinton and Newt Gingrich had formed an alliance about reforming health care. In 2005 Dana Milbank wrote in gushing terms in the Washington Post about a joint appearance.
“Clinton, asked about electronic medical records, deferred, again, to her friend. ‘Newt has a very dramatic way of saying this,’ she said, ‘which is “Paper kills.”’ Gingrich sent the praise right back at her, hailing Clinton’s legislation on medical records as a ‘major breakthrough’ in Congress. ‘This is absolutely the case that Hillary is making,’ he said.”
Of course, they were not alone. President Bush had already embraced the idea in his State of the Union speech to Congress. He envisioned a new era of “improved information technology to prevent medical error and needless costs.”
Later, President Obama built the HITECH Act into his 2009 stimulus package and appropriated some $20 billion in the first year alone to make it happen. All promised to get everyone’s complete medical records in digital form by 2014.
How are your medical records today? I recently had cataract surgery at my local hospital. They did each eye one month apart. Each time I had to complete the exact same questionnaire about my allergies, the drugs I’m taking, and my medical history. Apparently their information technology couldn’t retain the information for even a month.
We Could Have Foreseen This Outcome
The past decade of throwing taxpayers’ money at health information technology (HIT) makes the Solyndra boondoggle look like chump change. None of this should have been remotely surprising to anyone looking objectively at the evidence. In 2006, the United Kingdom’s $12 billion effort to computerize medical records in the National Health Service was already falling apart, according to a report to Parliament. A few years later, the government candidly admitted it had wasted all the money and was closing the program.
In the United States, even more modest efforts by our own government had already failed. The Veterans Administration spent $167 million to simply computerize its appointments system. This effort had “all but collapsed, and senior executives are worried about the repercussions it could cause on the Hill and in the White House, according to an internal memo obtained by NextGov,” a trade publication.
At the Department of Defense “top health officials lambasted the department’s central electronic health record system that manages patient files for millions of active duty and retired service members, saying it frustrates doctors because it crashes as often as once a week and generates duplicate records,” again according to NextGov. The article goes on to quote the deputy surgeon general of the Air Force as saying the system was, “slow, unreliable and so cumbersome that clinicians spend 40 percent of their time inputting data into the system, which is time spent away from patients.”
There was absolutely no evidence that this massive spending would succeed, and plenty that it would fail miserably. Now, even the editors of the Washington Post came to agree the whole project was a fiasco — but only after we wasted $27 billion of taxpayer money.
Doctors Warned About This ‘Exercise in Wishful Thinking’
On the ground where real people live and actual doctors practice medicine, the warning signs were nearly universal, both before the law was enacted and as it was being implemented. I wrote a report for the Heartland Institute summarizing the problems.
Jerome Groopman, MD and Pamela Hartzband, MD, both on the faculty of Harvard Medical School, wrote in the Wall Street Journal that, “The basis for the president’s proposal is a theoretical study published in 2005 by the RAND Corporation (but) in the four years since the report, considerable data have been obtained that undermine their claims.”
They call the proposal, “an elegant exercise in wishful thinking,” and add that the RAND researchers deliberately avoided looking at any negative information, saying, “We choose to interpret reported evidence of negative or no effect of health information technology as likely being attributable to ineffective or not-yet-effective implementation.”
In the Washington Post, Stephan Soumerai and Sumit Majumdar wrote that Obama was making a “Bad Bet on Medical Records.” The first author was a professor at Harvard’s Medical School and the second was at the University of Alberta’s Medical School. They wrote that, “The benefits of health IT have been greatly exaggerated.”
Specifically, they said, “Large, randomized controlled studies — the ‘gold standard’ of evidence — in this country and Britain have found that electronic records with computerized decision support did not result in a single improvement in any measure of quality of care for patients with chronic conditions including heart disease and asthma.” And, they add, “Health IT has not been proven to save money.”
As the system continued to be forced on people, the stories were even worse. The Washington Post ran an op-ed by Dr. Dan Morhaim, a Democrat member of Maryland’s House of Delegates. He wrote:
These systems tend to be fantastically complex. One doesn’t have to be intimately familiar with, say, Hertz or Enterprise to rent a car online. But many electronic health record systems have pull-down screens listing each of the 68,000 possible diagnosis codes in the World Health Organization’s International Classification of Diseases and 87,000 possible procedure codes.
Or consider what happens when I write a prescription: Every potential drug interaction or side effect listed generates a warning prompt. Inevitably, recognizing that the warnings are generally inapplicable and take time to sort out, clinicians start to bypass the alerts. Sooner or later, ignoring one will lead to serious complications.
Dr. Morhaim concluded: “Perhaps the most pernicious side effect is the erosion of the provider-patient relationship. When I first began working with electronic health records, I caught myself staring at the computer screen instead of engaging patients, who rightly felt ignored. Like many colleagues, I’ve reverted to the practice of talking with the patient and taking notes with pen and paper. After the evaluation is over and the patient has left, I type in the data. This takes much more time, but it is the only way to complete a proper history and exam. The result is decreased productivity and frustrated providers — and a lack of meaningful data to manage patient care.”
The American Journal of Emergency Medicine published a study finding that emergency room physicians are now spending 43 percent of their time on data entry and only 28 percent on direct patient care.
How Medical Records Went So Horribly Wrong
So what happened here? Why were the power brokers so convinced that this was such a great idea worth spending tens of billions of dollars on? The answer lies in injecting politics into what should be a pretty straightforward business decision about how and when to upgrade technology.
First, politicians love to tell other people what to do. That is, after all, the very definition of “power.” Politicians work very hard to gain power, but what good is it if they don’t exercise it?
Next, to retain their power politicians need to come up with simple answers for complex problems. Their answer should be easy to remember and short enough to fit on a bumper sticker. “Health Information Technology Saves Lives!” is perfect. They really don’t care if it works as long as it sounds plausible. You will notice that the politicians who were so excited about HIT—Gingrich, Clinton, Bush, and Obama—are all out of office now, on their merry ways and enjoying their taxpayer-funded retirements. They will never be held to account for their bloviating.
Politicians also need to have some intellectual support for the idea. The RAND study cited above perfectly fit the bill. It promised huge system-wide savings, but only by purposefully ignoring any contrary evidence. The New York Times reported that RAND published a mea culpa study in 2013 sort of apologizing for the earlier study that promised $81 billion a year in savings. It notes the HIT industry paid for the original study: “RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.”
That brings us to the final necessary element. The idea must be intensely supported by a concentrated interest group that expects to benefit from it. In this case, the cautions were raised by a widespread and diffuse group of analysts who had very little political power, while the supporting industry was focused and well-financed.
Even today those who are enriching themselves on the $27 billion are just happy as clams over the program. John Hoyt, the Executive Vice President of the Healthcare Information and Management Systems Society (HIMSS) was quoted in a recent issue of Healthcare Informatics as saying “This data suggests that the HITECH portion of the 2009 stimulus law is achieving its intended result of encouraging increased implementation and meaningful use of electronic health records among hospitals.”
This Is a Core Problem with Top-Down Politics
Look, none of this is to say health IT is a bad idea or that hopes for it are unwarranted. Quite the opposite. The health care system sorely needs better management tools and better application of technology. Before the HITECH Act was passed, companies were already investing a vast amount of entrepreneurial energy, innovation, and money in developing, refining, and marketing the tools the system needs to come into the twenty-first century.
The danger was that massive federal intrusion would curtail real innovation in favor of some anointed federally imposed system. Solutions work best when they are developed from the ground up, not imposed from on high. In ground-up development, flaws can be detected and eliminated without much system-wide damage. Poor vendors can be removed without disruption to the whole system.
What we have seen in this fiasco is that IT developers were put in the driver’s seat and the needs of actual physicians and clinicians were ignored. Instead of letting the needs of clinicians dictate how systems would work, the physicians were criticized for not changing their practices to fit the needs of the IT system.
Unfortunately, we are doomed to constantly repeat these errors as long as we think a handful of bright folks in Washington are better able to solve problems than the people who actually know what they are doing.