[Friedman's Update] ObamaCare and "Meaningful Use" Part I:

Let's take a little detour this week. The term ObamaCare is frequently used as a nickname for the Patient Protection and Affordable Care Act of 2010 (PPACA). But in reality, the structural changes to American health care were enacted in three separate pieces of legislation. The additional two are the Health Care and Education Reconciliation Act of 2010 and the American Recovery and Reinvestment Act of 2009 (the "stimulus" law). One of the critical sections of the stimulus law is where it creates the mechanism to convert 100% of the health care sector to electronic health records (EHRs). This mission is being carried out by the Office of the National Coordinator for Health Information Technology which is headed by David Blumenthal, MD. Just to give you a sense of how dramatic this change will be, the current penetration of fully function Electronic Medical Records into the market (yes, we used to have a marketplace in the health sector) is currently 10.1%. As a result of this drive towards universal HIT, numerous start-up companies have begun building software systems to meet the upcoming needs of the health care sector (here and here are just some samplings). Moreover, existing companies have begun dramatically increasing their capacity to provide software systems and technical support. All of this is being done due to government intervention.

Many of us who are scarred veterans of HIT have worried that this transition risks adversely affecting patients. Many were hopeful that the stated objectives of the move to HIT - increased patient safety and improved quality of care - would result in the federal government instituting mechanisms to insure these new systems would be safe, effective, easy to use, and result in better outcomes. They would be disappointed. As many of us suspected, the real reason for instituting national HIT is to make rationing care in real time a reality. How do I come to this conclusion? The regulations for new electronic health care systems have now been published under the title "meaningful use," and they don't address safety issues at all. I am not the only one who has noticed this omission. The Leapfrog Group has also expressed grave concerns. David Blumenthal himself was kind enough to write an editorial summarizing the "meaningful use" regulations. In this editorial, one can find a chart summarizing the system "objectives" necessary for health care companies and professionals to receive financial incentives. Let's break down what they really mean:

1. The first several objectives relate to some basic information that EHRs are expected to capture including vital signs, medications, problem lists, etc. The key issue here is that this information needs to be collected as "structured data." This reason structured data is so important is that it allows information to be mined and transferred. This isn't all bad. If we are going to move to an entirely electronic record keeping system, it would make sense to use structured data to allow easy transfer of records from one EHR system to another. On the other hand, the more structured the data the easier it is to mine for purposes unrelated to patient care. For example, one of the serious problems with the PPACA is that it requires the federal government engage in dramatic invasions of medical privacy. It is through this structured data that information will be collected by the government, insurance companies, and other entities. Of course the least structured data - and thus the most secure from electronic prying eyes - comes in the form of paper charts.

2. Further down the list of objectives comes the requirement for Computerized Physician Order Entry (CPOE) and electronic prescribing. Despite the claims that these requirements will improve safety, there is no evidence that simply requiring widespread adoption will accomplish this goal. In actuality, there is ample evidence that even well established CPOE systems come with significant risks to patients (my favorite part of the linked article is where the Advocate public relations specialist claims everything was fine, move along, nothing to see). Rather than implement some sort of safety evaluation similar to that undergone by drugs and medical devices, the regulation simply requires that they be used with minimum frequency. The real reason for this is the same as the reason for requiring structured data. It is impossible to intercept and modify prescriptions and other orders if they are written on paper. One should not underestimate the desire of the government and the insurance companies to get control of the order entry system. This would give them the ability to influence physician decisions in real time.

OK, that was a bit long. I'll continue next week.