Death by a Thousand Clicks

The Giant Experiment That is Killing Medicine

Introduction

What if you and everyone you know were the subject of a giant medical experiment? What if no one warned you or asked your permission before including you? What if that experiment drastically changed everything your doctor did? Guess what? That's exactly what started in 2009, when Obama passed the Health Information Technology for Economic and Clinical Health Act (HITECH Act). This is not the same thing as the Affordable Care Act (a.k.a., Obamacare), and I think it is far more ominous.

The HITECH Act allocated $44 billion of Medicare and Medicaid money to subsidize the adoption of privately-made, government-certified ‘Electronic Health Record’ (EHR) systems, and encourage (bribe and penalize) medical practices and hospitals to use them to carry out certain tasks in patient care. These tasks are called 'Meaningful Use' (MU) of the EHR as defined by regulation.

As time progresses, the bribes will taper to nothing and become penalties levied on practices or hospitals that do not reach these goals will have to pay penalties. So, effectively, HITECH is forcing doctors and hospitals to adopt these private programs for all of their patients or stop accepting Medicare and Medicaid--which means stop serving most of the sickest patients.

Based on my personal experience, I think this program misses the forest for the trees and sets up a series of incentives that impair doctors’ abilities to help patients. It is a reckless, unethical experiment, which, if it were a pharmaceutical, would be illegal. No one should have the authority to impose such a change on the entire system without scientific evidence that it will improve the concrete outcomes of longer, healthier, and happier lives.

Part 1. The Mismeasure of Medicine

There are dozens of Meaningful Use goals. Many seem appropriate for individual patients. Some seem deeply flawed to begin with. The sum of all of them may do more harm than good.

One Meaningful Use measure that at least seems sensible, at least in individual cases, is the requirement to document smoking status. But does documenting in the medical record the smoking status of every single patient lead to fewer patients smoking over all? Does it lead to fewer heart attacks and cancer and extend lives? How do you know the documentation is accurate? Are there more efficient ways to approach smoking? Apparently, nobody has tried systematically to find out.

There are Meaningful Use measures that are based on science that is in dispute or becomes obsolete before regulators can adapt the regulations. For instance, blood pressure control is one Meaningful Use measure, but acceptable systolic blood pressure for a diabetic patient over the age of 60 has gone up by 10 points since I have been in practice. So steps I took a few years ago trying to comply with this goal may have actually harmed my patients.

Meaningful Use does not necessarily measure real world activity. It is data entry, and data entry can be manipulated to suit the person entering the data. I can meet Meaningful Use goals to minimize inappropriate antibiotic prescription by describing the same symptoms as ‘cough’ instead of ‘bronchitis.’

Meaningful use takes money and resources away from interventions proven to work. There are hundreds of thousands of bureaucrats dedicated to implement this program that has no proven positive impact. In a world of limited resources wouldn’t it be better to improve access to prenatal care or life-saving medications? How about reimbursing mental health work decently?

Most personally galling to me, my time spent even on worthy Meaningful Use goals may take away from my time spent pursuing goals that are more important but not measured or even measurable.

There is the time learning these measures that I could otherwise spend learning more medicine. Lunch meeting after lunch meeting is taken up with Meaningful Use lessons. I would rather discuss the evidence behind new hypertension recommendations, or how I can best care for a difficult case.

And there is my time with the patients. I get 15 minutes for most visits. Many doctors get as few as 8 minutes. The average is 12. Meaningful Use takes a lot of that time. When can I comb through the record and catch mistakes or opportunities to improve care? When can I listen closely to my patient and examine them carefully? When can I look into their eyes and explain my reasoning in plain language? When can I practice meaningful medicine?

I am ready and willing to learn new rules and do boring, repetitive tasks, but only if they lead to meaningful outcomes for my patients—years of happy, healthy life. Until Meaningful Use has been proven to do that, it is a game for harvesting government money at the expense of patient care and the biggest unethical experiment of our time.

Next: Part 2. Electronic Health Records, the Hope, and the Reality

Center for Medicare and Medicaid Services Guidance on Meaningful Use

Campbell-Scherer, DL, et. al., ACC/AHA Guideline Update for the Management of ST-Segment Elevation of Myocardial Infarction, Am Fam Physician 2009:79(12)1080-1086.