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The HIT-EHR Blues

Posted by John McDonough  September 23, 2012 10:32 PM

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The bigger the build-up, the harder the fall. So it appears in the world of health information technology (HIT) and electronic health records (EHR).

For about 10 years now, many health policy experts have predicted that health system salvation lay in the universal adoption of HIT/EHR systems that would enable hospitals, physicians, and other medical providers to avoid duplicative tests and use advanced quality information available at their fingertips. If there were such a thing as health system salvation, it was digital. And across the board, health system leaders, public officials, and others accepted the gospel. I was one of them -- more on that below.

2012 will be known, among other things, as the year the bloom fell off the rose.

In March, researchers from the Cambridge Health Alliance and Harvard Medical School reported in Health Affairs that:

"Physicians' access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40-70 percent greater likelihood of an imaging test being ordered. The electronic availability of lab test results was also associated with ordering of additional blood tests. The availability of an electronic health record in itself had no apparent impact on ordering; the electronic access to test results appears to have been the key. These findings raise the possibility that, as currently implemented, electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering. We conclude that use of these health information technologies, whatever their other benefits, remains unproven as an effective cost-control strategy with respect to reducing the ordering of unnecessary tests."

On September 15, the Washington Post and the Center for Public Integrity reported on "Doctors, others billing Medicare at higher rates." Here is their conclusion:

"Thousands of doctors and other medical professionals have billed Medicare for increasingly complicated and costly treatments over the past decade, adding $11 billion or more to their fees -- and signaling a possible rise in medical billing abuse, according to an investigation by the Center for Public Integrity. Between 2001 and 2010, doctors increasingly moved to higher-paying codes for billing Medicare for office visits while cutting back on lower-paying ones, according to a year-long examination of about 362 million claims. In 2001, the two highest codes were listed on about 25 percent of the doctor-visit claims; in 2010, they were on 40 percent. ...

"Many doctors and hospitals say that computerized medical records encourage the move to higher codes because the software makes it easier for providers to quickly create documentation for charges. One electronic medical records company predicts on its Web site that its product will result in an increase of one coding level for each patient visit, potentially adding $225,000 in new revenue in a year. More than half the doctors who treat Medicare patients now use electronic records, according to HHS, and more are expected to follow. The federal government is spending billions of dollars to encourage the switch, hoping to cut costs and reduce medical errors and waste. Thomas Weida, a family physician in Hershey, Pa., said that as a result of his switch to electronic records, he typically spends an additional five minutes with patients reviewing their medical information and prescribing treatments. That alone could justify higher billing codes in many instances, said Weida, a medical coding expert for the American Academy of Family Physicians. ... Donald M. Berwick, an Obama appointee who headed CMS until December 2011, said he believes that only a small portion of the upswing in coding is the result of fraud. In most cases, he said, the hospitals have learned 'how to play the game,' and are targeting the vulnerabilities of the Medicare payment system. 'If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that?s what you'll get,' Berwick said."

And today's New York Times weighs in as well:

"...the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.
Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a New York Times analysis of Medicare data from the American Hospital Directory. Regulators say physicians have changed the way they bill for office visits similarly, increasing their payments by billions of dollars as well."


Back in 2003, when I started as executive director at Health Care for All, I was invited to join the steering committee of the newly formed Massachusetts eHealth Collaborative, funded by a $50 million grant from Massachusetts Blue Cross Blue Shield. The money was spent to create fully-integrated EHR systems in North Adams, Newburyport, and Brockton where physician offices and hospitals would seamlessly swap patient records. It happened in North Adams and not the other two. Blue Cross deserves credit for stepping up to make this experiment happen -- but the results were dismal.

Support for HIT/EHR was not limited to Democrats and lefties. Click here to read 2006 testimony before the U.S. House of Representatives by former House Speaker Newt Gingrich, promoted by the American Enterprise Institute. Lots and lots of parties have made vast sums of money pushing the HIT panacea -- lots of folks have gotten rich and the real return on this massive investment is hard to see.

So where are we left?

Seems clear to me that HIT/EHR alone, absent other systemic reforms, is only a prescription for higher costs. We don't know conclusively that HIT leads to higher costs, though it now should surprise no one if that turns out to be the case. At the same time, EHR systems are essential ingredients for Accountable Care Organizations (ACOs) and other new delivery system reforms that move health care payment away from fee-for-service and toward global payment.

That's the promise, and yet it's still only a promise -- because ACOs and other payment reforms are themselves still hypotheses, sounding good in theory and yet to be proven. Who knows how long it will be before we see studies and reports on how the new payment innovations are actually increasing, rather than decreasing, costs?


This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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