In a great paradox of 21st Century medicine, none other than Medicare is a violator of the timeless standard of medical ethics expressed in the Hippocratic rule: First, do no harm.
The worst part? It’s that bonuses paid to physicians, from Medicare and Medicaid, are tied to activities that may actually harm some patients.
The issue relates to Electronic Health Records (EHRs). No question, electronic data holds the potential to greatly improve patient treatments based on proven results. However, it is also true that bad data can result in deadly mistakes. And therein lies the problem.
Currently, Medicare is pushing doctors to enter data and make medical decisions based on statistical analysis. Yet, at the same time, health IT experts—including some in the federal government—are warning of hazards caused by shortcomings in EHR technology. The technology simply isn’t available yet to do the high-quality data analysis that Medicare is demanding prematurely.
EHRs and patient safety
Earlier this month, the federal agency responsible for healthcare technology hosted a webinar to address what the agency called “this important safety topic” of EHR usability. The webinar featured Dr. Andrew Gettinger, Executive Director of the federal Office of Clinical Quality and Safety, and Drs. Peter Provonost and Josh Rising from the Pew Charitable Trusts. The issues covered in the webinar are summed up on Pew’s website and include this warning:
“Although the United States has invested tens of billions of dollars to encourage providers to adopt electronic health records (EHRs), many clinicians have found that these systems have poor ‘usability.’ EHRs can put patients at risk of medical error, do little to enhance clinical care, and increase the time clinicians spend documenting patient care. Indeed, one study found that 15 percent of physicians reported that their EHR had caused a potential medication error within the past month.”
Fifteen percent within a month? That raises a huge question of how many people are being harmed—right now, today—without anybody knowing about it.
In a blog post earlier this year, Kaiser Health News reported on the ease of medical mistakes happening with the slip of a mouse, creating particular concern in rushed emergency room situations.
In a book on this topic, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” Dr. Bob Wachter, Chief of Hospital Medicine at University of California San Francisco and the father of Hospitalist Medicine, documents some of the harrowing real-life stories.
In one such incident, a teen narrowly escaped death following a hiccup in data processing. Quite routinely, a resident physician had learned she needed to make a change to her original orders for pediatric medication for a boy named Pablo Garcia. So, when the resident typed in 160 mg thinking that was the correct dose to be dispensed, the system changed it to 160 mg/kg. This, plus a series of seemingly minor events, culminated in Pablo taking a gigantic dose of pills.
Getting to the root causes
In July 2015, in an effort to identify the root causes of EHR problems such as this, Pew Charitable Trusts, in collaboration with the Johns Hopkins Armstrong Institute for Patient Safety and Quality, convened a meeting of 70 experts, including EHR vendors, hospital representatives, clinicians, and patient safety advocates.
Following the meeting, Pew identified three primary issues:
1. Some EHR makers don’t fully assess usability of their products before delivering them to hospitals and doctors’ offices.
2. There are no universal standards for measuring the safety and performance of EHR systems.
3. Heathcare providers fear the consequences of violating gag clauses that prohibit disclosure of problems involving their EHRs.
This latter point, relating to gag clauses commonly found in EHR contracts with health providers, means that the public can’t even intelligently assess the current state of EHR technology—even though $30 billion in federal tax dollars subsidized the installation of EHRs!
Indeed, evidence is stacked high in support of everything Pew says.
- A 2016 report by the nonprofit National Quality Forum (NQF) called for a coordinated effort to reduce risks associated with electronic health records, starting with an assessment of how well providers, vendors, and others are addressing IT-related safety concerns.
- Also, this year, the Journal of AHIMA reported on survey results indicating widespread problems in accurately matching individuals with their healthcare records. Duplicate records commonly exist, creating greater likelihood of errors in treating people.
- In 2015, 36 professional associations raised questions about the very security of patient information contained in EHRs. In a letter to the feds, the associations raised concerns about poorly functioning EHRs resulting in “medical record errors, inaccurate documentation, lack of interoperability, slow performance, lost patient information, and safety concerns.“
Against this backdrop, Medicare persists in giving financial rewards to physicians for how well they score—by Medicare’s standards—in the use of EHRs. And the score-keeping gets into the minutia of everyday routines. For example, physicians get points (which can turn into real money) for generating and transmitting prescriptions electronically.
The end goal, ideally, is about creating a system that rewards doctors for treating patients based on best practices that can be confirmed by data. However, at the moment, there is a foundational problem: The nation won’t even have the advanced technology for such comprehensive data analysis until 2024. That is by the government’s own estimate in a 2013 report titled, “Capturing High-Quality Electronic Health Records Data to Support Performance Improvement.”
The report points to highly functioning EHRs as key to the implementation of payment reform tied to performance measures. It notes that,
“as the industry moves toward value-based reimbursement—reimbursement based on quality and cost measures—improving the quality of the data used for measurement is imperative.”
Meanwhile, contrary to red flags, Medicare keeps pressuring doctors to step up usage of EHRs in return for higher pay. Right now. Today.
If the functionality of EHR systems is in question, which it clearly is, then Medicare fails the Hippocratic test by forcing these systems to serve purposes they are currently incapable of serving. The only question is: In the process of data entry, how many people are suffering undocumented harm?